3 YEARS CLINICAL-EXPERIENCE WITH INTESTINAL TRANSPLANTATION

BACKGROUND: After the successful evolution of hepatic transplantation during the last decade, small bowel and multivisceral transplantation remains the sole elusive achievement for the next era of transplant su rgeons. Until recently, and for the last thirty years, the results of the sporadic attempts of intestinal transplantation worldwide were dis couraging because of unsatisfactory graft and patient survival. The ex perimental and clinical demonstration of the superior therapeutic effi cacy of FK 506, a new immunosuppressive drug, ushered in the current e ra of small bowel and multivisceral transplantation with initial promi sing results. STUDY DESIGN: Forty-three consecutive patients with shor t bowel syndrome, intestinal insufficiency, or malignant tumors with o r without associated liver disease, were given intestinal (n=15), hepa tic and intestinal (n=21), or multivisceral allografts that contained four or more organs (n=7). Treatment was with FK 506 based immunosuppr ession. The ascending and right transverse colon were included with th e small intestine in 13 of the 43 grafts, almost evenly distributed be tween the three groups. RESULTS: After six to 39 months, 30 of the 43 patients are alive, 29 bearing grafts. The most rapid convalescence an d resumption of diet, as well as the highest three month patient survi val (100 percent) and graft survival (88 percent) were with the isolat ed intestinal procedure. However, this advantage was slowly eroded dur ing the first two postoperative years, in part because the isolated in testine was more prone to rejection. By the end of this time, the best survival rate (86 percent) was with the multivisceral procedure. With all three operations, most of the patients were able to resume diet a nd discontinue parenteral alimentation, and in the best instances, the quality of life approached normal. However, the surveillance and inte nsity of care required for these patients for the first year, and in m ost instances thereafter, was very high, being far more than required for patients having transplants of the liver, kidney or heart. CONCLUS IONS: Although intestinal transplantation has gone through the feasibi lity phase, strategies will be required to increase its practicality. One possibility is to combine intestinal transplantation with contempo raneous autologous bone marrow transplantation.