SMALL-INTESTINAL TRANSPLANTATION

The management of patients with intestinal failure has benefited from progress in parenteral nutrition (PN), especially home-based PN. Intes tinal transplantation is therefore possible and is now, in some condit ions, the logical therapeutic option. Since 1985, more than 180 small- bowel grafts have been done, involving the isolated small bowel with o r without the colon (38%), the liver-small bowel (46%) or several orga ns (16%). Two-thirds of recipients were under 20 years of age, and ind ications were short-bowel syndrome (64%), severe intractable diarrhoea (13%), abdominal cancer (13%) or chronic intestinal pseudo-obstructio n syndrome (8%). Of the patients, 51% survived > 2 years after the gra ft. Patient and graft survival depends on the type of immunosuppressio n, i.e. cyclosporine or FK506. The results must be interpreted careful ly as they represent the first experience in numerous centres using di fferent immunosuppressive protocols, without any randomization. The re sults from the largest of these centres reflect the current situation more closely. Functional grafts lead to gastrointestinal autonomy (wea ning of PN) while maintaining satisfactory nutritional status and norm al growth in childhood. Intestinal transplantation is theoretically in dicated for all patients permanently or dependent for a long time on P N, However, as PN is generally well tolerated, even for long periods, each indication for transplantation must be carefully weighed up in te rms of the iatrogenic risk and quality of life. When PN has reached it s limits, especially in those associated with vascular, infectious, he patic or metabolic complications, intestinal transplantation must be u ndertaken. Transplantation of the small bowel alone remains the first option, as combined liver-small bowel grafting is only indicated in th e case of life-threatening progressive cirrhogenic liver disease.