Combined liver-small bowel transplantation: digestive and nutritional aspects in the first adult recipient in France

OBJECTIVE: We report the digestive, hepatic, intestinal and nutritional his tory of the first combined liver-small bowel transplantation performed in F rance in an adult recipient Currently, the clinical course has been favorab le at 30 months. METHODS: In May 1997 a 21-year-old man under went a double liver-small bowe l transplantation for irreversible chronic bowel failure with severe chroni c liver disease subsequent to post-surgical short-bowel syndrome. Alter 28 laparotomies, there were 15 cm of small bowel left for the gastric anastomo sis. The patient had a terminal jejunostomy and a left colostomy, excluding a short segment of the transverse colon and the rectum. Total parenteral n utrition including lipids had been initiated in December 1992 (3500 kcal/d) and had led to severe complications Intestinal absorption before and alter the graft were studied with the balance method (input-output) and used bom b calorimetry and measurements or Vie steatorhhea and creatorrhea. Function al enterocyte mass was assessed from serum citrullin. RESULTS: The postoperative period alter the liver-bowel graft (220 cm small bowel with termianal ileostomy and jejunostomy) was uneventful. The immuno suppression protocol included tacrolimus, corticosteroids and azathioprin. One mild episode of acute rejection occurred at day 26 and was controlled w ith a corticosteroid bolus. No episode of liver rejection acquired. Moderat e renal failure regressed partially after re establishing the fluid-electro lyte balance and adapting tacrolimus dosage. Total parenteral nutrition whi ch had sustained the patient for 4 and a half years was definitely disconti nued three months alter transplantation. Oral nutrition was initially assoc iated with enteral nutrition (from day 30 to day 90) and became exclusive t hree months' after the transplantation. intestinal absorption coefficients measured before transplantation, at 3 months (2200 kcal/d, ileostomy flow 1 600 g/d), and at 18 months (2400 kcal/d, ileostomy flow 1300 g/d) post tran splantation were, respectively 22% 90% and 88% for overall calorie absorpti on, 25%, 65% and 73% for fat absorption, and 47%, 83% and 62% for nitrogen absorption. At 18 months post-graft there was a spectacular improvement in the patient's neurological status and his liver function was normal. Endosc opy, radiography, histology, and immunohistochemistry explorations were nor mal. Ileo-rectal anastomosis was reestablished at 23 months post-transplant ation. At 30 months the patient is living in his home and on 100% oral nutr ition. CONCLUSION: Clinical, nutritional and functional outcome at 30 months in th is first French case of liver-small bowel transplantation in an adult recip ient has been excellent.