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Small Bowel Transplant and the Efficacy of Surveillance Ileoscopy to Evaluate for Graft Rejection

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... defined by malabsorption, diarrhea, steatorrhea, fluid and electrolyte ... symptoms (bloating, cramping, diarrhea, increased stomal output) are often present. ... – PowerPoint PPT presentation

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Title: Small Bowel Transplant and the Efficacy of Surveillance Ileoscopy to Evaluate for Graft Rejection


1
Small Bowel Transplant and the Efficacy of
Surveillance Ileoscopy to Evaluate for Graft
Rejection
  • Dalia Ibrahim
  • PGY1
  • Department of Internal Medicine
  • Department of Gastroenterology
  • 30 April 2009

2
Short-Bowel Syndrome
  • The average length of the adult human small
    intestine is approximately 600 cm, as calculated
    from studies performed on cadavers, ranging from
    260-800 cm.
  • Any disease, traumatic injury, vascular accident,
    or other pathology that leaves less than 200 cm
    of viable small bowel or results in a loss of 50
    or more of the small intestine places the patient
    at risk for developing short-bowel syndrome.
  • Short-bowel syndrome is a disorder clinically
    defined by malabsorption, diarrhea, steatorrhea,
    fluid and electrolyte disturbances, and
    malnutrition.
  • The final common etiologic factor in all causes
    of short-bowel syndrome is the functional or
    anatomic loss of extensive segments of small
    intestine so that absorptive capacity is severely
    compromised.

3
Causes of Short-Bowel Syndrome
  • Adults
  • Crohns disease
  • Radiation enteritis
  • Mesenteric vascular accidents
  • Trauma
  • Recurrent intestinal obstruction
  • Desmoid tumors
  • Pediatrics
  • Necrotizing enterocolitis
  • Intestinal atresias
  • Intestinal volvulus
  • Congenital short small bowel
  • Gastroschisis
  • Meconium peritonitis

4
Indications for Small Bowel Transplant (AGA
recommendations)
  • Thus far, intestinal transplants have been
    performed only in patients who have developed
    life-threatening complications attributable to
    their intestinal failure and/or long-term TPN
    therapy
  • Medicare has approved payment for intestinal
    transplants in patients who fail TPN therapy for
    one of the following reasons
  • Impending or overt liver failure (increased serum
    bilirubin and/or liver enzyme levels,
    splenomegaly, thrombocytopenia, gastroesophageal
    varices, coagulopathy, stomal bleeding, hepatic
    fibrosis, or cirrhosis).
  • Thrombosis of major central venous channels (2
    thromboses in subclavian, jugular, or femoral
    veins). Evidence supporting this indication is
    weak.
  • Frequent central line-related sepsis (2 episodes
    of systemic sepsis secondary to line infection
    per year, 1 episode of line-related fungemia,
    septic shock, or acute respiratory distress
    syndrome). Evidence supporting this indication is
    weak.
  • Frequent severe dehydration.

5
Post Transplant Allograft Rejection
  • Rejection is the most common cause of graft loss
    in intestinal transplant recipients.
  • While clinical signs are frequently unreliable,
    fever and gastrointestinal symptoms (bloating,
    cramping, diarrhea, increased stomal output) are
    often present.
  • There are no reliable biochemical markers of
    rejection.
  • According to the American Gastroenterological
    Association recommendations in April 2003
    multiple biopsies (6 total biopsies) initially
    should be performed biweekly
  • Because early rejection may not be endoscopically
    apparent, biopsy specimens should be obtained
    even from normal appearing mucosa.

6
Our Study
  • Retrospective design we reviewed the medical
    records, histology reports, and endoscopy reports
    of all patients (78 total) who underwent small
    bowel transplant at Georgetown University
    Hospital from 2003-2008
  • Demographic data of the patients has not yet been
    evaluated.
  • During transplantation an ileostomy is created in
    all patients to facilitate postoperative
    surveillance endoscopy.
  • Surveillance endoscopy was performed initially
    biweekly and with clinical indication by fever,
    bacteremia, increased stomal output, diarrhea, or
    gastrointestinal bleeding.
  • Patients also underwent other procedures such as
    colonoscopy, EGD, enteroscopy, or ERCP if
    clinically indicated.

7
Our Study
  • We are currently compiling a database with the
    following data points
  • Name
  • MR
  • Date of procedure
  • Procedure
  • Indication for procedure
  • Anesthesia
  • Findings
  • Complications
  • Pathology
  • Difficulty
  • Use of glucagon
  • Location of biopsies
  • Type of forceps

8
Study Question
  • The efficacy of biweekly surveillance ileoscopy
    for evaluation of post transplant rejection.
  • We believe that this approach is too aggressive
    and transplant patients may not need to undergo
    this many endoscopies post-transplantation
    without clinical signs or symptoms of rejection.
  • We hope to prove that the number of surveillance
    ileoscopies need not be so frequent decreasing
    the large financial and social burden on both the
    patient and the health care system.

9
Transplant Centers
  • There are only 7 Medicare approved Centers for
    small bowel transplantation in the United States
  • Georgetown University Hospital
  • UCLA
  • University of Pittsburg Medical Center
  • Mount Sinai Hospital (New York)
  • Nebraska Health System
  • Clarion Health Methodist-IU-Riley (Indiana)
  • University of Miami, Jackson Memorial Hospital
  • This means that patients must relocate their
    entire lives for an indefinite period of time for
    small bowel transplantation.

10
Our Study
  • If we are able to prove that such frequent
    surveillance ileoscopies are not necessary we
    could possibly change the current standard of
    care post-transplantation.

11
Similar Study
  • A retrospective review of endoscopic and
    histologic reports in 41 children who received an
    intestinal transplant between 1990-1995 at
    Childrens Hospital of Pittsburgh.
  • Results
  • A total of 1273 endoscopies was performed of
    which 760 were ileoscopies via allograft
    ileostomy, 273 were upper endoscopies, and 240
    were colonoscopies.
  • One hundred four rejection episodes were
    documented histologically in 32 patients, 6 days
    to gt4yrs after transplantation.
  • Most episodes were mild and easily treated with
    increased immunosuppression however, severe
    rejection with mucosal exfoliation was seen in
    nine patients.
  • Rejection sometimes involved only part of the
    allograft.
  • Endoscopic appearance alone without biopsies was
    sensitive enough to diagnose only 63 of the
    rejection episodes.
  • Epstein-Barr and cytomegalovirus infections
    occurred in 11 and eight patients, repectively,
    and involved both native bowel and allograft in
    some.
  • Complicatons of endoscopy were few one
    perforation, three episodes of bleeding, and
    three episodes of transient respiratory
    compromise.
  • .

12
Similar Study
  • Conclusions
  • Frequent surveillance ileoscopies with biopsies
    should be performed after transplantation.
  • If patients clinically deteriorate with fever,
    diarrhea, bacteremia, or GI bleeding and a clear
    cause is not elucidated by ileoscopy, an upper
    endoscopy with biopsies is indicated

13
References
  • American Gastroenterological Association Medical
    Position Statement Short Bowel Syndrome and
    Intestinal Transplantation. Gastroenterology.
    200312411051110.
  • Scolapio JS, Fleming CR. Short bowel
    syndrome. Gastroenterol Clin North
    Am. Jun 199827(2)467-79, viii. 
  • Wilmore DW, Robinson MK. Short bowel
    syndrome. World J Surg. Dec 200024(12)1486-92. 
  • Sigurdsson L, Reyes J, Putnam PE, et al.
    Endoscopies in Pediatric Small Intestinal
    Transplant Recipients Five Years Experience. The
    Am J Gastroenterol. 199893(2)207-211.
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