=
;
‹#›
![](3D"master03_background.gif")
![3D"panoramic](3D"slide0204_image002.jpg")
=
Luca Cicalese MD, FACS
Professor of Surgery, Director, Texas Transpla=
nt
Center
![3D"approved](3D"slide0204_image004.jpg")
<=
![endif]>Intestinal Transplantation
=
=
•Intestinal and multi-visceral transplants
=
• are currently beyond the investigational stage.
<=
/div>
•
•These procedures merited recognition =
by
Medicare (April, 2001) and are eligible for reimburseme=
nt.
![](3D"slide0106_image005.gif")
Patient
with non-neoplastic irreversible intestinal failure (IF)
Chronic TPN
Intestinal rehabilitation/grow=
th
factors
Oral diet
Severe TPN related complicatio=
ns
SBTx
Liver-SBTx
Liver cirrhosis
Oral diet
The Spectrum of Intestinal Failure
=
<=
nobr>•In
1987 the incidence of patients on TPN in the US was 8/100,000.
<=
nobr>•225,000
patients on enteral or TPN nutrition in the US
•Number
of patients on TPN for IF doubled from 1989 (20,000) to 1992 (40,000).
=
;
L Howard, M Amen=
t, R
Fleming, et al. Gastroenterology. 1995 Aug; 109(2):355-65
<=
/nobr>
M Irving. Journal
Gastroenterology Hepatology. 2000 15:G26-G29
•Cost
of TPN: ~150.000$/year supply only
The
national cost of home TPN for Medicare was $780 million in 1992
Medicare data from 1992
=
L Howard, M Malone. Transpla=
nt
Proceedings 1996, 28(5):2691-2695=
<=
nobr>•Prevalence
of Medicare patients on home TPN is 238/million population (1989-92).
=
<=
nobr>•Prevalence
of patients on home TPN is 120/million population/year in US.
<=
/nobr>
<=
nobr>•Approximately
50% can be successfully rehabilitated and weaned off TPN.
•<=
/span>Between 795 and 3430 patients would be candidates =
for
SBTx, liver/SBTx and Multi=
visceral
Tx per year nationally.
• Home Parenteral =
and
Enteral Nutrition National Patient Registry
–
=
=
•<=
/span>Management of SBS/IF has to be undertaken by a multidisciplinary team including gastroenterology,
surgery, and nutrition
=
;
•<=
/span>The final therapeutic goal is favoring intestinal
adaptation by the bo=
wel so
that the patient can be weaned from TPN
•<=
/span>Some patients may survive indefinitely on TPN and =
oral nutritional support, others suffer multiple
complications, such as
recurrent infection, dehydration, vascular thrombosis, or progressive liver disease that may result in death=
Management of Intestinal Failure
Medical management of IF
=
=
•G=
lc-polymer
based oral rehydration solutions (ORS)
•E=
lectrolyte
replacement/polymer
•B=
lood
Glc, TG monitoring
•F=
luid
management
•H2
bolckers/PPIs first 6 months
•D=
iarrhea
control
•O=
ral
calcium supplements
•V=
itamin/Mineral
supplements
•H=
igh
complex carbohydrate diet
•C=
ycle
TPN
•C=
atheter
care teaching
•T=
PN
weaning
•P=
artial
TPN support with weaning
•L=
ow
oxalate diet
•M=
edium-chain
triglycerides (MCT) as part of diet
•D=
iagnosis
and treatment of TPN complications, including catheter-related complicatio=
ns
Mechanisms of adaptation
(multifactorial)
(multifactorial)
=
=
•Hormones, growth factors, and cytokine=
s are important in adaptation. Their levels are increased in the serum and tissues
after massive small bowel
resection, and exogenous administration of these substances =
has been demonstrated to enhance various component=
s of
the adaptation respon=
se
(e.g. IGF-1, glucagons, peptide-YY, EGF)
•<=
/span>The strongest stimulus for the adaptation is the
presence of enteral nutrition within the lumen. Nutrie=
nts
promote release of hormones and
secretions as well as stimulate peristalsis and splancnic blood flow
•Complex nutrients initiate a stronger adaptation response since require greater metabolic effort for digestion and
absorption. Fats, especially long-chained, unsaturated lipids, are t=
he
most trophic of the
macronutrients
•
TPN related complications in SBS
=
=
•<=
/span>The use of TPN in SBS can produce gallstones and <=
/span>liver disease
•Gallstones form due to interruption of the entero-=
hepatic circulation of bile acids
•Liver disease (steatosis, cholestasis, cirrhosis) =
is one of the long term consequences of TPN, with 50% having grade 2 fibrosis at > 5yrs
•<=
/span>With the failure of medical management, surgical <=
/span>intervention must be considered
=
Survival of patients with non-maligna=
nt IF
on TPN
=
<=
nobr>•Adult:
<=
nobr>•Pediatric:
• It is in approximately 20-35=
% of
patients who fare poorly on TPN that SBTx is indicated as a life saving procedur=
e.
However, other TPN dependent patients may benefit from SBTx.
•
Surgical Management of IF
(elongation procedures)
(elongation procedures)
![](3D"slide0236_image007.gif")
![](3D"slide0236_image009.jpg")
Bianchi
STEP