Pre-emptive Intestinal Transplant: The Surgeon's Point of View.

Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50 cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.

The morbidity, mortality, and costs associated with Clostridium difficile infection.

Clostridium difficile infection (CDI) is the most common cause of infectious health care-associated diarrhea and is a major burden to patients and the health care system. The incidence and severity of CDI remain at historically high levels. This article reviews the morbidity, mortality, and costs associated with CDI.

OPTN/SRTR 2013 Annual Data Report: intestine.

Despite improvements in medical and surgical treatment of intestinal failure over the past decade, intestine transplant continues to play an important role. Of 171 new patients added to the intestine transplant waiting list in 2013, 49% were listed for intestine-liver transplant and 51% for intestine transplant alone or with an organ other than liver. The pretransplant mortality rate decreased dramatically over time for all age groups, from 30.3 per 100 waitlist years in 2002-2003 to 6.9 for patients listed in 2012-2013. The number of intestine transplants decreased from 91 in 2009 to 51 in 2013; intestine-liver transplants decreased from 135 in 2007 to a low of 44 in 2012, but increased slightly to 58 in 2013. Ages of intestine and intestineliver transplant recipients have changed substantially; the number of adult recipients was double the number of pediatric recipients in 2013. Graft survival improved over the past decade. Graft failure in the first 90 days posttransplant occurred in 14.1% of intestine recipients and in 11.2% of intestine-liver recipients in 2013. The number of recipients alive with a functioning intestine graft has steadily increased since 2002, to 1012 in 2013; almost half were pediatric intestine-liver transplant recipients.

Cost-effectiveness of intestinal transplantation for adult patients with intestinal failure: a simulation study.

BACKGROUND: Home parenteral nutrition (HPN) and intestinal transplantation (ITx) are the 2 treatment options for irreversible intestinal failure (IF). OBJECTIVE: This study simulated the disease course of irreversible IF and both of these treatments--HPN and ITx--to estimate the cost-effectiveness of ITx. DESIGN: We simulated IF treatment in adults as a discrete event model with variables derived from the Dutch Registry of Intestinal Failure and Intestinal Transplantation, the Intestinal Transplant Registry, hospital records, the literature, and expert opinions. Simulated patients were enrolled at a rate of 40/mo for 10 y. The maximum follow-up was 40 y. Survival was simulated as a probabilistic function. ITx was offered to 10% of patients with <12 mo of remaining life expectancy with HPN if they did not undergo ITx. Costs were calculated according to Dutch guidelines, with discounting. We evaluated the cost-effectiveness of ITx by comparing models conducted with and without ITx and by calculating the cost difference per life-year gained [incremental cost-effectiveness ratio (ICER)]. RESULTS: The average survival was 14.6 y without ITx and 14.9 y with ITx. HPN costs were €13,276 for treatment introduction, followed by €77,652 annually. The costs of ITx were ∼€73,000 during the first year and then €13,000 annually. The ICER was €19,529 per life-year gained. CONCLUSION: Our simulations show that ITx slightly improves survival of patients with IF in comparison with HPN at an additional cost of €19,529 per life-year gained.

Small intestine transplantation today.

INTRODUCTION: Intestinal transplantation has become a life-saving therapy in patients with irreversible loss of intestinal function and complications of total parenteral nutrition. DISCUSSION: The patient and graft survival rates have improved over the last years, especially after the introduction of tacrolimus and rapamycin. However, intestinal transplantation is more challenging than other types of solid organ transplantation due to its large amount of immune competent cells and its colonization with microorganisms. Moreover, intestinal transplantation is still a low volume procedure with a small number of transplanted patients especially in Germany. A current matter of concern is the late referral of intestinal transplant candidates. CONCLUSION: Thus, patients often present after onset of life-threatening complications or advanced cholestatic liver disease. Earlier timing of referral for candidacy might result in further improvement of this technique in the near future.

Organ allocation for liver-intestine candidates.

1. Patients listed for combined liver and intestine transplantation have the highest waitlist mortality of any transplant candidates. 2. Liver-intestine candidates have higher mortality rates than other patients listed for liver transplantation at all model for end-stage liver disease (MELD) and pediatric end-stage liver disease (PELD) scores, sepsis rather than liver failure being the major cause of death in this group. 3. Increasing PELD scores appear to correlate with increasing waitlist mortality in patients awaiting combined liver and intestinal transplantation. 4. Present policy to increase MELD / PELD scores for liver-intestine patients by an additional estimated 10% mortality risk is an attempt to bridge the difference in waitlist mortality while maintaining the principle of allocating organs on the basis of disease severity. 5. Scheduled reevaluation of present allocation practices is essential to refine Organ Procurement and Transplantation Network United Network for Organ Sharing policy as it relates to patients in need of combined liver and intestinal transplantation.

Sequential physiology scoring facilitates objective assessment of resuscitation in patients with an intra-abdominal emergency.

BACKGROUND: Patients who present with an intra-abdominal emergency often require urgent surgery. Before surgery a period of resuscitation is undertaken pre-emptively, or to correct any overt physiological derangement. The assessment of response to resuscitation and the decision when to operate is subjective. This study examined the role of sequential physiology scores in assessing the response to resuscitation objectively. METHODS: Sequential physiology scores were recorded in 92 patients with abdominal pathology that subsequently required urgent or emergency surgery. The physiology component of the Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM), Acute Physiology And Chronic Health Evaluation (APACHE) II and III, and Simplified Acute Physiology Score (SAPS) II were determined at presentation, during resuscitation and immediately before surgery. RESULTS: There were 76 survivors;16 patients died. All scoring systems showed an improvement during resuscitation but subsequent deterioration before surgery. The POSSUM, and APACHE II and III physiology scores differentiated more effectively between survivors and patients who died than SAPS II. CONCLUSION: Sequential physiology scores may facilitate the assessment of patients' response to resuscitation. Patients who fail to respond to resuscitation when identified may benefit from more expedient surgery.

Decision theory analysis of the enteric morbidity and surgical staging in the treatment of advanced cervical cancer.

Decision theory analysis is a systematic approach to decision making under conditions of uncertainty. Using formal decision analysis, we analyzed the clinical course of 275 patients with advanced cervical cancer. As selection in the application of surgical staging made survival comparisons difficult, enteric morbidity was used as a valued outcome. While the probability of severe enteric morbidity in patients who undergo extended field radiotherapy and surgical staging is twice as high as that in those not receiving extended portals and undergoing surgical staging (0.095 versus 0.050), the increased precision of defining those patients in need of extended portals resulted in very little increased morbidity in the total group. The difference in probability of enteric morbidity in patients with surgical staging and those without was 0.065 versus 0.061. Efforts to increase the proportion of patients with metastatic disease in the surgical staging group by using as stratifying parameters undifferentiated histology or possibly, in premenopausal patients, progesterone receptor levels may allow for the best survival therapeutic ratio as the maximum survival benefit will be gained by a minimum of enteric morbidity.