Treatment of short bowel syndrome in children. Value of the Intestinal Rehabilitation Program / Tratamento da síndrome do intestino encurtado na criança: valor do Programa de Reabilitação Intestinal

Summary The main cause of acute intestinal failure is short bowel syndrome, generally as a result of resection of extensive segments of small intestine. As a result, the main symptoms are watery diarrhea, malabsorption syndrome, chronic malnutrition, and death, if the patient is not properly treated. If the length of the remaining intestine is greater than 30 cm, complete adaptation is possible and the patient may not require parenteral nutrition. The currently recommended treatment includes the use of prolonged parenteral nutrition and enteral nutrition, always aimed at constant weight gain, in conjunction with surgeries aimed at elongating the dilated bowel. This set of procedures constitutes what is called an Intestinal Rehabilitation Program. This therapy was used in 16 children in periods ranging from 8 months to 7.5 years, with survival in 75% of the cases. Finally, the last resort to be used in children with complete resection of the small bowel is an intestinal transplant. However, to date there is no record of a Brazilian child that has survived this procedure, despite it being attempted in seven patients. We conclude that the results of the intestinal rehabilitation program are encouraging for the continuation of this type of treatment and stimulate the creation of the program in other pediatric care institutions.

Resumo A principal causa da falência intestinal aguda é a síndrome do intestino encurtado, decorrente, em geral, de ressecção de extensos segmentos de intestino delgado. Em consequência, os principais sintomas são diarreia aquosa, síndrome de má absorção, desnutrição crônica e óbito, caso o paciente não seja adequadamente tratado. Se o comprimento do intestino remanescente for superior a 30 cm, poderá haver adaptação completa e o paciente poderá ficar livre da nutrição parenteral. O tratamento atualmente preconizado inclui a utilização de nutrição parenteral prolongada e de nutrição enteral, objetivando sempre o ganho ponderal constante, em paralelo a cirurgias que visem ao alongamento do intestino dilatado. Esse conjunto de procedimentos constitui o que se denomina Programa de Reabilitação Intestinal. Essa terapia foi utilizada em 16 crianças, em períodos que variaram de 8 meses a 7 anos e meio, com sobrevida em 75% dos casos. O último recurso utilizado em crianças com ressecção completa do intestino delgado é o transplante intestinal. Até o momento, não há registro de criança brasileira que tenha sobrevivido a esse procedimento, a despeito de sete pacientes terem sido submetidos a ele. Os resultados do Programa de Reabilitação Intestinal nos anima a continuar com esse tipo de tratamento e estimular a criação do programa em outras instituições de atendimento pediátrico.

Intestinal and multivisceral transplantation / Transplante intestinal e multivisceral

Intestinal transplantation has shown exceptional growth over the past 10 years. At the end of the 1990’s, intestinal transplantation moved out of the experimental realm to become a routine practice in treating patients with severe complications related to total parenteral nutrition and intestinal failure. In the last years, several centers reported an increasing improvement in survival outcomes (about 80%), during the first 12 months after surgery, but long-term survival is still a challenge. Several advances led to clinical application of transplants. Immunosuppression involved in intestinal and multivisceral transplantation was the biggest gain for this procedure in the past decade due to tacrolimus, and new inducing drugs, mono- and polyclonal anti-lymphocyte antibodies. Despite the advancement of rigid immunosuppression protocols, rejection is still very frequent in the first 12 months, and can result in long-term graft loss. The future of intestinal transplantation and multivisceral transplantation appears promising. The major challenge is early recognition of acute rejection in order to prevent graft loss, opportunistic infections associated to complications, post-transplant lymphoproliferative disease and graft versus host disease; and consequently, improve results in the long run.

O transplante de intestino, ao redor do mundo, tem crescido de maneira sólida e consistente nos últimos 10 anos. No final da década de 1990, passou de um modelo experimental para uma prática clínica rotineira no tratamento dos pacientes com complicação severa da nutrição parenteral total com falência intestinal. Nos últimos anos, vários centros têm relatado uma crescente melhora nos resultados de sobrevida do transplante no primeiro ano (ao redor de 80%), porém, a longo prazo, ainda é desafiador. Diversos avanços permitiram sua aplicação clínica. O surgimento de novas drogas imunossupressoras, como o tacrolimus, além das drogas indutoras, os anticorpos antilinfocíticos mono e policlonal, nos últimos 10 anos, foi de suma importância para a melhora da sobrevida do transplante de intestino/multivisceral, mas, apesar dos protocolos bastante rígidos de imunossupressão, a rejeição é bastante frequente, podendo levar a altas taxas de perdas de enxerto a longo prazo. O futuro do transplante de intestino e multivisceral parece promissor. O grande desafio é reconhecer precocemente os casos de rejeição, prevenindo a perda do enxerto e melhorando os resultados a longo prazo, além das complicações causadas por infecções oportunistas, doenças linfoproliferativas pós-transplante e a doença do enxerto contra hospedeiro.

Resultados do transplante multivisceral na trombose porto-mesentérica difusa / Outcomes of multivisceral transplantation in the setting of diffuse thromobisis of the portomesenteric venous

Objetivo: Avaliar o prognóstico clínico do transplante multivisceral (TMV) na vigência de trombose difusa do sistema porto-mesentérico. Introdução. O transplante hepático (TH) na vigência de cirrose e trombose difusa do sistema porto-mesentérico é controverso e muitas vezes contraindicado em muitos centros de transplante hepático. O transplante hepático utilizando técnicas alternativas como a hemitransposição portocava falha na eliminação de complicações provenientes da hipertensão portal. O TMV substitui o fígado e todo o sistema venoso porto-mesentérico. Métodos: Uma base de dados de pacientes submetidos a transplante intestinal foi mantida com análise prospectiva de resultados. O diagnóstico de trombose difusa do sistema porto-mesentérico foi estabelecido através de tomografia abdominal em fases arterial e venosa, ou por ressonância magnética com reconstrução venosa. Resultados: Vinte e cinco pacientes com trombose de porta, estádio IV, foram submetidos ao TMV. Onze pacientes receberam transplante renal concomitante. Rejeição aguda confirmada por biópsia foi notada em cinco pacientes, que foram tratados com sucesso. Com um seguimento médio de 2,8 anos, a sobrevida de enxertos e pacientes foi de 80%, 72% e 72%, respectivamente. Até a presente data, todos os sobreviventes estão com boa função de enxerto e sem nenhum sintoma ou evidência de hipertensão portal. Conclusão: O TMV deve ser considerado como opção para o tratamento de pacientes com trombose portomesentérica difusa. O transplante multivisceral é o único procedimento que reverte completamente a hipertensão portal e a doença de base com uma sobrevida superior ao TH com reconstruções vasculares alternativas.

Objective: To evaluate the clinical outcomes of multivisceral transplantation (MVT) in the setting of diffuse thrombosis of the portomesenteric venous system. Background: Liver transplantation (LT) in the face of cirrhosis and diffuse portomesenteric thrombosis (DPMT) is controversial and contraindicated in many transplant centers. LT using alternative techniques such as portocaval hemitransposition fails to eliminate complications of portal hypertension. MVT replaces the liver and the thrombosed portomesenteric system. Methods: A database of intestinal transplant patients was maintained with prospective analysis of outcomes. The diagnosis of diffuse PMT was established with dual-phase abdominal computed tomography or magnetic resonance imaging with venous reconstruction. Results: Twentyfive patients with grade IV DPMT received 25 MVT. Eleven patients underwent simultaneous cadaveric kidney transplantation. Biopsy proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 2.8 years, patient and graft survival were 80%, 72%, and 72% at 1, 3, and 5 years, respectively. To date, all survivors have good graft function without any signs of residual/recurrent features of portal hypertension. Conclusions: MVT can be considered as an option for the treatment of patients with diffuse DPMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease, while achieving superior survival results in comparison to the alternative vascular reconstructions.

Protocolos de selección y estudio del donante y receptor aplicables a la práctica chilena, en trasplante de intestino / Selection and pre transplant evaluation criterias for small bowell trasplantion: a chilean model

La insuficiencia intestinal se define como la pérdida de la autonomía nutricional debido a disfunción intestinal. Su única opción de tratamiento adecuado es la Nutrición Parenteral Total Central. El trasplante de intestino se presenta como una alternativa de tratamiento. Los resultados iniciales del trasplante de intestino evidenciaron una alta incidencia de rechazo, infección y complicaciones técnicas que frenaron el desarrollo de esta técnica, sin embargo con la disminución de los problemas técnicos por la experiencia acumulada y la mejoría de los tratamientos inmunosupresores los resultados mejoraron en forma importante. Si bien en Chile la experiencia es limitada la indicación para su realización existe y aumenta debido al interés creciente por los buenos resultados demostrados a nivel mundial. En este breve artículo se revisan las indicaciones y contraindicaciones del procedimiento, el estudio del receptor y del donante, la técnica de procuramiento y se analizan los resultados actuales y las perspectivas futuras.

Intestinal insufficiency is defined as the loss of nutricional autonomy as a result of intestinal malfunction. The only adequate treatment option is Total Central Parenteral Nutrition. Intestinal transplantation is proposed as a treatment alternative. Initial intestinal transplantation results showed a high incidence of rejection, infection and technical complications that stunted the development of this technique. Results have however greatly improved with the enhancement of immunosuppressive therapy and increased experience which has led to a subsequent decrease in technical problems. Even though Chile has limited experience, the demand for intestinal transplantation exists and increases due to a rising interest brought about by the good results presented worldwide. This short article addresses the indications and contraindications of this procedure, receptor and donor studies, the procurement technique and also analyzes current results and future prospects.

Intestinal transplantation (ITx): "who, when and how?" a general overview

O transplante de órgãos se tornou parte importante da medicina moderna. O transplante de intestino (ITx) foi introduzido no final da década de 1960 como um procedimento heróico para tratar falência do intestino. O Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo foi um dos pioneiros mundiais neste procedimento. Com a evolução biotecnológica na medicina, o transplante de intestino emergiu na década de 1990 como a única e permanente opção terapêutica para pacientes com falência intestinal irreversível. Àquele tempo, os resultados clínicos eram, ainda, desapontadores, principalmente devido às altas taxas de infecção pós-operatória e rejeição do enxerto. Entretanto, houve um grande desenvolvimento do transplante intestinal e multivisceral graças à melhoria da terapia imunossupressora, ao refinamento das técnicas cirúrgicas e dos cuidados pós-transplantes. O objetivo deste estudo é oferecer um panorama sobre quando o ITx deve ser indicado e sobre como o procedimento deve ser realizado...

Organ transplantation has become a substantial part of modern medicine. Intestinal transplantation (ITx) was introduced in the late sixties as a heroic procedure to treat intestinal failure. The Clinic Hospital of University of São Paulo Medical School is one of the world’s pioneer in this procedure. With the biotechnological evolution in medicine, intestinal transplantation emerged in the 1990s as the only curative, permanent therapeutic option for patients with irreversible intestinal failure. At that time, the clinical results were also disappointing mainly due to the high rates of post-operative infectious complications and graft rejection. However, the development of intestinal and multivisceral transplantation has been profound owing to the progress in immunosuppressive therapy, refinement of surgical techniques and post-transplant care. This study aims to give a general overview about when the ITx must be considered an option of treatment and how it must be done...

Neurorrafia do ramo bucal dorsal do nervo facial em coelhos com proteção de segmento intestinal alógeno / Neurorrhaphy of the dorsal buccal branch of facial nerve in rabbits with protection o f allograft intestinal segment

Foram utilizados 18 coelhos, Nova Zelândia, machos, adultos, para avaliação clínica e histológica do reparo do ramo bucal dorsal do nervo facial, decorridos 15, 30 e 60 dias de pós-operatório (PO). Os animais foram distribuídos em dois grupos para secção e aproximação epineural do ramo bucal com fio náilon monofilamentoso 10-0. Nos animais do grupo I, o nervo foi revestido com proteção de segmento de jejuno alógeno conservado em glicerina a 98% e o grupo II apenas aplicação de sutura epineural. Nos coelhos dos dois grupos ocorreu retorno da movimentação do lábio superior a partir da oitava semana.Verificou-se infiltrados celulares e células gigantes com fibrose desorganizada e fibras colágenas do envoltório alógeno entremeadas ao tecido conjuntivo. Aos 15 e 30 dias de PO, os cotos distais deambos os grupos encontravam-se com degeneração walleriana e aos 60 dias, com fibras regeneradas. A reparação do ramo bucal dorsal do nervo facial com o segmento intestinal não foi significativamente diferente nos coelhos do controle, quanto à avaliação de recuperação funcional e histológica.

18 rabbits, New Zealand, males, adults were used for clinical and histological evaluation of repair dorsal buccal branch of facial nerve after 15, 30 and 60 days postoperatively (PO). The animals were divided into two groups for transection and 10-0 nylon monofilament epineural suture of buccal branch. In animals in Group I, the nerve was coated with protection of jejunum allograft preserved in glycerin 98% and in group II was applied epineural suture. Both groups occurred the return of movement of the upper lip from the eighth week. There was infiltrated cellular and giant cells with fibrosis unsystematic and collagen fibers of the allograft jejunum joing to the connective tissue. At 15 and 30 days of PO, the distal nerve stumps of both groups were found with degeneration wallerian and in 60 days, regenerated fibers. The repair of the dorsal buccal branch offacial nerve with the allograft wasn’t significantly different between the control rabbits as to the assessment of histological and functional recovery.

Valor crítico da citrulina para as complicações do enxerto no transplante de intestino / Critical value of citrulline for complications of intestinal transplant graft

OBJETIVO: Analisar, numa ampla amostra, o valor crítico da citrulina que confirma a presença das principais complicações do enxerto: rejeição e infecção. MÉTODOS: Foram coletadas 2135 amostras de citrulina sérica, na forma de gota de sangue seca, de 57 doentes submetidos a transplante de intestino/multivisceral no Jackson Memorial Hospital na Universidade de Miami, de março de 2004 a abril de 2006. Todas as amostras são do pós-operatório três meses em diante, passada a conhecida curva de elevação da citrulina após a recuperação das lesões causadas pela isquemia e reperfusão do pós-transplante. RESULTADOS: Utilizando um valor limite menor que 13 µmoles/L, a sensibilidade da citrulina foi de 96,4 por cento para detectar rejeicão celular aguda (RCA) moderada ou grave. A especificidade para as complicações mais freqüentes, rejeição e infecção foi de 54 por cento-74 por cento nas crianças e 83 por cento-88 por cento nos adultos, e o valor preditivo negativo (VPN) foi > 99 por cento. CONCLUSÃO: A citrulina pode ser utilizada como método não-invasivo para avaliar a evolução do enxerto intestinal após três meses do TI. Os episódios de RCA moderado e grave podem ser afastados quando o valor da citrulina for maior que 13 µmoles/L devido ao alto valor preditivo negativo.

OBJECITIVE: A biochemical marker for detection of acute cellular rejection following small intestine transplantation has been sought. Citrulline, a non- protein amino acid synthesized mainly by functioning enterocytes, has been proposed. Trial sensitivity has been reportedly high but with low specificity. Thus, the goal was to determine, in a sufficiently large analysis, the significant value of citrulline level in the post-transplant setting, which would correlate with complications such as rejection and infection. METHODS: Since March, 2004 2,135 dried blood spot (DBS) citrulline samples were obtained from 57 small intestine transplant recipients three months or more after post-transplant, i.e., once the expected period of recovery in the citrulline levels had occurred. RESULTS: Using a <13 vs. > 13 µmoles/L cut off point, sensitivity of DBS citrulline for the detection of moderate or severe ACR was extremely high (96.4 percent). Furthermore, specificity estimates (given the absence of ACR and these particular infections), while controlling for time-to-DBS sample were reasonably high (54 percent-74 percent in children and 83 percent-88 percent in adults), and the negative predictive value (NPV) was >99 percent. CONCLUSION: Citrulline is a non-invasive marker to evaluate problems of the intestinal graft after three months post-transplant. Due to the high NPV, a moderate or severe ACR can be ruled out, based exclusively on knowledge of a high value for DBS citrulline.

Permanent intestinal failure.

CONTEXT: Intestinal failure (IF) requires the use of parenteral nutrition as long as it persists and may be in case of persistence an indication for intestinal transplantation. EVIDENCE ACQUISITION: Literature search was performed both electronically and manually. RESULTS AND CONCLUSIONS: Biological evaluation of IF is becoming possible with the use of plasma citrulline as a marker of intestinal mass. Short bowel syndrome (SBS) is the leading cause of intestinal failure in infants while few epidemiological data are available to date. Data on morbidity and mortality in pediatric patients with SBS are very limited while long-term outcome seems to be improving. Other causes of intestinal failure include neuro muscular intestinal disease and congenital disease of enterocyte development. The management of IF should include therapies adapted to each type and stage of IF based on a multidisciplinary approach, in centers involving pediatric surgery, pediatric gastroenterology, parenteral nutrition expertise, home parenteral nutrition program, and liver-intestinal transplantation experience. Timing for referral of patients in specialized centers remains a crucial issue. The main causes of IF are briefly reviewed emphasizing the medico-surgical strategy for prevention and care-provision, adapted to each type and stage of IF.

Overview of short bowel syndrome and intestinal transplantation / Actualización sobre síndrome de intestino corto y transplante intestinal

Short bowel syndrome is at once a surgical, medical, and a disorder, with potential for life-threatening complications as well as eventual independence from artificial nutrition. Navigating through the diagnostic and therapeutic decisions is ideally accomplished by a multidisciplinary team comprised of nutrition, pharmacy, social work, medicine, and surgery. Early identification of patients at risk for long-term PN-dependency is the first step towards avoiding severe complications. Close monitoring of nutritional status, steady and early introduction of enteral nutrition, and aggressive prevention, diagnosis and treatment of infections such as line sepsis, and bacterial overgrowth can significantly improve prognosis. Intestinal transplantation is an emerging treatment that may be considered when intestinal failure is irreversible and children are suffering from serious complications related to TPN administration.

El síndrome de intestino corto es una entidad médico-quirúrgico, con potencial riesgo para poner en peligro la vida de los niños, y que en su manejo incluye nutrición artificial. El estudio diagnóstico y terapéutico se logra idealmente con un equipo multidisciplinario compuesto de nutricionista, químico, trabajadora social, médico y cirujano. Uno de los primeros pasos, es la identificación anticipada de pacientes a riesgo de presentar complicaciones severas por el uso prolongado de nutrición parenteral. Su pronóstico se mejora con la estrecha supervisión del estado nutricional, por la introducción temprana de la nutrición enteral y la prevención a tiempo en el diagnóstico y tratamiento de infecciones bien de la línea arterial, o por sobrecrecimiento bacteriano. El transplante intestinal emerge como parte del tratamiento que puede ser considerado cuando la falla intestinal es irreversible y en los niños que presentan complicaciones serias relacionadas con la administración de nutrición parenteral.

Short bowel syndrome: an update review article

With the advent of anesthesia and better operative facilities, many patients suffering from dangerous gut diseases that were not likely to survive in near past are saved now. Non availability of parenteral nutrition was another factor in their early mortality. The advent of parenteral nutrition and its better availability has prolonged the misery of this killer disease. On the other hand development of rh-GH, IGF-I, short bowel lengthening, short bowel transplantation and better immunosuppressants have a ray of hope for the better survival of these patients. Some of the patients are saved and enjoying independent life, a lot are handicap of parenteral nutrition while majority is prey to this killer disease. Yet it is challenging era for the whole universe of medicine

Intestinal and Multivisceral Transplantation

Intestinal transplantation has been established as a treatment option for patients that suffer from intestinal failure with complications from total parenteral nutrition. It is still rapidly evolving and just reached a landmark of 1, 000 cases worldwide. Intestinal allografts can be transplanted as isolated, combined with the liver or as a part of a multivisceral allograft. Tacrolimus-based immunosuppression regimens have been used universally with improved outcomes. Clinical outcome in intestinal transplantation has improved significantly over time, impacted by refinement of surgical technique and novel immunosuppression. However rejection, infection, and technical complications still remain the most difficult barrier to improve patient and graft survival.

Intestinal transplantation.

Advances in immunosuppressive treatment as well as better monitoring and control of acute rejection have brought intestinal transplantation (ITx) into the realm of standard treatment for permanent intestinal failure. The results from the intestinal Transplant International Registry (www.intestinaltransplant.org) indicate that ITx is currently an acceptable clinical modality for selected patients with permanent intestinal failure. The goal of this short review is to deal with indications, clinical results and complications of ITx. Although it has been used in humans for the past two decades, very few data are available regarding graft function and its monitoring.

Short bowel syndrome in patients studied at the National Institute of Pediatrics in mexico. Care, cost and perspectives

Background. Short bowel syndrome (SBS) continues to be one of the most challenging problems in pediatric surgery. Intestinal transplantation (IT) seems to be best form of treatment for this pathology. However, it is thought that the development of an IT programs may be more expensive than the present manner of treatment. Methods. To assess this item, and to identify potential candidates for IT, we reviewed the charts of all the patients with SBS treated at our Institute from 1989 to 1994. Results. Nine patients were identified as carriers of SBS; six with intestinal atresia, two with midgut volvulus and one with post-traumatic mesenteric thrombosis. The small bowel remnants varied from 1 to 80 cm, seven patients had remnants shorter than 30 cm, and the ileocecal valve was resected in three. Results. The overall morbidity and mortality was extremely high; four patients died within the first 3 months postresection and those still alive have had several complications: sepsis; hydroelectrolyte imbalances secondary to loose stools; thrombosis or infection of the catheter; TPN-related cholestasis, and malabsorption syndromes, etc. No patient survived with an intestinal remnant shorter than 15 cm. Of the five survivors, four have a weight/age deficit greater than 40 percent, two have rickets, one still depends on TPN and all, except one, require special enteral diets. Multiple central venous accesses had to be performed in every patient (mean 4.8). They all required multiple readmissions and have spent a considerable part of their lives as inpatients. The mean of the calculated cost per patient was $50,000 USD, while the minimal wage in mexico is $1,616 USD/year (1). conclusions. The shorter the segment of the retained bowel and the longer the survival, the higher the cost. These results may be further improved with the development of IT and, probably, with the same economic burden

Transplante intestinal en pediatría / Intestinal transplantation in pediatrics

El transplante Intestinal siempre fue una utopía en medicina y esto debido principalmente a que al inicio la técnica operatoria no era la más óptima; al perfeccionarse ésta, se vió que lo que impedía un adecuado progreso era la poca disponibilidad de drogas anti-rechazo, ya que la Ciclosporina ha sido y es una droga poco efectiva. Con el advenimiento de nuevas drogas anti rechazo y con un mejor conocimiento del papel que el transplante concomitante de hígado tiene en el pronóstico de estos pacientes fue posible conseguir ya en esta década y más especificamente en los dos últimos años resultados extraordinarios; así por ejemplo de los 170 pacientes transplantados a nivel mundial más de la mitad han sido hechos por la Univerdad de Pittsburg, siendola supervivencia reportada por esta universidad del 62 por ciento. Estos porcentajes se vienen mejorando cada vez más, así la Universidad de Miami reporta una supervivencia del70 por ciento mediante la utilización de Corticoides y dos potentes drogas anti-rechazo, la FK-506 y el Mycophenolato.

Intestinal Transplantation used to be an utopia in Medicine, and this was mainly due to the factor that the surgical technique was not the best at the beginning. When this was perfectioned, the next obstacle for the adecuate progress of this surgery was thelimited availability of anti-rejection drugs due to the fact that Ciclosporine has been and still is a drug of relative effectiveness. With the discovery of new anti-rejection drugs and with a best knowledge of the concomitant liver transplantation roll on the prognosis ofthese patients, itwas possible to get in this decade, specifically in the last 2 years, extraordinary results; for example, from 170 pacients who underwent intestinal transplantation around the wortd, more than half were done by the University 01 Pittsburg. This universityreported a survival of 62 per cent. But, this percentage has been improved even more, the University of Miami reported a survival of 70 per cent through the use of corticoides and two powerful anti-rejection drugs: FK-506 and Mycophelate.

Comparación de dos tipos de trasplante experimental en el tratamiento del instestino corto letal / Comparison of two types of experimental transplant in the treatment of lethal shortgut syndrome

Objetivo. Evaluar la respuesta funcional, morbilidad y posibles cambios histoestructurales en animales enterectomizados y sin ciego, sujetos a dos tipos de trasplante anteral singénico. Material y método. Ensayo terapéutico-quirúrgico, aleatorio, controlado. Cuatro grupos de ratas Lewis macho de 8-10 semanas de vida se sometieron a los siguientes tratamientos: 1. Resección enteral letal (n=10). 2. Resección enteral letal + trasplante yeyuno-ileal total (n=28). 3. Resección enteral letal + trasplante segmentario distal de 40 por ciento y ciego (n=32). 4. Grupo testigo (n=10). Resultados. El 11 por ciento de los animales trasplantados falleció por fallas quirúrgicas. Hubo una proporción similar de complicaciones tardías en ambos grupos trasplantados: la más común fue obstrucción enteral; 20 por ciento de los trasplantes yeyuno-ileales presentó diarrea persistente. En los dos grupos trasplantados no se detectaron diferencias significativas, de sobrevida, incremento de peso, niveles séricos de proteínas, triglicéridos y prueba de absorción de la maltosa. En ambos tipos de injertos se observó hipertrofia de vellosidades y criptas. El injerto enteral se acompaño de cambios estructurales semejantes a los que se presentan en los remanentes inestinales en condiciones de déficit enteral postresección. Conclusión. El trasplante segmentario distal de intestino, con válvula íleaca y ciega, puede ser una buena opción terapéutica en la insuficiencia enteral irreversible, dado que la respuesta funcional y la morbilidad asociada no difieren de las del trasplante total

Transplante segmentario enteral experimental. Respuesta funcional y complicaciones quirúrgicas / Enteral segmentary experimental transplant. Functional response and surgical complications

Antecedentes: El trasplante intestinal segmentario es una opción prometedora en el tratamiento del intestino corto letal; el injerto enteral proximal reditúa experimentalmente mejor control inmunológico pero su efectividad funcional respecto a otros segmentos podría ser deficiente. Objetivo: Con el propósito de evaluar la mortalidad quirúrgica y el comportamiento funcional de tres variantes de trasplantes segmentarios enterales, se llevó a cabo el siguiente experimento. Método: Se formaron aleatoriamente cinco grupos de ratas Lewis, singénicas, en fase de crecimiento; en cuatro de ellas se efectuaron enterectomías del 90 por ciento, simultáneamente se trasplantaron segmentos del 30 por ciento de intestino proximal, medial o distal en los tres primeros grupos y del 90 por ciento en el cuarto; el quinto grupo se usó como testigo. Resultados. Se efectuaron 54 trasplantes, un tercio presentó complicaciones tardías, sólo en la mitad de ellos se pudo encontrar causas susceptibles de ser controladas; las complicaciones se presentaron en proporciones similares en todos los grupos. A cuatro meses de realizados los injertos, ninguna rata de las sobrevivientes interrumpió el crecimiento, sin embargo el grupo de trasplante proximal presentó déficit ponderal respecto a los otros grupos P < 0.05; los grupos de trasplante medial, distal y total alcanzaron patrones de crecimientos similar a grupo testigo; los niveles plasmásticos de triglicéridos, colesterol y glucosa después de la prueba de la maltosa fueron similares en todos los grupos, únicamente se observaron niveles inferiores de albúmina en el grupo de trasplante proximal P < 0.05. Conclusiones: los trasplantes segmentarios medial y distal mostraron una mejor respuesta en término de incremento ponderal, comparables a la obtenida en sujetos con restitución total o integridad enteral

Prevencion del dano intestinal mediante la utilizacion de un antagonista del factor de activacion plaquetaria en el trasplante intestinal / Prevention of intestinal damage through the utilization of an antagonist of the platelet activating factor in intestine transplantation

Se realiza un estudio comparativo en ratas singenicas de la cepa Wistar con objeto de valorar los efectos de preservacion del injerto al utilizar el antagonista del factor de activacion plaquetaria, WEB-2086. en la valoracion ultraestructural se ha podido comprobar los efectos de esta sustancia al nivel de las celulas epiteliales de intestino trasplantado