CHICAGO, May 18 -- With a one-year survival rate of 72 percent, University of Pittsburgh Medical Center (UPMC) surgeons say intestinal transplantation is a viable and a life-saving option for patients with intestinal failure. They reported their results of 127 transplants -- the most performed at any center -- today at the American Society of Transplantation 18th Annual Meeting and Scientific Sessions.
Overall, children between the ages of 2 and 18 had the best success, with a five-year survival rate of 68 percent, reported Kareem Abu-Elmagd, M.D., Ph.D., FACS, associate professor of surgery and director of intestinal transplantation at the University of Pittsburgh's Thomas E. Starzl Transplantation Institute. In addition, 55, or 95 percent, of the 58 patients currently alive are completely off intravenous nutrition, are eating normal diets and have improved quality of life.
Between May 1990 and March 1999, 127 transplants were performed in 121 adults and children who had irreversible intestinal failure.
The small intestine can be transplanted in one of three ways: alone; in combination with the liver; or in combination with the liver, pancreas and stomach. The majority (81 percent) of the patients at the UPMC required intestinal transplants because of short-gut syndrome, the loss of more than 70 percent of the intestine due to trauma, surgery or disease. For adults, short-gut syndrome may be caused by trauma, clotting of the intestine's vessels or Crohn's disease; for children, it may be a volvulus -- a twisting of the intestines, or congenital conditions.
Of the patients reported, 48 received small bowel alone, 58 received liver and small bowel and 15 received multiple organs.
Surgeons reported that a number of factors have contributed to improved one-year survival, including: improved management of rejection with a three-drug cocktail of tacrolimus, steroids and daclizumab; refined donor and recipient selection criteria; and modification of the surgical procedure, including donor bone marrow augmentation. Twenty-seven of the patients received donor bone marrow with their transplants.
In addition, these modifications have significantly improved survival for patients transplanted in the last four years, for whom there is a cumulative 65 percent survival rate. Thirty-five patients are alive and able to maintain good nutrition for more than three years, and 22 are beyond the five-year milestone. One patient who received a small bowel and liver has survived nearly nine years.
In the last year, since adding the drug daclizumab to the anti-rejection drug regimen, surgeons have been able to achieve a 92 percent one-year survival, reported Dr. Abu-Elmagd. The results are based on 14 patients.
Overall, those who had the best results were children with microvillis disease, a hereditary intestinal disease, or gastrochisis, a congenital condition that causes the intestine to die. Among adults, those with the best results had a diagnosis of Crohn's disease or a condition that involves severe clotting of the main vessels leading to the intestine.
Patients with intestinal failure must be sustained nutritionally with intravenous feedings called total parenteral nutrition (TPN). Liver failure often results after long-term use of TPN, hence the need for a life-saving combined liver and intestine transplant in some patients. But as a preventive measure against the likelihood of liver failure and to improve the quality of life for patients who still have the option of TPN, a transplant of the small intestine is a more cost-effective alternative.
According to 1992 Medicare figures, TPN's annual price tag is $150,000, a conservative figure that does not include associated costs for medical equipment, nursing home-health care and frequent hospitalizations. Today's costs are believed to be much higher.
"Based on these data, intestinal transplantation becomes cost-effective by the second year after transplantation," reported Dr. Abu-Elmagd, who noted the costs to perform the three types of transplants at their center have markedly declined.
The UPMC has performed about 40 percent of all the intestinal transplants performed worldwide and reported to the International Intestinal Transplant Registry.