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Objective: To report our experience with the combination of radical surgical excision and intestinal transplantation in patients with recurrent pseudomyxoma peritonei (PMP) not amenable to further cytoreductive surgery (CRS). Background: CRS and heated intraoperative peritoneal chemotherapy are effective treatments for many patients with PMP. In patients with extensive small bowel involvement or nonresectable recurrence, disease progression results in small bowel obstruction, nutritional failure, and fistulation, with resulting abdominal wall failure. Methods: Between 2013 and 2022, patients with PMP who had a nutritional failure and were not suitable for further CRS underwent radical debulking and intestinal transplantation at our centre. Results: Fifteen patients underwent radical exenteration of affected intra-abdominal organs and transplantation adapted according to the individual case. Eight patients had isolated small bowel transplantation and 7 patients underwent modified multivisceral transplantation. In addition, in 7 patients with significant abdominal wall tumor involvement, a full-thickness vascularized abdominal wall transplant was performed. Two of the 15 patients died within 90 days due to surgically related complications. Actuarial 1-year and 5-year patient survivals were 79% and 55%, respectively. The majority of the patients had significant improvement in quality of life after transplantation. Progression/recurrence of disease was detected in 91% of patients followed up for more than 6 months. Conclusion: Intestinal/multivisceral transplantation enables a more radical approach to the management of PMP than can be achieved with conventional surgical methods and is suitable for patients for whom there is no conventional surgical option. This complex surgical intervention requires the combined skills of both peritoneal malignancy and transplant teams. [ABSTRACT FROM AUTHOR]

Background: Recombinant human growth hormone (rhGH) is widely used to treat growth retardation in children. We aimed to examine the effect of rhGH therapy on growth and its impact on allograft function in children with growth retardation after intestinal transplant (IT). Methods: We retrospectively included children younger than 19 years who had received an IT with or without the liver, were diagnosed with growth retardation, and have received rhGH between January 2010 and January 2021. Changes in the patient's anthropometric parameters between baseline and various time points were compared using the paired t‐test or Wilcoxon signed‐rank test, as appropriate. Results: Seven patients (all males and prepubertal) received rhGH for the median duration of 2.3 years. The median age at rhGH start was 9.5 years. The median growth velocity z‐score improved from −0.95 before treatment to 2.3 (p =.04) and 1.9 (p =.06) after 1 and 2 years of treatment, respectively. The median height‐for‐age z‐score significantly improved from −3.4 at rhGH start to −1.3 (p =.005) at rhGH stop and remained above baseline at the last visit (−2.4, p =.002). The change in the first‐year growth velocity was negatively correlated with the change in the second‐year growth velocity (r = −.90, p =.04). No serious adverse effects or worsening allograft function were observed. Conclusions: Severely growth retarded children after IT could benefit from rhGH treatment. A larger, longitudinal study would be warranted to monitor the long‐term effect and safety of rhGH and examine predictors of growth response to rhGH therapy in these pediatric IT recipients. [ABSTRACT FROM AUTHOR]

Small bowel transplants are performed all over the world with acceptable success rates. Although there are isolated reports of small bowel transplants from India, a robust intestinal transplant programme similar to western countries is lacking. Our aim is to share our experience to build up on the evolving field of small bowel transplants in India. Deceased donor small bowel transplant was performed for three patients with intestinal failure, two for short gut syndrome following surgery and one for visceral myopathy. All were on preoperative total parenteral nutrition for varying periods of time (6 to 13 months). There were multiple episodes of line sepsis in all patients. Post-transplant, all received induction immunosuppression with anti-thymocyte globulin (first two patients) or alemtuzumab (3rd patient). All had systemic venous drainage and stoma. Protocol weekly intestinal biopsies were done in all patients. All died in hospital at 24, 12 and 28 days following surgery. Biopsy-proven rejection was observed in only patient who had received ABO-compatible non-identical graft (O to A). This patient subsequently developed vascular thrombosis necessitating explant of the graft. Sepsis due to multidrug resistant bacteria was the reason for mortality in the remaining two patients. Despite the absence of technical complications, successful small bowel transplant seems to be an elusive entity for the Indian transplant community. [ABSTRACT FROM AUTHOR]

• Small bowel resection following total ischaemia is feasible post-peritonectomy. • VAC dressing and skin grafting was beneficial following wound dehiscence. • Small bowel transplant is a potential means to avoid complications of long-term TPN. This report presents the rare case of a patient with complete bowel ischaemia following parastomal hernia, leading to total bowel resection, with consideration of post-operative complications and wound management. A 59 year old female was found to have complete small bowel ischaemia on exploratory laparatomy, on a background of recurrent appendiceal adenomucinosis, for which she had received previous peritonectomy, cholecystectomy, total colectomy, and partial small bowel resection. The patient was managed with total enterectomy and post-operative total parenteral nutrition. Total enterectomy represents a significant challenge in the postperitonectomy setting, including consideration of wound management with the empty abdomen, and the potential of small bowel transplant in management. Resection of the small bowel following total small bowel ischaemia is feasible in the post-peritonectomy setting, given appropriate post-operative care and wound management. However, long-term survival remains challenging, especially without small bowel transplant. [ABSTRACT FROM AUTHOR]

Background: Small bowel transplant (SBT) is a surgical procedure that may be used in patients with pathology resulting in severe intestinal failure resistant to conventional forms of surgical and nonsurgical treatment. Intestinal failure is defined as the failure of enterocytes to absorb sufficient macronutrients, water, and/or electrolytes to sustain homeostasis and/or promote growth. With the advancement of surgical techniques and advancements in perioperative transplant management, SBT has become an increasingly common treatment for intestinal failure, with survival rates for SBT comparable to those for other solid organ transplants. Materials and methods: This review provides background on SBT, its variations, and the associated preoperative and postoperative imaging studies with regard to surgical planning and anticipated complications. Results and conclusions: With the increasing use of SBT, radiologists will be expected to be familiar with the diagnostic studies and available endovascular interventions associated with this procedure. [ABSTRACT FROM AUTHOR]

In this study, we sought to determine the incidence of post-transplant complications including acute cellular rejection ( ACR), infection, and post-transplant lymphoproliferative disease ( PTLD) in mucosal allograft biopsies in patients with small bowel transplant at our institution. We retrospectively reviewed pathology reports from 5675 small bowel allograft biopsies from 99 patients and analyzed the following: indications for biopsy, frequency and grade of ACR, the presence of infectious agents, results of workup for potential PTLD, results of C4d immunohistochemistry ( IHC), features of chronic mucosal injury, and findings in concurrent native bowel biopsies. Findings from 42 allograft resection specimens were also correlated with prior biopsy findings. Indeterminate, mild, moderate, and severe ACR were seen in 276 (4.9%), 409 (7.2%), 100 (1.8%), and 207 (3.6%) of biopsies, respectively. Although ACR may show histologic overlap with mycophenolate mofetil toxicity, we found the analysis of concurrent native bowel biopsies to be helpful in this distinction. Adenovirus was the most common infectious agent seen (11%), and we routinely performed adenovirus IHC on biopsies. Eighteen patients (18%) developed PTLD, 83% of which were EBV associated, but only 28% of PTLD cases were diagnosed on mucosal allograft biopsies. C4d IHC did not correlate with the presence of donor-specific antibodies in limited cases. [ABSTRACT FROM AUTHOR]

Background & Aims Treatment of Crohn’s disease (CD) may require multiple bowel resections that lead to short bowel syndrome. Intestinal transplantation is an effective treatment for short bowel syndrome, but limited data are available on long-term outcomes in CD. We aimed to characterize the long-term risk of rejection, graft failure, and death among patients with CD after intestinal transplantation, and compare their outcomes with those of patients without CD. Methods We performed a retrospective study of adults in the Scientific Registry of Transplant Recipients who received intestinal transplants in the United States from May 1990 through June 2014. Outcomes data were collected at 3 months, 6 months, 1 year, and every year after the procedure. We compared risks of rejection at 1 year after transplantation between patients with and without CD using the chi-square test and logistic regression. Longitudinal risks of graft failure and death were compared between patients with and without CD using the Kaplan-Meier method and Cox proportional hazards. Multivariable analyses adjusted for recipient, donor, and institutional characteristics. Results Of 1115 cases of intestinal transplantation, 142 were performed for CD and 973 for non-CD indications. One year after the procedure, the transplant was rejected in 36.9% of patients with CD and 33.3% of patients without CD ( P = .48). For patients with CD, the actuarial risk of graft failure at 1, 5, and 10 years after intestinal transplantation was 18.6%, 38.7%, and 49.2%; the risk of death was 22.5%, 50.3%, and 59.7%, respectively. The risk of graft failure was greater for patients with CD (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.03–2.13; P = .04), but patients with versus without CD had similar risks of death (aHR, 0.88; 95% CI, 0.64–1.20; P = .41). In subgroup analyses, the risk of graft failure was increased among patients with CD undergoing transplantation between 1990 and 2000 (aHR, 3.49; 95% CI, 1.23–9.92; P = .02), but not after 2000 (aHR, 1.37; 95% CI, 0.92–2.04; P = .12). Conclusions In an analysis of patients who received intestinal transplants, the risks of graft rejection or death were similar between patients with versus without CD. Before year 2000, patients with CD had an increased risk of graft failure, but not thereafter. Changes in posttransplant immunosuppression around the same time might be analyzed to learn more about the mechanisms and management strategies to reduce graft failure in CD. [ABSTRACT FROM AUTHOR]

Small bowel transplantation from SARS-CoV-2 respiratory PCR positive donors: Is it safe? Hence, as organ transplantation continues globally, it is crucial to minimize the risk of donor derived severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in SOT recipients. Keywords: COVID-19; donor; small bowel transplant EN COVID-19 donor small bowel transplant 1 2 2 12/27/21 20211201 NES 211201 Dear Editor, We read with great interest the recently published article titled "The pandemic provides a pathway: What we know and what we need to know about COVID positive donors" by Eichenberger et al.1 The coronavirus disease of 2019 (COVID-19) pandemic has significantly affected the solid organ transplant (SOT) community. [Extracted from the article]

Abstract: Intestinal transplant is now considered a viable option for children with irreversible intestinal failure suffering life limiting complications of parenteral nutrition. Identifying the possible candidates and referring them early to the transplant centre allows consideration of transplantation before the clinical situation deteriorates, and ensures the establishment of communication pathways between the family, transplant centre and the patient's local team. This encourages optimal care both before and after transplantation, and has been shown to improve long-term outcome. There are different types of intestinal transplants that may be performed according to the indication. With improvements in surgical techniques, immunosuppression, early identification of rejection and good communication between professionals and families, outcomes for patients undergoing these procedures continue to improve. [Copyright &y& Elsevier]

Small bowel transplants are a challenging procedure. Simon Turley presents a case study highlighting the considerable challenges faced by stoma care nurses in the management of these patients. The case study presents a UK's first in transplant surgery with a unique twist - a small bowel transplant and a full-thickness abdominal wall replacement. A Bishop-Koop ileostomy was formed, but proved challenging to manage because of its extremely low position incorporated within the lower abdominal suture line; dehiscence of the upper abdominal wound added another care dimension. Collaborative working enabled good patient care, despite a poor outcome. [ABSTRACT FROM AUTHOR]

No therapeutic agent has yet been established as the definitive therapy for adenovirus infections. We describe the clinical experience of 13 immunocompromised patients who received CMX001 (hexadecyloxypropyl cidofovir), an orally bioavailable lipid conjugate of cidofovir, for adenovirus disease. We retrospectively analyzed 13 patients with adenovirus disease and viremia treated with CMX001; data were available for ≥4 weeks after initiation of CMX001 therapy. Virologic response (VR) was defined as a 99% drop from baseline or undetectable adenovirus DNA in serum. The median age of the group was 6 years (range, 0.92-66 years). One patient had severe combined immunodeficiency, 1 patient was a small bowel transplant recipient, and 11 were allogeneic stem cell transplant recipients. Adenovirus disease was diagnosed at a median of 75 days (range, 15-720 days) after transplantation. All patients received i.v. cidofovir for a median of 21 days (range, 5-90 days) before CMX001 therapy. The median absolute lymphocyte count at CMX001 initiation was 300 cells/μL (range, 7-1500 cells/μL). Eight patients (61.5%) had a ≥1 log10 drop in viral load after the first week of therapy. By week 8, 9 patients (69.2%) demonstrated a VR, with a median time to achieve VR of 7 days (range, 3-35 days). The change in absolute lymphocyte count was inversely correlated with the change in log10 viral load only at week 6 (r = −0.74; P = .03). Patients with VR had longer survival than those without VR (median 196 days versus 54.5 days; P = .04). No serious adverse events were attributed to CMX001 during therapy. CMX001 may be a promising therapeutic option for the treatment of severe adenovirus disease in immunocompromised patients. [Copyright &y& Elsevier]

Pasternak BA, Collins MH, Tiao GM, Rudolph JA, Alonso MH, Ryckman FC, Kocoshis SA. Anatomic and histologic variability of epithelial apoptosis in small bowel transplants. Pediatr Transplantation 2010: 14: 71–76. © 2009 Wiley Periodicals, Inc. Surveillance ileoscopies are performed regularly immediately post-transplantation to prevent allograft rejection. We investigated whether variability in apoptosis exists between proximal and distal intestinal limbs of double-barreled ileostomies, and if detection varies according to number of biopsies taken and sections prepared for evaluation. We retrospectively analyzed endoscopy/pathology reports of patients who underwent simultaneous proximal and distal ileoscopies during surveillance. We re-reviewed three sections of selected biopsies for the presence of apoptotic bodies and viral inclusions. Seven patients underwent 26 endoscopies in which both distal and proximal limbs were investigated simultaneously. Apoptosis was identified in each limb simultaneously in 21/26 cases (81%). Of the discrepant results, 3/5 (60%) revealed apoptosis in the proximal limb with normal distal limb and 2/5 (40%) had apoptotic bodies identified in the distal limb and normal proximal biopsies. Re-reviewing discrepant biopsies, two patients had at least one piece of mucosa without apoptosis and apoptotic bodies were seen in only 47% of sections. Histologic variability exists between proximal and distal limbs of double-barreled ileostomies and detection of apoptosis increases with number of pieces obtained and sections examined. Investigating both limbs with adequate sample size and rigorous processing may have clinical implications. [ABSTRACT FROM AUTHOR]

F. Gruz, C. Fuxman, A. Errea, M. Tokumoto, A. Fernandez, J. Velasquez, C. Nagel, A. Ruf, E. Mauriño, F. Nachman, M. Rumbo, G. Gondolesi. Isospora belli infection after isolated intestinal transplant. Transpl Infect Dis 2010: 12: 69–72. All rights reserved Isospora belli is a protozoan that only affects humans, after ingestion of Isospora's oocysts. Immunocompetent patients usually do not develop the infection. Immunocompromised hosts may have profuse diarrhea with other gastrointestinal symptoms. Treatment is based on trimethoprim-sulfamethoxazole. In 2006 we performed an isolated intestinal transplantation in a patient with ultra-short bowel syndrome. Neither rejection nor clinical problems occurred after transplant, but signs of intestinal inflammation were seen in every protocol biopsy starting at the first month post transplant. Almost 3 months after the procedure, the patient was re-admitted with diarrhea. I. belli infection was diagnosed by detection of the oocysts in stool samples. Antibiotic treatment with trimethoprim–sulfamethoxazole was initiated with excellent outcome and without relapses. To the best of our knowledge, this is the first case of isosporosis in a small bowel recipient. [ABSTRACT FROM AUTHOR]

Abstract: Herpes simplex virus (HSV) has been a rare cause of gastrointestinal (GI) infection, especially in immunocompromised patients. A variety of GI sites may be involved; however, only three reported cases of HSV colitis have been documented in the literature. To our knowledge, this is the first report of HSV colitis in a small bowel transplant recipient. [ABSTRACT FROM AUTHOR]

Clinical small bowel transplantation (SBTx) has been associated with a high rate of infectious complications. Laparotomy, preservation injury, abnormal motility, lymphatic disruption, aberrant systemic venous drainage, rejection and antibiotic therapy could all be implicated in the etiology of these complications. In addition to the underlying disease, total parental nutrition could determine infections and liver impairment. Recently, standardized techniques for segmental living related SBTx (LR-SBTx) have been developed. This technique allows reduction of some of these factors, thus resulting in a reduced incidence of infections. We report the infectious complications observed in 3 patients with short bowel syndrome treated with LR-SBTx at our institution. A segment of 180–200 cm of ileum was transplanted with a neglectably short cold ischemia time (CIT). The donor bowel was decontaminated. Oral tacrolimus, prednisone and IV induction with ATG were used for immunosuppression. Blood, stool, urine, sputum and peritoneal fluids were collected and cultured as a routine surveillance. All recipients are alive with a current follow-up time up to 21 months. No bacterial infections were observed during the post-transplant period. One patient developed cytomegalovirus (CMV) enteritis 4 months after LR-SBTx and was treated successfully with IV ganciclovir. In our limited experience, LR-SBTx is associated with a low infection rate. This could be due to optimal graft decontamination, short CIT and to the reduced incidence of rejection and lower immunosuppression used in this immunologically well-matched combination. [ABSTRACT FROM AUTHOR]