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  • Review Article
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The concept of gut rehabilitation and the future of visceral transplantation

Nature Reviews Gastroenterology & Hepatology volume 12, pages 108–120 (2015)Cite this article

Subjects

Key Points

  • Since the clinical introduction of intestinal transplantation in the 1990s, the evolving field of gut rehabilitation has witnessed advances in both medical and surgical management

  • Ethanol lock and omega-3 lipid formulation were introduced to enhance efficacy of total parenteral nutrition therapy

  • Enterocyte growth factors (including growth hormones and teduglutide (an analogue of glucagon-like peptide 2) have been used to enhance gut adaptation and achieve nutritional autonomy

  • Autologous surgical reconstruction and bowel lengthening have been increasingly utilized for patients with short-bowel syndrome and complex abdominal pathology

  • Intestinal transplantation has evolved with improved survival outcomes owing to innovative surgical techniques, immunosuppressive strategies and postoperative management

  • A novel management algorithm is proposed to optimize patient care through an integrated multidisciplinary approach

Abstract

In the 1990s, the introduction of visceral transplantation fuelled interest in other innovative therapeutic modalities for gut rehabilitation. Ethanol lock and omega-3 lipid formulations were introduced to reduce the risks associated with total parenteral nutrition (TPN). Autologous surgical reconstruction and bowel lengthening have been increasingly utilized for patients with complex abdominal pathology and short-bowel syndrome. Glucagon-like peptide 2 analogue, along with growth hormone, are available to enhance gut adaptation and achieve nutritional autonomy. Intestinal transplantation continues to be limited to a rescue therapy for patients with TPN failure. Nonetheless, survival outcomes have substantially improved with advances in surgical techniques, immunosuppressive strategies and postoperative management. Furthermore, both nutritional autonomy and quality of life can be restored for more than two decades in most survivors, with social support and inclusion of the liver being favourable predictors of long-term outcome. One of the current challenges is the discovery of biomarkers to diagnose early rejection and further improve liver-free allograft survival. Currently, chronic rejection with persistence of preformed and development of de novo donor-specific antibodies is a major barrier to long-term graft function; this issue might be overcome with innovative immunological and tolerogenic strategies. This Review discusses advances in the field of gut rehabilitation, including intestinal transplantation, and highlights future challenges. With the growing interest in individualized medicine and the value of health care, a novel management algorithm is proposed to optimize patient care through an integrated multidisciplinary team approach.

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Figure 1: Main types of visceral transplantation.
Figure 2: Bowel lengthening procedures for short-bowel syndrome.
Figure 3: Patient and graft survival.
Figure 4: Nutritional autonomy after visceral transplantation.
Figure 5
Figure 6: Donor-derived multilineage complete chimerism in a female recipient who received a multivisceral graft from a male donor.
Figure 7: A female patient who received a successful cluster transplant (liver, duodenum and pancreas) in 1988.
Figure 8

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  1. Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA

    Kareem Abu-Elmagd

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Abu-Elmagd, K. The concept of gut rehabilitation and the future of visceral transplantation. Nat Rev Gastroenterol Hepatol 12, 108–120 (2015). https://doi.org/10.1038/nrgastro.2014.216

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