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P336 Intestinal transplantation for Crohn's Disease: The Cambridge experience since 2008

T. Ambrose*, L. Sharkey, J. Louis-Auguste, C. Rutter, R. Prasad, D. Massey, N. Russell, A. Butler, J. Woodward, S. Middleton

Summary of cases

Case1234567
GenderMaleFemaleFemaleFemaleFemaleMaleMale
Age at transplant35643752616050
Montreal classificationA1L3B3pA2L3B3pA1L3B2A2L3B3pA2L3B3A1L3B2A2L3B2
Anatomy from DJF50cm to end jejunostomy, and left colon (not in continuity)60cm to colon with end colostomy120cm to full colon20cm to jejunostomy100cm to ileostomy120cm to ileostomy70cm to colon with end colostomy
Years from diagnosis to commencing PS18261110344213
Years on PS pre-transplant313102210311
IndicationShort gut with IFALDLoss of vascular accessLoss of vascular accessShort gut with IFALDEnd stage renal failure; SB/colon needed for enteral fluid managementNAFLD cirrhosis with short gutRecurrent line infections
Organs transplantedSt, SB, liver, pancreasSB1) SB; 2) SB, kidneySt, SB, liver, pancreas, kidneySB, colon, kidneySB, liver, pancreasSB, colon, pancreas
Year of transplant20082010Both 20102011201320132014

Key to table: DJF = duodenojejunal flexure, NAFLD = non-alcoholic fatty liver disease, SB = small bowel, St = stomach Case 3: 2nd transplant performed for rejection (non-compliance with immunosuppression)

Cambridge University Hospitals NHS Foundation Trust, Department of Intestinal Transplantation, Cambridge, United Kingdom

Background

Intestinal transplantation (either alone or part of a cluster of organs) is indicated in patients with Crohn's disease and intestinal failure who develop complications associated with parenteral support (PS) including recurrent line sepsis, loss of vascular access, or intestinal-failure associated liver disease (IFALD). Some may require other organs (e.g. liver, kidney) which cannot be undertaken without simultaneous bowel transplantation.

Methods

We retrospectively reviewed case notes for all patients with Crohn's disease who were transplanted at our institution between January 2008 and August 2014.

Results

Pre-transplant, median Body Mass Index (BMI) was 21.0kg/m2 (range 17.8–23.5), median handgrip strength 62% (range 22–78%), and 3 patients had low bone density (2 osteoporosis, 1 osteopenia). At latest follow up BMI had improved to median 22.0kg/m2 (range 19.4–29.9). Assessment of handgrip strength in those at least 1 year post-transplant showed improvement (n=3) as did bone density (n=2). Pre-operatively, 6 patients had developed complications of PS but currently no patients require ongoing PS. 6 patients are alive at a median 30.5 months post-transplant (range 7–76). Case 4 died at 15 months from invasive fungal infection and cerebellar haemorrhage. Overall 5-year survival following intestinal transplantation at our institution (41 patients) is 64% (100% isolated small bowel, 65% modified multivisceral, 58% multivisceral).

Conclusion

All patients had ileocolonic, stricturing and/or fistulising disease and were diagnosed at a median age of 17 years. They commenced PS at a median of 18 years from diagnosis and continued for a median 10 years before transplantation. Survival following intestinal transplantation in our cohort is good. Nutritional status (assessed by BMI, bone density, and handgrip strength) of these patients improved following transplant. No histological recurrence of Crohn's disease was seen in 229 specimens over 213 patient months of follow up.