Intestinal Transplant: Overview & Australian Perspective ( )
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1 Intestinal Transplant: Overview & Australian Perspective ( ) Dr Peter De Cruz On behalf of the Austin & RCH Intestinal Transplant Team
2 Intestinal Transplantation = Trying to Fix Train-Wrecks
3 If only fixing train-wrecks were easy
4 The Magnitude of the Carnage pre-tx
5 The Patient Immediately Post-Tx
6 Five Years Post-Tx Train wreck Fixed
7 Intestinal Transplant Overview Who we transplant & who is involved? Which organs we transplant? What sort of service we provide? Barriers to intestinal transplant in Australia Possible solutions for the Future How & When to refer for transplant?
8 Who do we transplant & who is involved?
9 Who do we Transplant? Patients with TPN failure: Impending/Overt liver failure due to TPN-induced liver injury Thrombosis of two or more central veins (IJ,SC, SVC, IVC) Two or more episodes/year of catheter related sepsis hospital Single episode of line-related fungaemia, septic shock, ARDS Frequent episodes of severe dehydration despite IV fluids + TPN
10 Prerequisites for Intestinal Tx in Australia Irreversible intestinal failure + TPN Failure OR Complex abdominal visceral pathology (Desmoids)
11 Mortality in Intestinal Failure Pironi et al Gut % mortality in world s best Intestinal Failure Centres Cause of death: < 2 years of TPN = Primary disease >2 years of TPN = Complications related to PN
12 Overall Actuarial Survival Post Intestinal Tx Grant et al Am J Trans 2015 Intestinal Transplant is indicated when anticipated 5 year survival is <57 %
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15 History of Intestinal Transplantation 1 st human bowel transplant Boston 1964 (not reported) 1 st human multivisceral transplant (Starzl) in Pittsburgh, yo girl: died immediately post-op from haemorrhage Advent of tacrolimus st successful (enteral autonomy) liver-intestinal Tx (Grant) 1990 ~3000 ITx conducted since centres worldwide Nth America accounts for 76% of world activity ~40 active centres
16 Intestinal Transplant in Australia Adult and Paediatric intestinal transplant (ITx) program developed in Australia in 2009 Built upon success of Victorian Liver Transplant Unit Established in liver transplants Pre 2009 IF pts either died or sent overseas for ITx
17 Intestinal Transplant in Australia New hybrid program built upon best-practice Staff training and up-skilling at high-volume IF & ITx centres Surgeons: Pittsburgh USA, Birmingham UK Physicians: Pittsburgh, Birmingham, Cambridge, St Mark s, Salford UK Dietitian: Pittsburgh USA Pathologist: Pittsburgh USA, Birmingham UK Nursing staff: Pittsburgh USA Australia s first ITx in July 2010 Australia s first combined ITx and Kidney transplant October 2015
18 Intestinal Rehabilitation: How do we achieve nutritional autonomy? A Multidisciplinary Approach is Essential Photo from the Trout in Oxford
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21 An Intestinal Transplant Program for Australia
22 Australia s 1 st ITX - BC 33yo male Chronic Intestinal Pseudo-obstruction Constipation Large B obstruction Bowel obstruction Bilat hydronephrosis PN IFALD TX Pyeloplasty Laparotomy Colostomy Recto sigmoid Multiple SB resection Total colectomy J Pouch Duodenal bypass SB resection jejunostomy Right nephrectomy Cholecystectomy Infarction R liver AV fistula AV Fistula take down Total laparotomies 17 Outpatient visits 120 / 2 yrs
23 Pre Tx State BC PN related complications: Recurrent line sepsis»multiple bacterial + candidal Thromboses Patent: SVC, IVC, RIJ, RSCV Left saphenous vein thigh AV fistula Venous obstruction left leg IFALD
24 Pre Tx State BC Residual gut 90 cm jejunum? Recurrent admissions Dehydration Stomal output 3 10 L PN/IVT > 6 L / night Q of L
25 g Intestinal Failure Associated Liver Disease Jun-07 Sep-07 Albumin Bilirubin Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 Jun μm 100 ol/ 50 L 0
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28 50 cm
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30 Pre-transplant Unemployed >120 hospital appointments in 2 years TPN 14h/d Pension for 17 yr 17 laparotomies Complications Post-transplant Enteral autonomy Off pension Working full-time Paying taxes Living in rural Victoria
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32 Which organs do we transplant?
33 Isolated Intestine Tx Liver-Intestine Tx Multivisceral Tx (Intestine, Liver ± Stomach ± Pancreas ± Kidney) Garg et al. J Gastroenterol Hepatol 2011
34 What sort of service do we provide?
35 Austin & RCH Intestinal Transplant Program Assessment of Suitability for Intestinal/Multivisceral Transplant Advice regarding Intestinal Rehabilitation Pre-Transplant Work-up Intestinal/Multivisceral Transplant Post-Transplant Management and Follow-up
36 Intestinal Rehab + Tx The Australian Experience ( ) Chapman B et al Transpl Proceedings 2015 AIM To analyse the outcomes of patients treated by our service over the past 5 years
37 Methods Retrospective audit Data collection: Patient demographics Underlying disease Nutrition support TPN complications Transplant program status
38 Results: Demographics 60 PATIENTS IF Aetiology: SBS Dysmotility
39 Results: Location
40 Results: Nutrition Support
41 Results: TPN-complications
42 Results: Patient Outcomes
43 Results: Current ITx Program Status
44 What are the barriers to Intestinal Transplant in Australia?
45 Barriers to ITx in Australia Donor shortage Median donor age 58 years Funding arrangement/ Tyranny of Distance Lack of consensus between State Governments 56% of pt s referred from interstate High rate DSA Highly HLA-sensitised Increases waiting periods Complex late-stage patients High rate of co-morbid medical conditions
46
47 What are the possible solutions?
48 Possible Solutions Establishment of Organ and Tissue Authority (2009) Application for National Centre Funding Innovative strategies to reduce antibody burden Novel desensitization strategies Program promotion & links with other Australian/NZ HPN centres & alignment of activity with AusPEN HPN registry Development of ASIT Australian Intestinal Transplant Forum Link with ISIT International Small Intestinal Transplant Forum
49 How & when to refer for Intestinal Transplant consideration?
50 When to refer for Intestinal Transplantation If in doubt Ask Irreversible Intestinal Failure (TPN dependent) +TPN failure = 1 of: Impending/Overt Intestinal Failure Associated Liver Disease (IFALD) Recurrent Catheter Related Blood Stream Infections (Line sepsis) Central Venous Thrombosis (IJ, SC, SVC,IVC) Complex abdominal pathology Desmoid tumours
51 Referral Process Phone: Fax :
52 Conclusion ITx is now an available and life-saving option for patients with IF in Australia and NZ Pt characteristics and indications for ITx in the Australian pt group are consistent with international literature Early referral to specialist centre is imperative Ongoing challenges to overcome
53 Acknowledgements Austin/RCH ITx Team Adam Testro Brooke Chapman Kate Hamilton Winita Hardikar Bob Jones & Surgical Team Julie Lokan & Path Team ITX Program Development Darius Mirza Geoff Bond AusPEN Ibolya Nyulasi Sharon Carey Julie Bines David Russell International Mentors/Collaborators Simon Gabe, Mia Small, Alison Culkin Steven Middleton Jeremy Woodward Kareem Abu-Elmagd, Laura Materese Girish Gupte Guilherme Costa Kishore Iyer
54 The history of medicine is that what was inconceivable yesterday, and barely achievable today, often becomes routine tomorrow. Thomas E. Starzl
55 The Future of Intestinal Transplant in Australia
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