Download PDF
Allgemein- und Viszeralchirurgie up2date 2017; 11(06): 585-602
DOI: 10.1055/s-0043-109355
Viszerale Transplantationen
Georg Thieme Verlag KG Stuttgart · New York

Intestinales Versagen und Darmtransplantation

Manuel Braun
,
Alfred Königsrainer
,
Silvio Nadalin
Further Information

Publication History

Publication Date:
30 November 2017 (online)

Also available at
    Permissions and Reprints All articles of this category

Das Darmversagen ist ein ernst zu nehmendes Krankheitsbild; etwa die Hälfte der Betroffenen sind Kinder. Dieser Artikel soll einen Überblick über die Definition, Klassifikation, Epidemiologie und Ätiologie des Darmversagens bieten mit einem kurzen Einblick in konservative Therapiemöglichkeiten. Einen Schwerpunkt bildet die chirurgische Therapie und insbesondere die Darmtransplantation als Ultima Ratio.
Kernaussagen

  • Ziel der Therapie des intestinalen Versagens (IV) ist die Adaptation und Rehabilitation, um die vielfältigen Komplikationen zu vermeiden oder zumindest zu verringern.

  • Die Standardtherapie des intestinalen Versagens besteht aus einer im interdisziplinären Setting gestalteten Optimierung der enteralen und parenteralen Ernährung und Elongationsverfahren.

  • Wenn die oben genannten Optionen erschöpft sind, ist eine Darmtransplantation (DT) allein oder als kombinierte Leber-Darm-Transplantation (LDT) oder sogar Multiviszeraltransplantion mit/ohne Leber (MVT) indiziert.

  • Die Darmtransplantation (DT) in ihren verschiedenen Varianten ist mittlerweile ein standardisiertes Verfahren, welches jedoch unbedingt in einem hochspezialisierten Umfeld durchgeführt werden sollte.

  • Aufgrund der nach wie vor hohen Abstoßungsrate ist das Langzeitüberleben der Transplantate begrenzt.

Schlüsselwörter

Darmversagen - Darmtransplantation - Darmrehabilitation - Kurzdarmsyndrom (KDS) - parenterale Ernährung - enterale Ernährung - Darmverlängerung
 

  • Literatur

  • 1 von Websky MW, Liermann U, Buchholz BM. et al. Das Kurzdarmsyndrom in Deutschland. Chirurg 2014; 85: 433-439 doi:10.1007/s00104-013-2605-x
    PubMedGoogle Scholar
  • 2 Lamprecht G, Pape UF, Witte M. et al. S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin e. V. in Zusammenarbeit mit der AKE, der GESKES und der DGVS. Aktuelle Ernährungsmed 2014; 39: e57-e71 doi:10.1055/s-0034-1369922
    Google Scholar
  • 3 Bharadwaj S, Tandon P, Gohel TD. et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf) 26.01.2017; pii:gow045 doi:10.1093/gastro/gow045
    CrossrefPubMedGoogle Scholar
  • 4 Pironi L, Arends J, Baxter J. et al. ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults. Clin Nutr 2015; 34: 171-180 doi:10.1016/j.clnu.2014.08.017
    CrossrefPubMedGoogle Scholar
  • 5 Abu-Elmagd KM, Costa G, McMichael D. et al. Autologous reconstruction and visceral transplantation for management of patients with gut failure after bariatric surgery: 20 years of experience. Ann Surg 2015; 262: 586-601 doi:10.1097/SLA.0000000000001440
    PubMedGoogle Scholar
  • 6 Fishbein TM. Intestinal transplantation. New Engl J Med 2009; 361: 998-1008 doi:10.1056/NEJMra0804605
    CrossrefPubMedGoogle Scholar
  • 7 Grant D, Abu-Elmagd K, Mazariegos G. et al. Intestinal transplant registry report: global activity and trends. Am J Transplant 2015; 15: 210-219 doi:10.1111/ajt.12979
    CrossrefPubMedGoogle Scholar
  • 8 Pironi L, Arends J, Bozzetti F. et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35 (02) 247-307
    CrossrefPubMedGoogle Scholar
  • 9 Iyer KR, Kunecki M, Boullata JI. et al. Independence from parenteral nutrition and intravenous fluid support during treatment with teduglutide among patients with intestinal failure associated with short bowel syndrome. JPEN J Parenter Enteral Nutr 2017; 41: 946-951
    CrossrefPubMedGoogle Scholar
  • 10 Jeppesen PB, Gilroy R, Pertkiewicz M. et al. Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome. Gut 2011; 60: 902-914 doi:10.1136/gut.2010.218271
    CrossrefPubMedGoogle Scholar
  • 11 Harrison E, Allan P, Ramu A. et al. Management of intestinal failure in inflammatory bowel disease: small intestinal transplantation or home parenteral nutrition?. World J Gastroenterol 2014; 20: 3153-3163
    CrossrefPubMedGoogle Scholar
  • 12 Lacaille F, Gupte G, Colomb V. et al. Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation. J Pediatr Gastroenterol Nutr 2015; 60: 272-283
    CrossrefPubMedGoogle Scholar
  • 13 Sudan D. The current state of intestine transplantation: indications, techniques, outcomes and challenges. Am J Transplant 2014; 14: 1976-1984 doi:10.1111/ajt.12812
    CrossrefPubMedGoogle Scholar
  • 14 Grant JP. Anatomy and physiology of venous system vascular access: implications. JPEN J Parenter Enteral Nutr 2006; 30 (Suppl) S7-S12
    CrossrefPubMedGoogle Scholar
  • 15 Denny jr. DF. Venous access salvage techniques. Tech Vasc Interv Radiol 2011; 4: 225-232
    Google Scholar
  • 16 Schaffler H, Daraban AM, Roggenbrod S. et al. Characterization of refractory port-related blood stream infections in intestinal failure patients on parenteral nutrition. Z Gastroenterol 2011; 49: 335-339
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Versleijen MW, Huisman-de Waal GJ, Kock MC. et al. Arteriovenous fistulae as an alternative to central venous catheters for delivery of long-term home parenteral nutrition. Gastroenterology 2009; 136: 1577-1584
    CrossrefPubMedGoogle Scholar
  • 18 Christensen LD, Holst M, Bech LF. et al. Comparison of complications associated with peripherally inserted central catheters and Hickman catheters in patients with intestinal failure receiving home parenteral nutrition. Six-year follow up study. Clin Nutr 2016; 35: 912-917
    CrossrefPubMedGoogle Scholar
  • 19 Piper HG, Wales PW. Prevention of catheter-related blood stream infections in children with intestinal failure. Curr Opin Gastroenterol 2013; 29: 1-6
    CrossrefPubMedGoogle Scholar
  • 20 Ardura MI, Lewis J, Tansmore JL. et al. Central catheter-associated bloodstream infection reduction with ethanol lock prophylaxis in pediatric intestinal failure: broadening quality improvement initiatives from hospital to home. JAMA Pediatr 2015; 169: 324-331
    CrossrefPubMedGoogle Scholar
  • 21 Olthof ED, Nijland R, Gulich AF. et al. Microbiocidal effects of various taurolidine containing catheter lock solutions. Clin Nutr 2015; 34: 309-314
    CrossrefPubMedGoogle Scholar
  • 22 Olthof ED, Versleijen MW, Huisman-de Waal G. et al. Taurolidine lock is superior to heparin lock in the prevention of catheter related bloodstream infections and occlusions. PLoS One 2014; DOI: 10.1371/journal.pone.0111216.
    CrossrefPubMedGoogle Scholar
  • 23 Selvaggi G, Gyamfi A, Kato T. et al. Analysis of vascular access in intestinal transplant recipients using the Miami classification from the VIIIth International Small Bowel Transplant Symposium. Transplantation 2005; 27: 1639-1643
    Google Scholar
  • 24 Rege A. The surgical approach to short bowel syndrome – autologous reconstruction versus transplantation. Viszeralmedizin 2014; 30 (03) 179-189 doi:10.1159/000363589
    Google Scholar
  • 25 Bianchi A. Intestinal loop lengthening – a technique for increasing small intestinal length. J Pediatr Surg 1980; 15: 145-151
    CrossrefPubMedGoogle Scholar
  • 26 Kim HB, Fauza D, Garza J. et al. Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg 2003; 38: 425-429
    CrossrefPubMedGoogle Scholar
  • 27 Sudan D, Thompson J, Botha J. et al. Comparison of intestinal lengthening procedures for patients with short bowel syndrome. Ann Surg 2007; 246: 593-601
    CrossrefPubMedGoogle Scholar
  • 28 King B, Carlson G, Khalil BA. et al. Intestinal bowel lengthening in children with short bowel syndrome: systematic review of the Bianchi and STEP procedures. World J Surg 2013; 37: 694-704 doi:10.1007/s00268-012-1879-3
    CrossrefPubMedGoogle Scholar
  • 29 Eid KR, Costa G, Bond GJ. et al. An innovative sphincter preserving pull-through technique with en bloc colon and small bowel transplantation. Am J Transplant 2010; 10: 1940-1946 doi:10.1111/j.1600-6143.2010.03167.x
    CrossrefPubMedGoogle Scholar
  • 30 Goulet O, Colomb-Jung V, Joly F. Role of the colon in short bowel syndrome and intestinal transplantation. J Pediatr Gastroenterol Nutr 2009; 48 Suppl 2: S66-S71
    CrossrefPubMedGoogle Scholar
  • 31 Kato T, Selvaggi G, Gaynor JJ. et al. Inclusion of donor colon and ileocecal valve in intestinal transplantation. Transplantation 2008; 86: 293-297
    PubMedGoogle Scholar
  • 32 Grant D, Abu-Elmagd K, Reyes J. et al. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg 2005; 241: 607-613
    CrossrefPubMedGoogle Scholar
  • 33 Abu-Elmagd KM, Costa G, Bond GJ. et al. Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg 2009; 250: 567-581 doi:10.1097/SLA.0b013e3181b67725
    CrossrefPubMedGoogle Scholar
  • 34 Abu-Elmagd KM. The small bowel contained allografts: existing and proposed nomenclature. Am J Transplant 2011; 11: 184-185 doi:10.1111/j.1600-6143.2010.03354.x
    CrossrefPubMedGoogle Scholar
  • 35 Krawinkel MB, Scholz D, Busch A. et al. Chronic intestinal failure in children. Dtsch Ärztebl Int 2012; 109: 409-415
    PubMedGoogle Scholar
  • 36 Fischer-Frohlich CL, Konigsrainer A, Schaffer R. et al. Organ donation: when should we consider intestinal donation. Transpl Int 2012; 25: 1229-1240 doi:10.1111/j.1432-2277.2012.01556.x
    CrossrefPubMedGoogle Scholar
  • 37 Abu-Elmagd K, Fung J, Bueno J. et al. Logistics and technique for procurement of intestinal, pancreatic, and hepatic grafts from the same donor. Ann Surg 2000; 232: 680-687
    CrossrefPubMedGoogle Scholar
  • 38 Ceulemans LJ, Monbaliu D, De Roover A. et al. Belgian multicenter experience with intestinal transplantation. Transpl Int 2015; 28: 1362-1370 doi:10.1111/tri.12615
    CrossrefPubMedGoogle Scholar
  • 39 Konigsrainer A, Ladurner R, Iannetti C. et al. The ‘Blind Innsbruck Ostomy’, a cutaneous enterostomy for long-term histologic surveillance after small bowel transplantation. Transpl Int 2007; 20: 867-874
    CrossrefPubMedGoogle Scholar
  • 40 Gupte GL, Haghighi KS, Sharif K. et al. Surgical complications after intestinal transplantation in infants and children – UK experience. J Pediatr Surg 2010; 45: 1473-1478 doi:10.1016/j.jpedsurg.2009.08.026
    CrossrefPubMedGoogle Scholar
  • 41 Sheth J, Sharif K, Lloyd C. et al. Staged abdominal closure after small bowel or multivisceral transplantation. Pediatr Transplant 2012; 16: 36-40 doi:10.1111/j.1399-3046.2011.01597.x
    CrossrefPubMedGoogle Scholar
  • 42 Gondolesi G, Selvaggi G, Tzakis A. et al. Use of the abdominal rectus fascia as a nonvascularized allograft for abdominal wall closure after liver, intestinal, and multivisceral transplantation. Transplantation 2009; 87: 1884-1888
    CrossrefPubMedGoogle Scholar
  • 43 Pascher A, Kohler S, Neuhaus P. et al. Present status and future perspectives of intestinal transplantation. Transpl Int 2008; 21: 401-414 doi:10.1111/j.1432-2277.2008.00637.x
    CrossrefPubMedGoogle Scholar
  • 44 Gerlach UA, Vrakas G, Sawitzki B. et al. Abdominal wall transplantation: skin as a sentinel marker for rejection. Am J Transplant 2016; 16: 1892-1900 doi:10.1111/ajt.13693
    CrossrefPubMedGoogle Scholar
  • 45 Lacaille F, Irtan SA-Ohoo, Dupic L. et al. Twenty-eight years of intestinal transplantation in Paris: experience of the oldest European center. Transpl Int 2017; 30: 178-186 doi:10.1111/tri.12894
    CrossrefPubMedGoogle Scholar
  • 46 Pirenne J, Kawai M. Intestinal transplantation: evolution in immunosuppression protocols. Curr Opin Organ Transplant 2009; 14: 250-255 doi:10.1097/MOT.0b013e32832b2eb7
    CrossrefPubMedGoogle Scholar
  • 47 Sasaki T, Hasegawa T, Nakai H. et al. Zoom endoscopic evaluation of rejection in living-related small bowel transplantation. Transplantation 2002; 73: 560-564
    CrossrefPubMedGoogle Scholar