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Intestinal transplantation comes of age.

Intestinal transplantation has evolved as a creditable therapeutic option that offers the only chance for cure for patients with intestinal failure who fail parenteral nutrition. The Editors of Transplantation are pleased to publish in this issue the first group of a series of selected articles based on papers presented at the Xth International Small Bowel Transplantation Symposium held in Los Angeles, CA on September 6–8, 2007. All of the articles to be published from this meeting have undergone our standard peer review process. The first articles included in this issue are described below. Additional articles will be published in succeeding issues. The intestine is less tolerant of ischemia than most other transplanted solid organs and, due to frequent significant donor organ size restraints in the majority of intestine recipients, donors are less likely to be procured locally, therefore emphasizing the need to minimize ischemia time. Schaefer et al. (Transplantation 2008; 85: 1300–1310) evaluated the efficacy of intravenous glycine administration in minimizing certain phenomena commonly associated with ischemia–reperfusion injury in a rat intestine model. Their data suggest that perioperative glycine treatment reduces molecular and cellular inflammatory responses within the graft and improves smooth muscle dysfunction posttransplantation. Protocol endoscopy with biopsy has been widely adopted as the standard for small bowel transplant rejection monitoring, but it is invasive, costly, and can be associated with complications. Akpinar et al. studied the use of Fecal Calprotectin levels (FCL) as a possible non-invasive marker for monitoring in small bowel transplant patients (Transplantation 2008; 85: 1281–1286). They present data to show that although no significant FCL difference was found between rejection and inflammation, FCL evolution in individuals could predict rejection days before histopathological diagnosis, suggesting its potential usefulness as a prescreening marker to avoid unnecessary biopsies. Induction immunosuppression is now common practice after intestinal and multivisceral transplantation. Vianna et al. (Transplantation 2008; 85: 1290–1293) describe their experience in 27 patients given antithymocyte globulin, rituximab, and steroids as induction therapy with Tacrolimus and tapered steroids as maintenance. One year patient and graft survival was 81% and 76%. Thirteen patients (48%) experienced 19 episodes of acute rejection; patients with multivisceral grafts experienced fewer episodes of acute rejection. Their data suggest that this induction regimen may have a protective effect against posttransplant lymphoproliferative disease and chronic rejection. Mian et al. (Transplantation 2008; 85: 1287–1289) present a retrospective analysis to determine factors affecting survival of intestinal transplantation in very young pediatric patients. Such patients awaiting intestinal transplantation have a high mortality rate due to long waiting times, scarcity of appropriate size donor organs, and mortality due to sepsis and liver failure. In children under 18 months of age, risks factors affecting survival to intestinal transplantation include small body size and advanced liver disease. No differences in residual small bowel length, presence of the colon, number of line infections or number of central lines were identified in the transplant and not transplanted groups. Intestinal transplantation is only one of a continuous of possible treatments for intestinal failure. Andres et al. (Transplantation 2008; 85: 1294 –1299) examined the efficacy of repeat surgical bowel lengthening with the socalled reSTEP procedure (Repeat Serial Transverse Enteroplasty) after previous surgical lengthening procedures. They concluded that in the stable patient who is otherwise unable to wean from parenteral nutrition repeat lengthening via a reSTEP surgery resulted in discontinuation of parenteral nutrition in almost half of a carefully selected group of patients. Most importantly, such repeat procedures did not preclude intestinal transplantation.