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Living donor intestinal transplantation – Should it be used more frequently?

Since Dr Joseph Murray performed the first successful kidney transplant in a patient utilizing the kidney of that patient’s identical twin brother, living donor kidney transplantation has been extensively performed worldwide (1–3). In the United States alone, >6000 kidneys were transplanted from the living donors in 2004 (2). However, the use of living donors in other solid organ transplants (i.e. liver, lung, pancreas and small intestine) is not so common, mostly because of the risk to the donor. Use of a living donor has the significant advantage in that the patient is able to be transplanted without a long waiting time and an optimal timing of the transplant can be achieved. It may also have certain immunological advantages particularly in case of identical twins or human leucocyte antigen (HLA) six antigen-matched siblings. The second most common solid organ that has been transplanted from living donors is the liver (4). Use of a living donor in liver transplantation has also been successful particularly in caseswhere an adult donates a piece of liver to a child. More recently, adult to adult living donor liver transplants have been performed in order to decrease the candidate’s risk on the waiting list; however, enthusiasm has been moderated by the realization of a significant risk to the donor (5). Still, the use of a living donor is often the only choice in those countries where deceased donors are rarely available. This procedure has also been used in countries with established deceased donor programs in situations where the benefit to the recipient is considered to outweigh the risk to the donor (6). Intestinal transplantation is an emerging procedure in the transplant field. The world-wide experience now exceeds 1000 cases (7). Approximately 140 cases of intestinal transplants including isolated intestinal transplants, combined liver– intestinal transplants, and multivisceral transplants have been added to the world experience every year with significantly improved outcomes (7). These transplants are mostly with deceased donors, because there is no shortage of deceased donor intestines. Reports on living donor intestinal transplantation is still quite limited (8–16). A standardized technique was proposed by Gruessner et al. (12). The first successful living donor intestinal transplant using a donor/recipient identical twin pair was reported by Morris et al. (8). A HLA non-identical living donor was used successfully for the first time in 1988 (9). In the United States, the group from the University of Illinois recently presented a successful series of living donor intestinal transplants (14–16). In this issue of Pediatric Transplantation, Ishii et al. (17) reports their first case of living donor intestinal transplantation in a child with intestinal dysmotility. The successful outcome of cases like this one may stimulate the use of intestinal transplantation in countries like Japan where deceased donors are rarely available. In order to successfully perform a segmental intestinal transplant, there are two size constraints: (i) the size of donated organ must be large enough to meet the absorptive needs of the recipient and (ii) the donated intestinal segment must be small enough to fit into the recipient’s abdominal cavity. Therefore, themost suitableageof recipients for segmental intestinal transplantation from a live donor appears to be school age children or older, as 150– 200 cm of segmental intestine from an adult is likely to meet above size criteria. However, it is also possible that with proper preoperative preparation, a segment of a small living donor’s intestine could be successfully transplanted into a much smaller size recipient. The optimal choice of anatomical segment to be used in segmental intestinal transplantation has been considered. In using a segmental graft from the living donor, use of the distal ileum is the most common approach since the artery of this small bowel portion is usually the longest and technicallyhandled easier (12).The use of distal ileum is also preferred, because the Pediatr Transplantation 2006: 10: 140–141 Copyright 2006 Blackwell Munksgaard