La transplantation intestinale.

Abstract

L’intestin est un organe complexe dont la transplantation a connu un développement moins important que celle d’autres organes. La qualité de la nutrition parentérale – thérapeutique de l’insuffisance intestinale – rend compte de cette situation. Les résultats actuels de la transplantation intestinale, nettement améliorés depuis l’utilisation du FK-506, justifient d’envisager plus largement cette thérapeutique. L’analyse de la survie actuarielle des greffons après transplantation intestinale, d’après les données du registre international, doit tenir compte des différences dans les protocoles thérapeutiques utilisés par les équipes. Elle atteint 60 % à quatre ans chez l’enfant, dans l’équipe qui en a la plus grande expérience. La transplantation intestinale ne peut être envisagée qu’en cas de complications vasculaires, métaboliques ou hépatiques limitant la poursuite de la nutrition parentérale. La transplantation combinée du foie et de l’intestin grêle est indiquée en cas d’hépatopathie mettant en jeu le pronostic vital.

The management of patients with intestinal failure has benefited from progress in parenteral nutrition (PN), especially home-based PN. Intestinal transplantation is henceforth possible and appears now, under certain conditions, the logical therapeutic option. Since 1985, more than 180 small-bowel grafts have been performed, involving the isolated small bowel with or without the colon (38%), the liver plus the small bowel (46%) or several more organs (16%). Two thirds of the recipients were under 20 years of age, and indications were short-bowel syndrome (64%), severe intractable diarrhea (13%), abdominal cancer (13%) or chronic intestinal pseudo-obstruction syndrome (8%). Fifty one per cent of the patients survived more than two years after graft. Patient and graft survival depend on the type of immunosuppression, i.e. CyA or FK506. The results must be carefully interpreted as they represent the first experience in numerous centers using different immunosuppression protocols, without any randomization. Results obtained in the largest of these centers are more indicative of the current situation. This article reviews the main aspects of human intestinal transplantation with special focus on graft rejection in terms of immunohistochemical expression which is decisive for diagnosis and specific treatment. Functional grafts lead to gastrointestinal autonomy (weaning of PN) while maintaining satisfactory nutritional status and normal growth in childhood. Intestinal transplantation is theoretically indicated for all patients permanently or lengthily dependent on PN. However, as PN is generally well tolerated, even for long periods, each indication of transplantation must be carefully weighed up in terms of iatrogenic risk and quality of life. When PN has reached its limits, especially those associated with vascular, infectious, hepatic or metabolic complications, intestinal transplantation must be considered. Transplantation of the small bowel alone remains the first option, as combined liver-small bowel grafting is indicated only in case of life-threatening progressive cirrhogenic liver disease. [References: 59]