A 38-year-old male with intestinal failure and home parenteral nutrition for 18 months.
She had a history of morbid obesity, so she had been operated on in 2002.
After four years of good general condition and a significant weight loss presented an intestinal volvulus, requiring resection of the entire small intestine and right colon.
The digestive tract was closed at the level of the fourth duodenal portion without continuity with the transverse colon, so the patient was carrying a discharge gastrostomy.
Due to the loss of total small intestine, the patient received parenteral nutrition at home, without the possibility of any kind of intestinal rehabilitation.
The patient was admitted to our hospital for evaluation of intestinal transplantation.
Given the circumstances of the patient and considering that he had presented repeated episodes of catheter-related sepsis in the last year, isolated intestinal transplantation was indicated.
The patient was included in the waiting list with a weight of 60 kg, 180 cm high and 18.3 body mass index.
Two months after inclusion in the waiting list, intestinal transplantation was performed with an isogroup donor.
Thymoglobulin was administered to the donor at a dose of 2 mg/kg in order to deplete to the maximum the number of lymphocytes and thus reduce the probability of rejection and graft versus host disease.
The recipient had a transposition of the great vessels with the vena cava located to the left of the aorta artery.
This problem was settled with a rotation of 180o of the graft over its mesenteric axis, with the objective that the vein and superior mesenteric artery of the receiver were rotated with the vena cava and aorta artery.
The first jejunal loop of the graft was anastomosed laterolaterally to the fourth duodenal portion and the terminal ileum of the graft to the transverse colon in a latero-terminal fashion making ileochiostomy easy to perform.
When the graft was rotated 180o, the ileostomy was fixed on the right flank of the abdomen instead of the left.
In addition, a loop ileostomy was left and a cholecystectomy for biliary mud was performed, very common in these patients.
The patient received induction treatment with thymoglobulin 1.5 mg/kg and antibiotic prophylaxis with vancomycin, aztreonam and liposomal amphotericin B.
During the immediate postoperative period the patient continued to receive tacrolimus triple therapy: thymoglobulin 1.5 mg/kg/day (for 5 days), 0.15 mg/kg/day (administered in two doses) by nasogastric tube 200 mg/day
By not achieving adequate tacrolimus blood levels on the 3rd postoperative day, intravenous administration was started for 4 days until the levels were correct, returning again to the enteral route.
In addition, PGE1 (Alprostadil®) was administered in the immediate postoperative period in order to improve reperfusion injury (4).
72 hours after transplantation, the patient developed digestive hemorrhage secondary to a carial ulcer that was treated endoscopically with "clip".
Ten days later the patient was discharged from the ICU and discharged to the hospital ward.
Within the rejection control protocol, biopsies were performed twice a week through the ileostomy during the first month, and once a week during the second month.
During the six weeks of admission, only one biopsy showed indeterminate rejection and another mild rejection, which was treated with 3 boluses of 500 mg methylprednisolone.
From the nutritional point of view, at 7 days post-transplant began the administration of water and later of enteral nutrition by means of the jejunostomy tube.
After three weeks, the patient started oral intake progressively up to 2100 kcal, which allowed discontinuation of parenteral nutrition.
The patient weighed 10 kg in the 6 weeks of admission and was discharged from the hospital on week 7 of transplantation without requiring parenteral nutrition.
The evolution to date has been excellent with an increase, indicating the viability and good function of the intestinal graft.
