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Reconnection surgery after intestinal and multivisceral transplantation in children: how, when and why

Sara Gozzini¹, Khalid Sharif¹, Paolo Muiesan², Sue Beath¹, Jane Hartley¹, Girish Gupte¹, Darius Mirza²

¹Liver Unit, Birmingham Children's Hospital, Birmingham, United Kingdom; ²Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom

Background: Following pediatric intestinal transplant (ITx) ileostomy is performed to monitor for rejection. Once the risk decreases, reconnection surgery (RS) can be considered as an option to improve quality of life, although it abolishes an easy way of graft surveillance. The aim was to study criteria influencing graft reconnection.

Material and Methods: Retrsospective review of 77 paediatric ITx and  34 (data available in 30) transplanted for short gut syndrome and eligible for RS were included. Group 1 (stoma closed) and group 2 (stoma opened) were identified, analyzing recipient data, trend of rejection, complications, survival and outcome.

Results:

	Group 1 N=10	Group 2 N=20	P-value
Median Length of bowel left	30 cm	20 cm	0.177
Age at ITx	5.2 yr	1.5 yr	0.031
Weight at ITx	19.5 kg	9.4 kg	0.008
Onset of early rejection	8	11	0.051
number of rejections	10	20	0.12
Median grade of rejection (1-4 score)	3.5	3.0	0.524
Median length of time from ITx to RS	20 months (10-43)
Median rime from last episode of rejection to RS	13 months (6-30)
Overall survival	90%	50%	0.032

Discussion: In Group 1-2 patients had stoma refashioned because of bowel perforation and acute rejection, 1 developed late acute rejection and 7 are still in continuity. In group 2- 9 patients died in the first 18 months, 2 developed chronic rejection, 4 are still in the early post ITx period and 1 parent refused RS. 4 patients are not yet eligible for RS because of medical issues.

Conclusion: Onset, number and grade of rejection, may be not considered as excluding criteria to reconnect a graft. Patients with relatively uneventful post operative period are better candidates for RS. From our little experience, we would recommend a 1 year wait from the last episode of rejection before RS