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Background: Short-bowel syndrome remains the primary cause of intestinal failure (IF) in adult patients. We aim to report the long-term results of medical and surgical rehabilitation in a cohort of patients with type III IF (III-IF) and develop a formula to predict parenteral nutrition (PN) independency. Methods: We used a retrospective analysis of a prospective database for III-IF patients undergoing autologous gastrointestinal reconstruction surgery (AGIRS) from March 2006 to August 2018. Analyzed variables included demographic data, postsurgical intestinal length (PSIL), postsurgical anatomy, teduglutide (TED) treatment, and PN volume reduction. Univariate analysis, Cox regression, logistic regression forward stepwise models, and receiver operating characteristic (ROC) curve were done using SPSS v20. Results: AGIRS was performed in 88 patients. The most frequent anatomy at first visit was type 1. Prevailing anatomy after surgery was type 3. Eight patients started TED; 6 achieved freedom from PN. At a mean follow-up time of 1606.1 ± 1190.25 days, freedom from PN survival was achieved in 83%. Variables identified at the logistic regression analysis led to a novel formula to predict intestinal rehabilitation, including PSIL, presence of ileocecal valve, and use of TED as part of postsurgical treatment. Conclusions: AGIRS in this group of patients enabled intestinal length increase and also intestinal anatomy conversion into a more favorable type for intestinal rehabilitation. TED treatment was useful to discontinue PN in patients with classical negative anatomical predictors. The novel predicting formula has an ROC area under the curve = 0.82. Further studies are necessary to validate this formula.

Intestinal transplantation (ITx) faces the challenge of grafting a high immunogenic organ, which is certainly one of the major obstacles for intestinal allograft acceptance. The allograft has to guarantee the proper functioning of the mucosal immune machinery under immunosuppressive conditions. Recently, it has been elucidated that isolated lymphoid follicles (ILFs) are an indispensable part of mucosal immunity to maintain IgA synthesis and consequently to control commensal microflora. No data about these follicular structures in the setting of ITx are available so far. Therefore, we addressed the question whether constitution, integrity and function of allograft ILFs are disturbed by immunosuppressive regimen. We compared allograft ILFs from terminal ileum of transplant patients with ILFs from nontransplant patients via flow cytometry, quantitative real-time polymerase chain reaction and immunohistochemistry. We found that host leukocytes rapidly repopulate allograft ILFs and that maintenance immunosuppressive regimen, tacrolimus and corticosteroids, does not affect their cellular integrity and function. However, allograft ILFs revealed a higher maturation state than control samples and IgA positive plasma cells were increased in number in allograft mucosa. Our results open the path for a better understanding of allograft mucosal immunity.

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