Endoscopy Following Pediatric Intestinal Transplant

Abstract

Objectives Biopsies remain the gold standard in the diagnosis of intestinal transplant (ITx) rejection, and gastrointestinal endoscopy plays a pivotal role in patient management. Herein, we describe a single center 23 year endoscopic experience in pediatric ITx recipients. Methods A retrospective review of endoscopy and pathology reports of all ITx recipients <18 years old transplanted between 1991 and 2013 was performed with the aim of describing the procedural indications, findings, and complications. Results A total of 1770 endoscopic procedures within 1014 sessions were performed. Combination EGD and ileoscopy was the most common procedure (36%). Increased stool output (35%) and surveillance endoscopy (32%) were the most common indications. 162 episodes of biopsy proven rejection were diagnosed. First episode of rejection occurred at a median of 1 month post-ITx. 45% of histology-proven rejection had normal appearing endoscopies. The rate of procedural complications including but not limited to bleeding and perforation was 1.8%. Conclusions Endoscopy with biopsy plays a significant role in the care of ITx recipients. Multiple procedures are required for graft surveillance, diagnosis of rejection, subsequent treatment, and follow-up of therapy. The gross endoscopic appearance, particularly in mild to moderate acute cellular rejection, does not correlate well with histology. Complex anatomy, complication rates which are higher than non-ITx pediatric endoscopy cases, and timely histologic interpretation by experienced pathologists are reasons that these procedures should be performed at centers accustomed to caring for ITx recipients. The field would benefit from the development of a noninvasive biomarker to reliably and efficiently detect rejection.

Routine surveillance endoscopy and biopsy after isolated intestinal transplantation—Revisiting the gold standard

“…We recognize that our findings need to be confirmed in larger cohorts. The incidence of ACR of 32% in both of our groups is in line with other centers’ reports, and there was no difference in the percentage of patients with severe ACR (11 to 12% in both groups). The efficacy of E&B performed “for cause” in both groups, seemed similar at 12% (8/67 in study group) and 14% (8/57 in control group), respectively.…”

“…The purpose of this study was not to prove the benefits of fewer E&B, but rather to confirm our impression of the very limited value, if at all, of routine surveillance E&B in ITX. Complications of endoscopy and biopsy seem to be more in transplant patients than general population according to available literature, and our own experience is consistent with this observation . This might be another reason to favor endoscopy and biopsy for cause only without routine surveillance scope and biopsy.…”

Pediatric small bowel transplantation: A single-center experience from Turkey

“…The incidence of EBV was reported to be 25-33% in pediatric SBTx during the first 6 months. The prevalence of PTLD was 16-17% in pediatric SBTx (11,18). The use of anti-T-cell antibodies has been considered as a risk factor (14).…”

5-gene differential expression predicts stability of human intestinal allografts

“…Monitoring of IT integrity relies on endoscopic and histological examination of intestinal mucosa biopsies, continuously performed during the first post-Tx period. However, in a recent series investigating 1770 endoscopies in pediatric transplants, 45% of biopsyproven rejections showed a normal gross appearance, suggesting a low correlation between endoscopy and histology (Yeh et al, 2015). Thus, in many cases, these ACCEPTED MANUSCRIPT…”