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

Abstract

The value of endoscopy and biopsy after intestinal transplantation in the absence of clinical concerns has never been investigated. We examined clinical yield of routine surveillance endoscopy and biopsy (control group, n = 28, Jan 2011 to Jun 2014).Most episodes of acute rejection were diagnosed when there were clinical symptoms or signs such as increased stoma output, fever, or bacteremia, but not by routine surveillance endoscopy and biopsy. The new protocol abandoned routine surveillance.Intestinal allografts were examined only when relevant clinical symptoms and/or signs raised concern for graft dysfunction. We compared outcomes between control and study groups (new protocol, n = 25, Jul 2014 to Dec 2016). Incidence of acute rejection (32% vs 32%), graft salvage rate after acute rejection treatment (78% vs 63%), patient survival (75% vs 88% 1 year, 71% vs 83% 3 years after intestinal transplantation), and graft survival (68% vs 80% 1 year, 61% vs 76% 3 years after intestinal transplantation) were similar between control and study groups. Protocol-driven, routine surveillance endoscopy, and biopsy do not appear to confer any survival advantage to patients or grafts. Endoscopy and biopsy "for cause" without routine surveillance seem to be effective and adequate to monitor intestinal allografts. K E Y W O R D Sdiagnostic techniques and imaging, guidelines, protocol biopsy

“Stoma or no stoma”: First report of intestinal transplantation without stoma

“…In our series, all patients who developed stoma‐related complications had difficult abdominal wall (significantly compromised abdominal fascia layer from previous multiple surgeries), which led to imperfect stoma creation and complications. Recently the authors presented data that revealed no benefits of protocol‐driven routine surveillance E&B in the diagnosis of AR and survival 6 . We reported that the median number of E&B was 2 times and about 20% of patients did not need E&B during the first year after ITX.…”

“…clinical research/ practice, intestinal (allograft) function/ dysfunction, intestine/ multivisceral transplantation, patient survival, rejection: acute and adequate to monitor intestinal allografts. 6 This observation led our center to abandon protocol-driven routine surveillance E&B and establish a new protocol performing E&B only for cause following ITX. Under this new policy, number of E&B after ITX was significantly decreased to 2 times (median), and more importantly, about 20% of patients did not need E&B during the first year, a time period in which AR occurs most frequently.…”

“…We recently reported that frequent protocol‐driven surveillance E&B does not appear to confer survival advantage to patients and grafts, and E&B only when clinically indicated seems to be effective and adequate to monitor intestinal allografts 6 . This observation led our center to abandon protocol‐driven routine surveillance E&B and establish a new protocol performing E&B only for cause following ITX.…”

The role of endoscopy in the small intestinal transplant recipient: A review

“…However, this practice requires validation outside of our center. 10 Patients with an ileostomy generally will not require bowel preparation, as small intestinal contents can be easily suctioned.…”

Graft assessment for acute rejection after intestinal transplantation: current status and future perspective

“…In total, a reduction of the number of endoscopies from 226 (historical cohort) to 57 (symptomatic cohort) was observed. Although, there were limitations regarding the sample size and the follow-up time (2014-2016) the concept is intriguing [52]. Nevertheless, the absence of a reliable biomarker and the fact that rejection might occur in asymptomatic patients makes this strategy somewhat challenging to adopt especially for smaller centres.…”