We read with interest the article on “The current status of small bowel transplantation in the UK and internationally” by Middleton et al (Gut 2005;54:1650–7). This is a timely article about the improving worldwide outcome following small bowel transplantation but does not fully reflect the status of small bowel transplantation in the UK. In the UK, the Department of Health through NSCAG (National Specialist Commissioning Advisory Group) recognises and funds three units for small bowel transplantation (2 adult centres—Addenbrooke's Hospital, Cambridge and St James Hospital, Leeds; and a single paediatric centre—Birmingham Children's Hospital (BCH)) since 1997. The majority of transplants in the UK to date have been carried out in children, which also reflects the international situation. Thirty eight intestinal transplants have been performed in children at BCH since 1993 compared with 14 transplants in the adult population in the last 15 years at two adult centres.
The paediatric experience has taught us many useful lessons which also benefit adult recipients, such as: reduction of graft size,1 increased awareness of post‐transplant infectious enteritis, and Epstein Barr virus (EBV) related post‐transplant lymphoproliferative disease (PTLD), which are risk factors for death following small bowel transplantation in both adults and children.2,3
Since the introduction of graft reduction techniques, we have performed 21 en bloc reduced combined liver and small bowel transplants, thus extending the donor pool and facilitating transplantation of small children from older donors.1
In a recent report from the UCLA group, infectious enteritis (IE) with viruses (adenovirus, EBV, and rotavirus) and protozoa (giardia lamblia, cryptosporidium) has been reported in three adults and 10 children following small bowel transplantation. This is an underreported and underdiagnosed complication following intestinal transplantation. A high index of suspicion and prompt laboratory investigations are necessary to arrive at an early diagnosis as the clinical features can mimic acute cellular rejection (ACR) and the treatment of IE is very different to ACR.2
EBV related PTLD is seen more commonly in children who, unlike adults, are EBV seronegative pre‐transplant, but also occurs in adults following small bowel transplantation.3 The diagnosis of EBV related PTLD is based on high viral EBV polymerase chain reaction (PCR) loads and histopathological examination. Treatment modalities such as reduction of immunesuppresssion, surgical resection for control of local complications, anti‐CD20 monoclonal antibody (Rituximab), adoptive immunotherapy, and cytotoxic chemotherapy are helpful in the treatment of this invasive disease.4 Awareness about PTLD and serial EBV PCR monitoring has reduced the incidence of PTLD in the last decade.
In conclusion, this article does not acknowledge the contribution of the paediatric experience in this developing field.
Footnotes
Conflict of interest: None declared.
References
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