December 18, 2014

Advances in Gut Rehabilitation and Transplantation

Piecing Together the Puzzle for a Premier Center of Care

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“Outcomes with intestinal and multivisceral transplantation have markedly improved over the last two decades.” If there is a single message that Kareem Abu-Elmagd, MD, PhD, has had for the digestive disease community since arriving at Cleveland Clinic in December 2012 as the new Surgical Director of the Center for Gut Rehabilitation and Transplantation (CGRT), formerly known as the Intestinal Rehabilitation and Transplant Program, that would be it.

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Dr. Abu-Elmagd has been advancing that message over the last several years, in his previous post at University of Pittsburgh Medical Center (UPMC), as current president of the Intestinal Transplant Association (ITA) and as a pre-eminent innovator and researcher in the field for more than two decades. In fact, he was intimately involved in the clinical introduction and further development of intestinal transplantation and has played a dominant role in the development of multivisceral transplantation.

Indisputably Positive Visceral Transplant Outcomes

The message itself is indisputable. While early attempts at intestinal transplant were hampered by technical and immunologic complications that resulted in patient death and/or graft failure, continual technical and immunologic innovations have lifted one-year patient survival rates above 90 percent at experienced large-volume centers. Dr. Abu-Elmagd embodies experience in the procedure, having been involved in more than 20 percent of all intestinal transplants performed worldwide, according to the most recent report from the Intestine Transplant Registry.

As that experience has mounted, long-term outcomes have improved and compare well with outcomes for other organ transplants. In a landmark review of their first 500 intestinal and multivisceral transplants, Dr. Abu-Elmagd’s team reported overall patient survival rates of 61 percent at five years, 42 percent at 10 years and 35 percent at 15 years.1 Notably, the best survival rates, 70 percent at five years, were achieved more recently because surgical techniques and immunosuppression have improved. A subsequent report among five-year survivors found significant post-transplant improvement across a range of quality-of-life measures.2

Completing the Puzzle for Unparalleled Care

Dr. Abu-Elmagd’s arrival represents the final piece of the puzzle to make Cleveland Clinic one of the world’s premier centers for the management of intestinal failure, says Donald Kirby, MD, Medical Director of Cleveland Clinic’s CGRT. “We have one of the largest and most comprehensive intestinal rehabilitation programs in the world, and we have developed a multidisciplinary approach to patients with intestinal failure,” he explains. “Now we have the world’s most experienced surgeon in intestinal transplantation. He has dealt with almost ever y possible complication, and he knows how to work the immune system — that’s the hardest part of intestinal transplants, which pose a greater immunologic challenge than do other transplant types.”

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At Cleveland Clinic, intestinal transplant is not new territory. Cleveland Clinic performed its first adult intestinal transplant in 2008 and received Centers for Medicare & Medicaid Services (CMS) certification for adult intestinal/multivisceral transplantation in December 2010. It is one of the few U.S. medical centers to perform intestinal transplants, which remain far less common than other transplant procedures. Whereas several hundred thousand kidneys and livers have been transplanted to date, fewer than 3,000 intestinal transplants have been performed worldwide.

Dr. Kirby sees Cleveland Clinic’s intestinal transplant volumes increasing substantially with Dr. Abu-Elmagd’s arrival. “Because of his international reputation in this field, people want him as their surgeon and are willing to come from afar,” he says. “And he is helping to train the next generation of intestinal and multivisceral transplant surgeons here.”

Intestinal Rehab: A Long-Term Relationship

Both Drs. Kirby and Abu-Elmagd note that all the patients the CGRT manages for intestinal failure, including those with short bowel syndrome (SBS), motility disorders, malabsorption , Gardner’s syndrome with desmoid tumors, complex abdominal pathology and other rare disorders, should be thoroughly evaluated using a multidisciplinary approach and treatment tailored according to the primary disease and expected long-term outcome. Commonly utilized therapeutic modalities are diet management, augmented medical therapy, autologous surgical reconstruction and ultimately visceral transplantation, when indicated.

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“In our center, we aim to establish long-term relationships to successfully manage intestinal failure patients with optimization of their gut function and improvement of their quality of life,” explains Dr. Kirby, who also is Director of the Center for Human Nutrition in Cleveland Clinic’s Digestive Disease Institute. Such a task is achievable through a comprehensive assessment of each patient by a dedicated team that consists of an experienced gastroenterologist, certified dietitian, surgeon with vast experience in complex abdominal surgery, psychosocial worker, financial counselor and other highly specialized staff. The evaluation process addresses the anatomical and functional capacity of the gut and guides short- as well as long-term management.

Medical management involves intensive, personalized diet/nutrition counseling with use of oral rehydration solutions, enteral feeding and, if necessary, medications or growth factors that reduce the transit time of food to improve absorption by the remaining bowel. “Commonly, we have successful outcomes with these methods,” Dr. Kirby observes. He also notes that some of these patients had lost continuity of their gut and required reconstructive operations by Cleveland Clinic’s surgical team.

Home parenteral nutrition (HPN): Promise and Challenges

“Cleveland Clinic’s nutrition support program, part of the Center for Human Nutrition, is caring for the largest HPN cohort followed in one U.S. center — and one of the largest in the world,” says Mandy Corrigan, a dietitian with the program, which has been recognized as a program of excellence by the American Society for Parenteral and Enteral Nutrition. The program team’s expertise is reflected in an invitation to write an HPN tutorial for the November 2012 issue of the Journal of Parenteral and Enteral Nutrition.3

Long-term HPN is not easy for many patients to endure because most patients need to infuse HPN daily. “If they do it at night to free up their day, then they need to go back and forth to the bathroom at night, which doesn’t allow for a good night’s rest,” says Dr. Kirby. “It’s more burdensome than dialysis.” That’s why one of the CGRT’s major goals is to continue working with patients to enhance their bowel adaptation with the aim of reducing or potentially eliminating the need for HPN. “It behooves patients who need nutrition support to be seen at an HPN center of excellence so they can improve their quality of life through the type of intensive education we offer here,” he says. “We look at the endgame and how well we can make a patient’s present physiology work, with transplantation used as a rescue therapy for those who fail comprehensive medical therapy and no longer can be maintained on HPN.”

Surgical Restoration and Transplant

Before recommending intestinal transplant, the CGRT can offer surgical treatments, short of transplant, to enhance the absorptive function of the residual native intestine in selected patients. These include lengthening procedures such as serial transverse enteroplasty. “Only a couple of other U.S. centers are offering the lengthening procedures that we are now doing here,” says Dr. Abu-Elmagd.

He also performs reconstructive operations in many patients with very complex abdominal pathology or “hostile abdomen” that few other surgeons nationally are willing to take on, for conditions such as abdominal cocoon syndrome, extensive abdominal adhesions, multiple enteric fistulae and extensive thrombosis of the portal venous system of the GI tract. “For the patients who cannot undergo reconstructive surgery because of the nature of the underlying disease, transplantation may be the only solution,” he explains.

“One of the things that distinguish our center now is that Dr. Abu-Elmagd doesn’t think simply in terms of ‘transplant’ vs. ‘no transplant,’” observes Dr. Kirby. “He is highly creative in looking at a patient’s problem and arriving at a surgical solution that might not be a transplant and might not be easy but is the best option for the given patient. That type of comfort and versatility is enormously valuable in a surgeon, and our next generation of surgeons is being trained in it.”

An Interdisciplinary Ethic

That clinical creativity is drawn upon in the center’s weekly interdisciplinary conferences, which discuss potential transplant candidates and ways to possibly stave off the need for transplant in difficult cases. The conferences bring together a team of transplant surgeons, gastroenterologists with vast experience in nutrition, dietitians, social workers, transplant immunologists, nurses and physicians who are highly specialized in transplant psychology and behavioral science.

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With the GCRT being part of the Digestive Disease Institute, patients are managed by physicians and surgeons who are highly specialized in a wide spectrum of gastrointestinal disorders. These disorders include inflammator y bowel disease (IBD), Gardner’s syndrome, gut dysmotility and other GI disorders. “Because of Cleveland Clinic’s international reputation in treating IBD, severe IBD is one of the leading causes of short bowel syndrome in the patients we manage in the program,” says Dr. Kirby.

For Dr. Abu-Elmagd, postoperative care is where Cleveland Clinic’s collaborative ethic shines brightest. “You can operate on any high-risk patient, but postoperative care can be the most important factor in saving the patient’s life,” he says. “I am very confident that my colleagues at Cleveland Clinic are providing my patients with the best care they could have anywhere.”

Dr. Abu-Elmagd sees Cleveland Clinic’s current group practice model as a wonderful and impressive outgrowth of its past, further demonstrating the value of healthcare and academic medicine. “The multidisciplinary team approach for patient care and the vision of the physician-based administrative leadership that I’m seeing at Cleveland Clinic should be a model for most of the healthcare providers across the country,” he says.

For more information, please contact Dr. Abu-Elmagd at 216.445.8876 or abuelmk@ccf.org

1. Abu-Elmagd KM, Costa G, Bond GJ, et al. Five hundred intestinal and multivisceral transplantations at a single center. Ann Surg. 2009;250(4):567-581.
2. Abu-Elmagd KM, Kosmach-Park B, Costa G, et al. Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation. Ann Surg. 2012;256(3):494-508.
3. Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr. 2012;36(6):632-644.

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