AT MEDANTA: Country’s first successful intestinal transplant

Chandigarh, January 4, 2013: Thirty year old software engineer Himanshu became India’s first recipient of a successful intestinal transplant as he gets ready to be discharged home about 6 weeks after his 10 hour operation on 24 November last.

Leading transplant surgeon, Dr AS Soin, who has performed more than 1500 liver transplants, led a team of 30 doctors who conducted the historic operation at Medanta-The Medicity Hospital at Gurgaon. The team included the experts Dr R Mohanka, Dr Randhir Sud, Dr V Vohra, Dr. A Rastogi and others. As congratulatory messages pour in from all corners of the world, doctors have termed it as the conquest of the final frontier in transplant surgery.

Congratulating the patient and the team of doctors, Dr. Naresh Trehan, the hospital Chairman and Managing Director and the chief Cardiac Surgeon, said that “the teamwork required to keep Himanshu alive on TPN and then take him through transplant has been phenomenal. Medanta was able to pull it off due to a rare amalgam of surgical expertise, dedicated gastroenterology and nutrition team, one of the most sophisticated laboratory services, experienced ICU and infection-control teams, and a state-of the art dedicated transplant ICU. We have now joined a select band in the world who have done this successfully, he said.

Chairman of the institute of Transplantation and Chief surgeon of the team, Dr. AS Soin explains that intestinal failure is defined as the inability to maintain sufficient electrolyte, nutrient, and fluid balance for more than 1 month without intravenous (parenteral) nutrition. Patients with intestinal failure are considered candidates for transplant when total parenteral nutrition (TPN) has been tried for a while but cannot be tolerated due to its complications, and the remaining intestine cannot adapt enough to recover its function. He says the most common causes of intestinal failure in adults are short bowel syndrome that results from extensive bowel removal due to blood clots in the major veins or arteries of the intestine, major abdominal trauma or, inflammatory bowel diseases like Crohn’s disease. In children it is usually due to failure of intestinal development (atresia) or Gastroschisis. Many people with short bowel syndrome, like Himanshu are dependent on TPN to supply their daily nutrition. Administered in the hospital or at home, intravenous nutrition usually requires a central venous catheter, which can lead to chronic/repeated infections. Over time, the intravenous nutrition solution also carries risk of venous thrombosis and liver toxicity and jaundice. If any of these complications occur, an intestinal transplant is considered, explained Soin.

Explaining the circumstances surrounding Himanshu’s disease, Dr Ravi Mohanka, Senior Transplant Surgeon, said that life was good for the (then) 27 year old until December 2009, when he was suddenly seized by severe abdominal pain. He underwent an emergency laparotomy at a city hospital in which the surgeons found thrombosis (blockage) of the main vein of his intestine (superior mesenteric vein) resulting in loss of blood supply to most of his intestine. Consequently, 95% of his small intestine (normally 6 metres) had to be removed and only 28 cm was left. While this saved his life, he became an intestinal cripple. He could not digest anything normally ever again! Not able to absorb the nutrients his body needed, he would remain dependent on intravenous nutrition permanently. He would also have to hook himself up intravenously for fluids to prevent dehydration. He would be constantly at high risk for intravenous infection and multiple hospital admissions, said Dr Mohanka.

Himanshu’s whole world fell apart as he realized that he would never be able to eat normally again. Most of what he ate was not absorbed, and to live, he needed total parenteral (intravenous) nutrition (TPN) on a regular basis. Unless he could have an intestinal transplant – the toughest of all transplants, and something that had never been successful in India before. They then approached Drs Soin and Mohanka, who had acquired the expertise for intestinal transplants in USA and UK. The doctors devised an intravenous nutrition plan along with oral food (although the latter was hardly absorbed) that marginally improved his quality of life. They evaluated and counseled Himanshu for an intestinal transplant and put him on the waiting list. He waited 2 long years before he got lucky with a matched organ. During the 3 years after his intestinal failure, he suffered several episodes of life-threatening infections and was hospitalized 11 times. He underwent 6 minor surgeries to place or change feeding tubes into his veins.

On the night of 24th November, he finally got the phone call he had been waiting for. It was a perfect match! The doctors had found a blood group matched 20 year old deceased donor who was fit to donate the small intestine.

“Fortunately, the surgery went very much to the plan, remarked Soin. During the operation, we removed most of Himanshu’s remaining small intestine and a part of the large intestine to make space for the new intestine. This was necessary as his abdominal cavity had shrunk due to the missing bowel over the past 3 years. The new small intestine was then transplanted, joining the blood vessels to the recipient’s and the ends of the new intestine to the existing proximal and distal bowel. The joining of the vessels was the first challenge as both the artery and the main vein of the intestine were clotted. This necessitated grafting of extra conduits to the aorta and the portal vein to construct new source of blood supply for the transplanted intestine.  The joining of the blood vessels is always difficult in such cases due to the curled up nature of bowel which makes it likely for the vessel joints to twist, which can destroy the transplanted bowel rapidly. We kept the last 20 cm portion of the  new intestine diverted to open on the abdominal wall to enable repeated endoscopy and biopsy of the intestine for possible rejection, said Soin.

Dr Mohanka explained that the next major challenge was the postoperative management since intestinal transplants reject easily, much more so than any other organ. This necessitated large doses of immune suppressant medication – approximately 3 times that used in liver transplants. This makes the chances of developing infection very high. For this reason, a totally sterile, a zero-infection zone was provided for Himanshu’s care. Another problem with such patients is the difficulty of differentiating rejection and infection since both produce the same symptoms. The differentiation is vital as the treatment of both conditions is very different. A peculiar problem with intestinal transplants is that as soon as there is any inflammation, rejection or infection of the bowel, its wall becomes permeable to the bacteria that normally reside within the bowel, and these escape out into the abdominal cavity and blood-stream causing life-threatening systemic infection, he said. 

Dr Randhir Sud, Chairman of the Digestive Diseases Institute, said that they monitored the transplanted intestine for rejection by a special technique called magnification endoscopy which was conducted 14 times along with biopsies during his hospital stay. “While the risk of rejection is lower now than in the 1^st 6 weeks, it can develop later too. This means that this monitoring must continue for at least 6 months”, said Dr Sud.

During the past 6 weeks, Himanshu had one episode of rejection and 3 episodes of infection all of which were swiftly managed with appropriate anti-rejection drugs and antibiotics.

Starting about 2 weeks after the surgery, he was given feeding into his new intestine via a tube followed by introduction of oral feeding. “I had to re-learn how to eat normally and understand the signals of satiety. Even the ‘khichdi’ given to me tasted divine”, remarked Himanshu. He said that is now off TPN for the past 10 days, and can eat normally.

According to Dr Trehan, about 2/ million  or 2000-2500  people suffer intestinal failure annually in India, who need permanent TPN or intestinal transplant. We have already started enrolling more patients into our dedicated TPN and short gut care program, and hope to do more of such transplants in the future, he said.

Asked whether the transplant would change Himanshu’s life, Soin said, "it'll have an extraordinary affect on his life. Whilst parenteral nutrition kept Himanshu alive as he waited for a transplant, it was associated with potentially life-threatening complications such as sepsis and loss of venous access.Not only does intestinal transplantation reduce the risks of TPN for Himanshu, he will now enjoy food and eat just as any normal person does,” added Soin.