其次則是提升生活品質與腸道復建，如何讓這些病人在點滴與口慾上達到一種平衡，針對合適的個案進行腸道復健，主要有四項：1. 促進消化吸收的藥物，2.挑選適合的腸道靜脈營養品與給予方式，3. 增進腸絨毛成長與吸收營養品，4.增進腸黏膜生長與吸收的內分泌如第二型類升糖胜類似物 GLP-2或生長因素。GLP-2類似物因為相當昂貴，一個月的藥費就超過百萬，因此目前國內雖有藥証，尚無人使用報告。我們團隊有幸參加一個跨國第三期的GLP-2類似物臨床試驗，可以不用費用使用藥物，相關的結果尚在觀察。總是希望對合適的腸衰竭病人有幫忙。
A new milestone in 30 cases of small intestine transplantation-talk about the care of patients with intestinal failure
In February this year, our team successfully completed the 30th case of small bowel transplantation in our hospital. She is about 30 years old and is a patient with chronic intestinal pseudo-obstruction syndrome, that is, a patient with poor bowel peristalsis. She can’t eat well; vomiting and burping became her daily routine, and she was often hospitalized for enteritis due to intestinal obstruction before transplantation. One month after the intestinal transplant, she was successfully discharged from the hospital, and now she can start to try various foods, which makes her very happy, and thanks the one who donate bowel. These patients after small bowel transplantation return to our special outpatient clinic on a monthly basis. Some of them have been transplanted for 4-12 years, and some of them have been transplanted for 1-3 years. Every time they meet at our outpatient clinic, they will squeak and chatter. It is also an alternative patient association, providing mutual support. There are also other patients with intestinal failure in the outpatient clinic. The etiology of intestinal failure is very diverse, and not everyone needs intestinal transplantation. For short bowel disease, we also have the most cutting-edge Phase III clinical trials of GLP-2 analogs to improve intestinal absorption. In children, it also supports intestinal growth with growth hormone in cooperation with endocrinologist. In the home parental nutrition patients, catheter management is important to prevent infection, we also use pure fish oil infusion to avoid the occurrence of liver failure. The care complexity is high, but we strive to provide these patients with the most complete and high-quality treatment.
Causes of intestinal failure
Intestinal failure is a kind of disease. The causes are basically divided into three categories. The first category is short bowel syndrome. In adults, it is more often due to ischemic bowel disease; the second category is bowel dysmotility, which is mostly chronic small intestinal pseudo-obstruction syndrome in adults, which is characterized by gradually increasing abdominal distension, vomiting, hiccups, and inability to eat food; the third category is intestinal mucosal dysplasia, which lead to food malabsorption, in infants, the mucosa of the small intestine may be dysplasia, and the presentation is intractable diarrhea. These patients with intestinal failure, because they cannot absorb enough nutrients from the intestines, must be supplemented with intravenous nutrition. Furthermore, it is a long-term thing, they will turn to home parenteral nutrition program.
Treatment of intestinal failure
The priority in the treatment of intestinal failure is to reduce the complications of parenteral nutrition. There are four main items: 1. Reduce artificial blood vessel catheter-related infection: once infection, it is life-threatening sepsis, so the team put great effort to prevent catheter infection; 2. Reduce the risk of major veins thrombosis: We have four large blood vessels for infusion parenteral nutrition, so the team is very cherished for these blood vessels to prevent thrombosis. 3. Reduce liver cirrhosis and liver failure: parenteral nutrition can lead to liver cholestasis. In addition, there are some components of parenteral nutrition, and some bacterial toxins in the intestinal tract can cause liver toxicity and progress to cirrhosis and liver failure. Therefore, how to adjust parenteral nutrition and provide treatments need to be tailored individually. 4. Metabolic diseases: These patients are prone to kidney stones or gallstones due to abnormal absorption patterns. Others are prone to osteoporosis and fractures due to vitamin deficiency, or anemia or hair loss due to insufficient trace elements. The team must also provide timely monitoring and give medications to reduce complications. The second is to improve the quality of life and intestinal rehabilitation. How to make these patients achieve a balance between PN and oral intake, and intestinal rehabilitation for suitable cases, there are mainly four: 1. Drugs to promote digestion and absorption, 2. Choose the appropriate enteral nutrition and delivery method, 3. Enhance intestinal villus growth by nutrients such as glutamine, 4. Enhance intestinal mucosal growth and absorption by endocrine such as GLP-2 or GLP-2 analogs. Because commercial GLP-2 analogues are quite expensive, the monthly drug cost exceeds one million NTD currently. Therefore, no one has reported their use in Taiwan. Our team is fortunate to participate in a multinational Phase III clinical trial of GLP-2 analogs, and the drug can be used at no cost, and the relevant results are still under observation. We always hope to help these bowel failure patients in every direction.
Patients with intestinal failure hope that one day they can return to eating like normal people. Small intestine transplantation is the last hope for these patients. The patients who meet the indications for intestinal transplantation is on the waiting list and the team is on call 365 days a year, to carry out immediate organ transplantation when brain-death donor comes. Because the intestinal immune system is very strong, acute rejection and opportunistic infection are easy to occur six months within transplantation. After a successful discharge from the hospital, a careful observation period of six months is required. After that, the ileostomy for rejection monitoring can be closed, remove the artificial blood vessels catheter, and live a normal life. Of course, at the outpatient clinic, we will carefully look at each parameter and adjust immunosuppression drugs. So far, excluding the pre-clinical trial period, the overall 5-year patient survival rate is 75% , which is good and comparable with other big centers in USand EU.
Dilemmas and challenges: Living donor intestinaltransplantation
Since the first small bowel transplantation in 2007, we have now performed 30 cases. The team has encountered many challenges, medical problems, such as rejection and infection, we have established SOPs one by one and can handle them well now. Because the intestinal failure of the children needs a size match donor,it is not easy to wait for the brain-death donor, and there are many regrets of dying while waiting. Therefore, we strive to complete the animal experiment of living-donor intestinal transplantation and approve the clinical trial of living-donor intestinal transplantation by MOH. Hope the trial can help these patients who cannot wait for organs, critical patient groups, or cases of intestinal failure abroad, and part of the intestine can be donated by relatives for living-donor intestinal transplantation.