Monday, 7 January 2013

India's first recipient of a successful intestinal transplant.............4013

Had Damini / Nirbhaya lived long, she too would have ultimately needed one.

Himanshu's long wait for food has finally come true after more than two years' wait that involved being hospitalized 11 times, undergoing six surgeries and suffering from serious infections thrice.

Himanshu, a 30-year-old software engineer who has had better luck than the 23-year-old Delhi gang-rape victim Nirbhaya, has become India's first recipient of a successful intestinal transplant.

Back in 2009, Himanshu had complained of severe stomach ache. An emergency laparotomy was conducted and doctors found that he was suffering from thrombosis (blockage) of the main vein of his intestine (superior mesenteric vein) which resulted in loss of blood supply to most of his intestine.

Subsequently, 95% of his small intestine (usually six metres long) had to be removed, leaving him with just 28 cm of it. This saved his life, but also meant that he would never be able to eat solid food orally.

The small intestine is where 90% of the digestion and food absorption occurs. Chemical digestion with enzymes and bile acids take place here which breaks down food into a form that can be absorbed and then sent to various tissues of the body. Once broken down, the nutrients are absorbed by small intestines' inner walls into the blood stream.

Doctors at Gurgaon's Medanta Medicity evaluated and counseled Himanshu for an intestinal transplant and put him on the waiting list.

Himanshu waited for two years before he got lucky with a matched organ. On November 24, 2012, doctors found a perfect match.

A 20-year-old patient who had passed away had the same blood group and was fit to donate.

Dr A S Soin, who headed the team of 30 doctors from Medanta which conducted the surgery, said, "During the surgery, 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 three years. The new small intestine was transplanted, joining the blood vessels to the recipient's and the ends of the new intestine to the existing proximal and distal bowel."

"I had to re-learn how to eat normally and understand the signals of satiety. Even the 'khichdi' given to me tasted divine," said Himanshu. He said that is now off TPN for the past 10 days, and can eat normally.

According to the doctors, joining 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.

Two weeks after the surgery, Himanshu was given food through a tube into his small intestine after which oral feeding was resumed.

According to Dr R Mohanka the main challenge after the surgery was the post-operative management since intestinal transplants reject easily, much more than any other organ.

This necessitated large doses of immune suppressant medication - approximately three times than used in liver transplants.

"This makes the chances of developing infection very high. Hence, 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 are 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 added 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 first six weeks, it can develop later too. This means that this monitoring must continue for at least six months," he added.

According to Dr Soin, the most common causes of intestinal failure in adults are short bowel syndrome that results from extensive bowel removal due to blood clots in major veins or arteries of intestine, major abdominal trauma or, inflammatory bowel diseases like Crohn's disease.

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. "My son had been on TPN for almost two years. It cost us close to Rs 40,000 to 50,000 per month. The transplant, through costly, has given us some hope for a better future," said J P Singh, the patient's father. Himanshu said he was feeling much better post-surgery, and could digest khichdi.

According to Dr Naresh Trehan, chairman of Medanta, about 2,000-2,500 people suffer intestinal failure annually in India, who need permanent TPN or intestinal transplant.

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