There has been a lost of discussion regarding intestinal transplantation in the context of the victim of the brutal gang-rape in New Delhi recently. Irate protestors, politicians, armchair philosophers and all the usual suspects have been clamouring for 'severe punishment' read 'mutilation', 'torture' and 'death' for the perpetrators of this heinous crime. Some members of the medical fraternity have shockingly and appallingly joined voice with their irresponsible and impulsive suggestions for painless 'mutilation' of the accused forgetting that as professionals they are sworn not to do anything to harm a human being.
Media and medical fraternity have been fairly verbose and prosaic in describing the medical condition of the victim with frequent and graphic updates regarding her condition with the need for intestinal transplantation being thrown-in fairly frequently for good measure. There have also been 'ill-disguised' attempts at garnering fifteen minutes of fame and scoring brownie points in certain quarters provoking comments like 'harvesting the rapists intestines to help the victim' among the less informed and emotional public. There have also been sane and sage voices of reason appearing as well but these have been largely drowned out by the raucous cacophony on part of the rabble-rousers. The medical-media circus has culminated in the shifting the ill-fated victim outside the country to an institution that has 'multi-organ transplant facilities' and 'infrastructure' to help the victim recover despite contradicting reports regarding her condition varying between 'repeated cardiac arrests' to 'extremely critical' and critical but stable' depending on which version you choose to believe. The government itself has contradicted itself on the current condition of 'Nirbhaya', 'Amanat' or 'Jane Doe' depending on what you choose to call her .... (why they could not use her first name however boggles my imagination).
As a responsible medical professional privileged to understand the facts, I feel beholden to try and scatter the chaff regarding intestinal transplantation to provide some scientific perspective to the muddled situation created by contradicting and confusing inconsistent statements.
Intestinal failure occurs when there is insufficient surface area of small intestine to digest and absorb nutrients to meet the demands of the body entirely through enteral route. This usually occurs when large parts of the intestine are lost due to massive removal at one sitting or repeated removals. Traumatic injury is a rare cause of intestinal failure. Patients with intestinal failure have massive diarrhoea, dehydration and nutritional deficiencies due to inability to absorb water, fat, protein and vitamins all of which have to be supplemented through the intravenous route (parenteral) for survival. Parenteral nutrition needs to be delivered through large central veins using indwelling catheters.
The intestine has significant but not infinite potential to compensate for loss of length by increasing absorptive mechanisms and allow nutritional independence through a series of intrinsic changes called 'intestinal adaptation'. Extent of adaptation depends on various factors including the residual length, which part has been resected, presence of large intestine, blood supply as well as general health and age of the patient. It is generally believed that the ileum has higher potential to adapt than the jejunum. Most authorities agree than when less than 50cm small intestine is left behind, it is extremely unlikely that the patient will ever be able to be free for parenteral nutrition.
Long term parenteral nutrition has several consequences including line infections, clotting of veins, nutritional deficiencies, fluid overload, hyperglycaemia and development of progressive liver dysfunction any or all of which are life threatening. More importantly this severely impacts the quality of life of the patient and imposes significant costs. Successful transition to home-based and night time parenteral nutrition is not possible in all cases.
Intestinal transplantation is offered to those who fail all attempts at rehabilitation or develop complications of parenteral infections like repeated line infections, fungal infections or who develop extensive clotting of veins precluding continuation of parenteral nutrition or severe liver dysfunction. In the latter case combined liver and intestinal transplantation can also be necessitated.
INTESTINAL TRANSPLANTATION IS NEVER AN EMERGENCY!
Somehow this fact though mentioned in the current context has been drowned out.
What a patient with massive loss of intestine acutely needs is to be kept free from infection and provided optimal fluid volume, electrolytes and nutrients to compensate for loss of intestinal function. It is important that dehydration, electrolyte disturbances and hypotension be avoided as these can further compromise the ability of the residual intestine or even be fatal. Unless the status of the patient can be optimised and rehabilitation on parenteral nutrition achieved there is no question of performing an intestinal transplant in the future.
Intestinal transplant like any transplant requires a donor organ. This may be a deceased (brain-dead or cadaver) donor or a live donor. The former is preferred due to the ability to provide larger length and inherently larger vessels to join. It is not possible to transplant just anyone's intestine. The donor should be 30-50% of the patient's size ( to allow intestine to fit), be of same or compatible blood group and ideally should be HLA matched. SO ASKING FOR HARVESTING THE RAPIST'S INTESTINES MAY NOT BE OF ANY HELP TO THE VICTIM.
Results of intestinal transplant have been improving but are not yet as good as liver or kidney transplant. This is because the intestine is a hollow organ loaded with bacteria and has much larger population of immune cells (lymphocytes ) in its wall than other organs that make it prone to infection and more likely to incite an immune response (rejection) when transplanted. Intestinal transplant is much more resource intensive in the intermediate to long term rather than solid organ transplant. Despite improvement in critical care, infection control and anti-rejection therapy results of intestinal transplantation are 50-65% at 1 year on average ( 70-80% at the best centres) and at 3 years between 40-50% (55-60% at best centers). THEREFORE UNLESS THEY ARE WILLING TO PROVIDE LIFELONG FREE CARE, A POPULIST OFFER TO FUND AN INTESTINAL TRANSPLANT FOR THE VICTIM IS ONLY WINDOW-DRESSING.
I have the greatest sympathy for the victim's plight and empathise with the outrage it has generated. However while we condemn the incident in the strongest terms and our heart goes out to the victim, it will do us no favour or credit to lose sight of the medical facts!
Media and medical fraternity have been fairly verbose and prosaic in describing the medical condition of the victim with frequent and graphic updates regarding her condition with the need for intestinal transplantation being thrown-in fairly frequently for good measure. There have also been 'ill-disguised' attempts at garnering fifteen minutes of fame and scoring brownie points in certain quarters provoking comments like 'harvesting the rapists intestines to help the victim' among the less informed and emotional public. There have also been sane and sage voices of reason appearing as well but these have been largely drowned out by the raucous cacophony on part of the rabble-rousers. The medical-media circus has culminated in the shifting the ill-fated victim outside the country to an institution that has 'multi-organ transplant facilities' and 'infrastructure' to help the victim recover despite contradicting reports regarding her condition varying between 'repeated cardiac arrests' to 'extremely critical' and critical but stable' depending on which version you choose to believe. The government itself has contradicted itself on the current condition of 'Nirbhaya', 'Amanat' or 'Jane Doe' depending on what you choose to call her .... (why they could not use her first name however boggles my imagination).
As a responsible medical professional privileged to understand the facts, I feel beholden to try and scatter the chaff regarding intestinal transplantation to provide some scientific perspective to the muddled situation created by contradicting and confusing inconsistent statements.
Intestinal failure occurs when there is insufficient surface area of small intestine to digest and absorb nutrients to meet the demands of the body entirely through enteral route. This usually occurs when large parts of the intestine are lost due to massive removal at one sitting or repeated removals. Traumatic injury is a rare cause of intestinal failure. Patients with intestinal failure have massive diarrhoea, dehydration and nutritional deficiencies due to inability to absorb water, fat, protein and vitamins all of which have to be supplemented through the intravenous route (parenteral) for survival. Parenteral nutrition needs to be delivered through large central veins using indwelling catheters.
The intestine has significant but not infinite potential to compensate for loss of length by increasing absorptive mechanisms and allow nutritional independence through a series of intrinsic changes called 'intestinal adaptation'. Extent of adaptation depends on various factors including the residual length, which part has been resected, presence of large intestine, blood supply as well as general health and age of the patient. It is generally believed that the ileum has higher potential to adapt than the jejunum. Most authorities agree than when less than 50cm small intestine is left behind, it is extremely unlikely that the patient will ever be able to be free for parenteral nutrition.
Long term parenteral nutrition has several consequences including line infections, clotting of veins, nutritional deficiencies, fluid overload, hyperglycaemia and development of progressive liver dysfunction any or all of which are life threatening. More importantly this severely impacts the quality of life of the patient and imposes significant costs. Successful transition to home-based and night time parenteral nutrition is not possible in all cases.
Intestinal transplantation is offered to those who fail all attempts at rehabilitation or develop complications of parenteral infections like repeated line infections, fungal infections or who develop extensive clotting of veins precluding continuation of parenteral nutrition or severe liver dysfunction. In the latter case combined liver and intestinal transplantation can also be necessitated.
INTESTINAL TRANSPLANTATION IS NEVER AN EMERGENCY!
Somehow this fact though mentioned in the current context has been drowned out.
What a patient with massive loss of intestine acutely needs is to be kept free from infection and provided optimal fluid volume, electrolytes and nutrients to compensate for loss of intestinal function. It is important that dehydration, electrolyte disturbances and hypotension be avoided as these can further compromise the ability of the residual intestine or even be fatal. Unless the status of the patient can be optimised and rehabilitation on parenteral nutrition achieved there is no question of performing an intestinal transplant in the future.
Intestinal transplant like any transplant requires a donor organ. This may be a deceased (brain-dead or cadaver) donor or a live donor. The former is preferred due to the ability to provide larger length and inherently larger vessels to join. It is not possible to transplant just anyone's intestine. The donor should be 30-50% of the patient's size ( to allow intestine to fit), be of same or compatible blood group and ideally should be HLA matched. SO ASKING FOR HARVESTING THE RAPIST'S INTESTINES MAY NOT BE OF ANY HELP TO THE VICTIM.
Results of intestinal transplant have been improving but are not yet as good as liver or kidney transplant. This is because the intestine is a hollow organ loaded with bacteria and has much larger population of immune cells (lymphocytes ) in its wall than other organs that make it prone to infection and more likely to incite an immune response (rejection) when transplanted. Intestinal transplant is much more resource intensive in the intermediate to long term rather than solid organ transplant. Despite improvement in critical care, infection control and anti-rejection therapy results of intestinal transplantation are 50-65% at 1 year on average ( 70-80% at the best centres) and at 3 years between 40-50% (55-60% at best centers). THEREFORE UNLESS THEY ARE WILLING TO PROVIDE LIFELONG FREE CARE, A POPULIST OFFER TO FUND AN INTESTINAL TRANSPLANT FOR THE VICTIM IS ONLY WINDOW-DRESSING.
I have the greatest sympathy for the victim's plight and empathise with the outrage it has generated. However while we condemn the incident in the strongest terms and our heart goes out to the victim, it will do us no favour or credit to lose sight of the medical facts!
