Crohn Disease and Intestinal Transplantation
Original Investigation Research
Invited Commentary
Crohn Disease and Intestinal Transplantation Benefit Balance J. Michael Millis, MD
The article by Gerlach et al1 published in this issue of JAMA Surgery has the promise to usher in an era in which the time to cease traditional medical and surgical therapies and initiate transplantation care is defined. The role of intestinal Related article page 1060 transplantation, although proven to be of value in many patients with intestinal failure, has not been identified in patients with Crohn disease. Unlike many diseases that lead to intestinal failure and transplantation in which there are few additional medical or surgical options, Crohn disease has a broad armamentarium of treatment options, although some of these treatments may complicate or ultimately contraindicate intestinal transplantation. The current state of intestinal transplantation is at the same phase as liver transplantation for biliary atresia was in 1988 and defining the risk-benefit ratio in liver transplantation with MELD.2,3 The question for patients with biliary atresia was whether a portoenterostomy was indicated and, if so, whether patients should continue with surgical revision or pro-
ceed with liver transplantation. Similarly, patients with Crohn disease have many surgical and medical options that markedly complicate the analysis of the decision algorithm. The authors retrospectively applied their modification of the American Gastroenterology Association intestinal transplantation guidelines to objectively define the optimal time for transplantation referral and transplantation. This is an initial attempt to determine when the risk-benefit ratio favors transplantation and when transplantation is futile. They make a case that the Karnofsky performance status score increased 35% in the patients who survived. I believe this significantly misses the point because the 20% mortality in patients undergoing transplantation indicates that transplantation is indicated only when there is a significant risk of death without transplantation. Early transplantation intervention is only warranted if the posttransplantation mortality increases after exhaustive surgical and medical therapies, as was the case in multiple revisions of the portoenterostomy for biliary atresia. As experience increases, this critical decision will become clearer.
ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
Author Affiliation: Section of Transplantation, University of Chicago, Chicago, Illinois.
REFERENCES
Corresponding Author: J. Michael Millis, MD, Section of Transplantation, University of Chicago, 5841 S Maryland Ave, MC 5027, Chicago, IL 60637 ([email protected]).
1. Gerlach UA, Vrakas G, Reddy S, et al. Chronic intestinal failure after Crohn disease: when to perform transplantation [published online August 27, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014 .1072.
Published Online: August 27, 2014. doi:10.1001/jamasurg.2014.1804.
jamasurgery.com
2. Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe RA. The survival benefit of liver transplantation. Am J Transplant. 2005;5(2):307-313. 3. Millis JM, Brems JJ, Hiatt JR, et al. Orthotopic liver transplantation for biliary atresia: evolution of management. Arch Surg. 1988;123(10):1237-1239.
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/02/2015
1067
Original Investigation Research
Invited Commentary
Crohn Disease and Intestinal Transplantation Benefit Balance J. Michael Millis, MD
The article by Gerlach et al1 published in this issue of JAMA Surgery has the promise to usher in an era in which the time to cease traditional medical and surgical therapies and initiate transplantation care is defined. The role of intestinal Related article page 1060 transplantation, although proven to be of value in many patients with intestinal failure, has not been identified in patients with Crohn disease. Unlike many diseases that lead to intestinal failure and transplantation in which there are few additional medical or surgical options, Crohn disease has a broad armamentarium of treatment options, although some of these treatments may complicate or ultimately contraindicate intestinal transplantation. The current state of intestinal transplantation is at the same phase as liver transplantation for biliary atresia was in 1988 and defining the risk-benefit ratio in liver transplantation with MELD.2,3 The question for patients with biliary atresia was whether a portoenterostomy was indicated and, if so, whether patients should continue with surgical revision or pro-
ceed with liver transplantation. Similarly, patients with Crohn disease have many surgical and medical options that markedly complicate the analysis of the decision algorithm. The authors retrospectively applied their modification of the American Gastroenterology Association intestinal transplantation guidelines to objectively define the optimal time for transplantation referral and transplantation. This is an initial attempt to determine when the risk-benefit ratio favors transplantation and when transplantation is futile. They make a case that the Karnofsky performance status score increased 35% in the patients who survived. I believe this significantly misses the point because the 20% mortality in patients undergoing transplantation indicates that transplantation is indicated only when there is a significant risk of death without transplantation. Early transplantation intervention is only warranted if the posttransplantation mortality increases after exhaustive surgical and medical therapies, as was the case in multiple revisions of the portoenterostomy for biliary atresia. As experience increases, this critical decision will become clearer.
ARTICLE INFORMATION
Conflict of Interest Disclosures: None reported.
Author Affiliation: Section of Transplantation, University of Chicago, Chicago, Illinois.
REFERENCES
Corresponding Author: J. Michael Millis, MD, Section of Transplantation, University of Chicago, 5841 S Maryland Ave, MC 5027, Chicago, IL 60637 ([email protected]).
1. Gerlach UA, Vrakas G, Reddy S, et al. Chronic intestinal failure after Crohn disease: when to perform transplantation [published online August 27, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014 .1072.
Published Online: August 27, 2014. doi:10.1001/jamasurg.2014.1804.
jamasurgery.com
2. Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe RA. The survival benefit of liver transplantation. Am J Transplant. 2005;5(2):307-313. 3. Millis JM, Brems JJ, Hiatt JR, et al. Orthotopic liver transplantation for biliary atresia: evolution of management. Arch Surg. 1988;123(10):1237-1239.
JAMA Surgery October 2014 Volume 149, Number 10
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/02/2015
1067
