Surveillance of Allograft Rejection After Intestinal Transplantation Using a Magnifying Endoscopy With Narrow Band Imaging Scoring System ("VENCH" Score)

Study design

This cohort study was conducted prospectively and approved by the ethics committee of Far Eastern Memorial Hospital (IRB No. FEMH-105023-F). Consecutive patients who received IT between November 2016 and September 2017 were enrolled. The inclusion criteria were as followings: post-IT patients older than 7-year-old, and with informed consent for endoscopy and biopsy. Those with bleeding tendency (platelet count <80k/ul, or prothrombin time international normalized ratio >1.5), without informed consent, or leukopenia (absolute neutrophil count <1,500/ul) were excluded.

Endoscopic and histological grading for allograft rejection Endoscopic surveillance was carried out after IT twice a week during the first month, once a week in the second month and then once per month until ileostomy closed. IEE examinations were performed with magnifying endoscopy (ME) which has powerful 80 times optical magnification under narrow-band imaging (NBI) system (Evis Lucera CLV-260NBI, GIF-H260Z endoscopy, Olympus Medical Systems Corp, Tokyo, Japan).14 ME was intubated through chimney ileostomy to anastomosis site to evaluate the changes of superficial mucosal surface and vascular architecture. Biopsy samples were taken from endoscopically suspicious rejection areas for histological examination. All the endoscopic procedures were done by one experienced endoscopist (C.S-C.) who was blinded to the histological reports.

All the histological reports were carried out by one experienced pathologist (C.C.-T.). The severity of histological rejection was graded according to followings:11 1) Indeterminate:

minimal histological changes including localized inflammatory infiltrate, crypt epithelial injury, increased crypt epithelial apoptosis but less than 6 apoptotic bodies/10crypts, no to minimal architectural distortion, no mucosal ulceration, or changes insufficient for the diagnosis of mild rejection; 2) Mild: mild localized inflammatory infiltrate with activated lymphocytes, mild crypt epithelial injury, increased crypt epithelial apoptosis > 6 apoptotic bodies/10crypts, mild architectural distortion but no mucosal ulceration; 3) Moderate: widely dispersed inflammatory infiltrate in lamina propria, diffuse crypt epithelial injury, increased crypt apoptosis with focal confluent apoptosis, more prominent architectural distortion, possible mild to moderate intimal arteritis, no mucosal ulceration; 4) Severe: features of moderate ACR, possible ulceration and denudation of mucosa, severe intimal arteritis or transmural arteritis may be seen. We classified those with apoptotic body≦1/10crypts and without other findings associated with indeterminate, mild, moderate to severe rejection as no rejection.