Approximately 274 candidates are currently on the waiting list for an intestinal transplant, with 147 transplants performed in 2016. It still remains as one of the most challenging and least frequently performed abdominal transplant procedure. This has been mainly due to poor long term survival and a higher rate of post-procedure complications in the recipients. Recent and continuing advancement in surgical techniques and better monitoring and management of post-operative complications have improved outcomes in this challenging group of patients.
The most common indication for intestinal transplantation is intestinal failure with the development of severe complications due to total parenteral nutrition (TPN).
The most important cause for intestinal failure is short bowel or short gut syndrome. This refers to a serious condition where there is a lack of well functioning small intestine which can result in diarrhea and failure to absorb adequate nutrients leading to weight loss and severe malnutrition.
There are multiple causes of short gut syndrome. In children, congenital malformations , infections, extensive surgical removal and an inability to absorb nutrients are the major reasons for which TPN is required for survival. Similarly, in adults, extensive resections because of conditions like Crohn’s disease, tumors or ischemia are responsible for the need for TPN.
Most patients will do well with chronic home TPN. Recent data has shown more than 80 % survival in a 3 year period. Severe complications due to TPN such as recurrent catheter related infections, lack of central venous options, chronic liver failure and a poor quality of life will be the major reason for considering intestinal transplantation.
Surgical procedures for intestinal failure are divided into intestinal transplant alone or in combination with the liver or other abdominal organs. Donors are usually deceased but some live donor intestinal transplants are being performed as well. Extensive pre-operative testing that includes blood tests, xrays of the remaining bowel, liver biopsy if there is any liver dysfunction and tests to ensure that the heart and lungs are healthy enough to undergo this major surgery are done prior to listing a patient for transplantation.
Post-operative care is in the ICU where there is close monitoring to make sure all the organs are functioning well. Antibiotics are used to prevent infections and immunosuppressive medications are given to prevent rejection of the transplanted organ. Once there is good functioning of the intestinal transplant, oral diet is started. Close monitoring after discharge is standard to prevent complications such as severe infections, drug reactions, post-transplant cancers and rejections.
Recent data suggests improving survival rates with better patient and graft selection, improved monitoring of post-transplant related complications and transplants performed at relatively high volume centers.