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Small-bowel transplantation is indicated for patients who have malabsorption because of intestinal disorders (eg, gastroschisis, Hirschsprung's disease, autoimmune enteritis) or intestinal resection (eg, for mesenteric thromboembolism or extensive Crohn's disease) and who are at high risk of death (usually due to congenital enteropathies such as microvillus inclusion disease) or who develop complications of TPN (eg, liver failure, recurrent sepsis, total loss of venous access). Patients with locally invasive tumors that cause obstruction, abscesses, fistulas, ischemia, or hemorrhage (usually desmoid tumors associated with familial polyposis) are also candidates.
Procedure
Procurement from a brain-dead, beating-heart donor is complex, partly because the small bowel can be transplanted alone, with a liver, or with a stomach, liver, duodenum, and pancreas. The role of living-related donation for small-bowel allografts has yet to be defined. Procedures vary by medical center; immunosuppressive regimens also vary, but a typical regimen includes antilymphocyte globulin for induction, followed by high-dose tacrolimus and mycophenolate mofetil for maintenance.
Weekly endoscopy is indicated to check for rejection. Symptoms and signs of rejection include diarrhea, fever, and abdominal cramping. Endoscopic findings include mucosal erythema, friability, ulceration, and exfoliation; changes are distributed unevenly, may be difficult to detect, and can be differentiated from cytomegalovirus enteritis by viral inclusion bodies. Biopsy findings include blunted villi and inflammatory infiltrates in the lamina propria. Treatment of acute rejection is high-dose corticosteroids, antithymocyte globulin, or both.
Prognosis
Surgical complications affect 50% of patients and include anastomotic leaks, biliary leaks and strictures, hepatic artery thrombosis, and chylous ascites. Nonsurgical complications include graft ischemia and graft-vs-host disease caused by transplantation of gut-associated lymphoid tissue.
At 3 yr, > 50% of grafts with small-bowel transplantation alone survive, but patient survival is around 65%. With liver and small-bowel transplantation, survival rate is lower because the procedure is more extensive and the recipient's condition is more serious.
Last full review/revision September 2008 by Martin Hertl, MD, PhD; James F. Markmann, MD, PhD; Paul S. Russell, MD; Heidi Yeh, MD
Content last modified September 2008
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