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Small BowelTransplantation

Dr Nilay BiswasPost Graduate Resident

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Background

100 patients receive small bowel

transplants each year.

Between 60 and 70 are kids age 18and under.

Small bowel transplantation was first

attempted in humans in 1964.

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Small bowel transplant is thetransplantation of an intestinal allograft to

an individual with irreversible intestinal

failure.

The purpose of this transplant

is to restore intestinal function.

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Indications

Irreversible intestinal failure

not successfully managed by TPN

life-threatning complications whileon TPN

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Intestinal failure

In children

1. Necrotising enterocolitis

2. Gastroschisis

3. Volvulus4. intestinal atresia

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Intestinal failure

In adults

1. Crohns disease

2. Mesenteric vascular thrombosis

3. Trauma

4. Desmoid tumors

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Types of intestinal

transplantation

alone

along with liver

multivisceral (liver, pancreas,stomach, duodenum & colon )

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Types of donors

deceased donors

living donors

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Preoperative evaluation

Medical

Surgical

Immunologic

Psychosocial

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Surgical procedure

Isolated intestinal transplant

In living donor 200 cm of distal small bowelis used.

Inflow to the graft is via ileocolic artery

Outflow is via ileocolic vein

In deceased donor graft is based onsuperior mesenteric artery for inflow andon the superior mesenteric vein for outflow

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Surgical procedure

Combined liver and intestinal transplant

Graft is procured intact with an aorticconduit containing both celiac and

superior mesenteric arteries

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Surgical procedure

Arterial inflow to the graft is achieved

using the recipients infrarenal aorta by

end-to-side anastomosis

Venous drainage can be performed to

the systemic or portal circulation

GI continuity achieved

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Surgical procedure

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Postoperative care

Initial care in ICU

Monitoring of fluid, electrolyte and

blood product replacement

Broad spectrum antibiotics

Monitoring of rejection by

endoscopic biopsy of the graftmucosa

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Problems

Immunologically small intestine is the most

dificult organ to transplant

Monitoring for rejection is difficult

Bacterial translocation

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Contraindications

Life expectancy of less than five years due to age-related debilitation and co-morbiditiesAbility to ingest oral nutrition

Unresectable malignancySerious, uncontrolled psychiatric illness that wouldhinder compliance with any stage of the transplantprocessNeurologic illness independent of the diseaseprocess being treated

Drug or alcohol addiction

HIV (positive)

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Contraindications

Active and / or life-threatening infection

Severe body / organ system diseaseunrelated to transplanted organ

Compromised cardio-pulmonary functionunrelated to transplanted organ

Inability or unwillingness of the individual or

legal guardian to give signed consent andto comply with regular follow-uprequirements

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