Intestinal Transplantation 

  • Author: Stuart M Greenstein, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Jan 14, 2009
 

Background

As with the transplantation of other organs, the history of intestinal transplantation begins with Carrel and his description of a method of performing vascular anastomosis.[1, 2] In 1959, the first canine model of intestinal transplantation was reported by Lillihei and coworkers at the University of Minnesota.[3] The first intestinal transplant in humans was performed by Deterling in Boston in 1964 (unpublished data). The first reported human intestinal transplant was performed by Lillihei and coworkers in 1967.[4] Before 1970, 8 clinical cases of small-intestine transplantation were reportedly performed worldwide; maximum graft survival time was 79 days, and all patients died of technical complications, sepsis, or rejection.

In 1988 Deltz and coworkers in Kiel, Germany, performed what is considered to be the first successful intestinal transplant.[5] Soon after, other successful outcomes were reported by the groups headed by Goulet and coworkers in Paris[6] and Grant and coworkers in London, Canada, who had established the first intestinal transplant programs.[7, 8] A total of 15 isolated small-intestine transplantations were performed from 1985-1990 using cyclosporine. Graft survival time in these cases ranged from 10 days to 49 months.

Intestinal transplantation has evolved in the past decade from being considered an experimental procedure to what is considered today as the only long-term option for patients with intestinal failure who have developed irreversible complications associated with the chronic use of parenteral nutrition. Over the past decade, intestinal transplantation has shown remarkable advancement not only in volume of transplants performed but also in outcomes, thanks to progress in various aspects of organ preservation, surgical technique, immunosuppression, and postoperative management.

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Problem

The incidence of intestinal failure with complications of total parenteral nutrition (TPN) is difficult to measure. From studies of TPN-dependent patients, the incidence of irreversible intestinal failure is estimated to be 2-3 cases per million persons per year. The number of candidates listed for the various forms of intestine transplantation has steadily increased.

Number of candidates on the intestine waiting listNumber of candidates on the intestine waiting list active at year-end (1997-2006).

As of December 2008, the United Network for Organ Sharing (UNOS) database listed 224 patients awaiting intestinal transplantation.

Most candidates are younger than 6 years, white, and male. The number of listed patients with a prior organ transplant, including the intestine, has nearly tripled from 3% in 1997 to 14% in 2006. Short gut syndrome still represents most waiting list primary diagnoses.

Number of candidates on the intestine waiting listNumber of candidates on the intestine waiting list by age at year-end (1997-2006).

The median time to transplant for new list registrations is one of the longest of any solid organ transplant. Currently, median time to transplant is 261 days.

Median time to transplant for new intestine waitinMedian time to transplant for new intestine waiting list registration (1998-2006).

Although the median time to transplant does not appear to be dramatically influenced by ethnicity, race, gender, and blood group, some differences are noted. The median time to transplant tends to be longer for males than females. The mortality in the waiting list is more than double that for candidates of other solid organ transplants.

For intestine candidates, the age groups with the highest waiting list mortality are patients aged 1–5 years, patients aged 35–49 years, and patients aged 50–64 years. Race and ethnicity may also play a role in waiting list mortality, with Asians and Hispanics having the highest rates. Blood groups also differ in mortality, with groups B and AB having a higher mortality than the mean. The primary diagnosis also affected waiting list mortality rates, with short gut syndrome and functional bowel problems having the lowest death rates.

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Indications

Intestinal failure is characterized by the inability to maintain protein energy, fluid, electrolyte, or micronutrient balance due to GI disease when on a normal diet. Intestinal failure ultimately leads to increase malnutrition and even death if the patient does not receive parenteral nutrition or become a recipient of an intestinal transplant. Worldwide, the leading cause of intestinal failure is short bowel syndrome caused by surgical removal.

The leading causes of intestinal failure differ between adult and pediatric populations. In children, the following are the leading causes of intestinal failure:

The following are the leading causes of intestinal failure in adults:

  • Crohn disease
  • Superior mesenteric artery thrombosis
  • Superior mesenteric vein thrombosis
  • Trauma
  • Desmoid tumor
  • Volvulus
  • Pseudo-obstruction
  • Massive resection secondary to tumor
  • Radiation enteritis

Parenteral nutrition is the current standard of care for patients with intestinal failure. Never than less, the chronic use of parenteral nutrition is often associated with potentially life-threatening complications, including catheter-related sepsis, catheter-related thrombosis, severe dehydration, metabolic derangements, loss of sites for vascular access, and parenteral nutrition associated liver disease (PNALD). Severe liver injury has been reported in as many as 50% of patients with intestinal failure who receive parenteral nutrition for longer than 5 years; this is typically fatal.

Currently, parenteral nutrition continues to be the therapy of choice for patients with intestinal failure. However, intestinal transplantation should be recommended in patients with the following conditions:

  • Failure of the parenteral nutrition
    • Impending or overt liver failure secondary to PNALD
    • Thrombosis of 2 or more central veins
    • Two or more episodes per year of systemic sepsis secondary to line infections
    • Frequent episodes of severe dehydration
  • High risk of death
  • Severe short bowel syndrome (gastrostomy, duodenostomy, residual small bowel [< 10 cm in infants, < 20 cm in adults])
  • Intestinal failure with frequent hospitalizations, narcotic dependency, or pseudoobstruction
  • Patient unwillingness to accept long-term parenteral nutrition

In addition to intestine-only and intestine-liver transplants, multivisceral transplants represent a third type of intestinal transplant. UNOS defines a multivisceral transplant as one that includes the intestine and liver and either the pancreas or kidney; however, several combinations may be used (see Media files 4-6).

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Relevant Anatomy

See Treatment.

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Contraindications

The contraindications of intestinal transplantation are essentially the same as is seen in other types of transplants. For example, significant coexistent medical conditions that have no potential for improvement following transplantation, an active uncontrolled infection or malignancy that is not eliminated by the transplant process, and psychosocial factors (eg, the lack of capability to assume the responsibilities of the day-to-day management following the transplant or the absence of family support).

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Contributor Information and Disclosures
Author

Stuart M Greenstein, MD  Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center

Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Coauthor(s)

Javier Chapochnhick Friedmann, MD  Multiorgan Transplant Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center; Assistant Professor of Surgery, Albert Einstein College of Medicine

Javier Chapochnhick Friedmann, MD is a member of the following medical societies: American Society of Transplant Surgeons

Disclosure: Nothing to disclose.

Owen Prowse, MD, MPH, FRCSC  Assistant Professor, Department of Surgery, Northern Ontario School of Medicine, Lakehead University and Laurentian University

Owen Prowse, MD, MPH, FRCSC is a member of the following medical societies: Canadian Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Casimir F Firlit, MD, PhD  Attending Urologist, Department of Urology, Cardinal Glennon Children's Medical Center; Surgical Director, Pediatric Urology Specialists, PC, Cardinal Glennon Children's Medical Center

Casimir F Firlit, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Society of Transplant Surgeons, American Urological Association, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Steve Dunn, MD  Chief, Solid Organ Transplantation, Department of Surgery, Alfred I DuPont Hospital for Children at Wilmington

Steve Dunn, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, American Society of Transplantation, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Ron Shapiro, MD  Professor of Surgery, Robert J Corry Chair in Transplantation Surgery, Director, Kidney, Pancreas, and Islet Transplantation, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center

Ron Shapiro, MD is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, Association for Academic Surgery, Central Surgical Association, and Society of University Surgeons

Disclosure: Astellas Honoraria Speaking and teaching; Brystol Meyer Squibb StemCell Data Monitoring Committee Consulting fee Review panel membership; Wyeth Honoraria Speaking and teaching; Stem Cells, Inc Consulting fee Review panel membership; Up To Date contracted Author; Medscape contracted Video Blogger

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

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Number of candidates on the intestine waiting list active at year-end (1997-2006).
Number of candidates on the intestine waiting list by age at year-end (1997-2006).
Median time to transplant for new intestine waiting list registration (1998-2006).
Isolated small bowel graft.
Liver-small bowel graft, including the pancreas.
Multivisceral graft, including stomach-liver-pancreas-small bowel and right colon.
Isolated intestinal transplant. A gastrostomy tube, jejunostomy tube, and loop ileostomy are in place.
 
 
 
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