INDICATIONS FOR INTESTINAL TRANSPLANT

Intestinal transplantation is now a therapy for patients with irreversible intestinal failure. Intestinal failure is defined as the inability of the intestine to absorb and process nutrition given by mouth or feeding tube. It can be divided into two major classes: intestinal failure due to congenital absence or surgical removal of long segments of the intestine (short gut syndrome), or intestinal failure due to a functional inability of the intestine. The latter is the cause of intestinal failure in patients with intestinal pseudo-obstruction or total Hirschsprung disease (aganglionosis). In this disease, the intestine has normal length, but it can not move food distally to be absorbed and digested. So, even if there is no lack of length, there is a lack of function of the bowel. When patients are diagnosed with intestinal failure, they have often had multiple surgeries, they have had some of their intestines removed, and most times they have a part of the intestine brought out to the skin (ostomy). Nutrition has to be given through the veins, in form of parenteral nutrition (TPN or HAL, hyperalimentation). This is a good way of giving calories and nutrition to those who cannot get any food by mouth or feeding tube, but it has many potential complications. The most important complications of TPN are: line infection, liver failure and loss of vein access for the line. When these complications become life-threatening, TPN has failed and this is when intestinal transplant is indicated. Therefore, intestinal transplant is indicated when the liver function worsens, when a patient develops multiple episodes of line infection that require hospitalization, and when more than half of the veins available for line placement are clotted off and cannot be used any longer. Another, less common, indication for intestinal transplant is if a patient has intractable diarrhea, requiring continuous intravenous hydration and frequent admissions to the hospital for dehydration episodes. Patients with motility disorders have been receiving successful intestinal transplantation for many years now, but they present a specific set of complicating factors, which have to be considered before and after transplant. First of all, the disease is often extended to other organs (bladder, for instance) or to other parts of the intestine like the esophagus and rectum, which cannot be transplanted. This is important because transplantation will not cure motility disorders in these organs. For example, a patient with Hirschsprung disease can have a successful intestinal transplant, but when time comes to close the stoma and reconnect the transplant intestine to the native rectum, functional obstruction may happen again. In addition, if there were esophageal or stomach motility problems, after isolated intestinal transplant, these problems will not disappear. These are things that transplant surgeons, parents and patients need to discuss before surgery, so that they can plan the type of transplant or if there will be a need for more surgeries after transplant. Generally speaking, intestinal transplantation can be divided into different categories: first of all it is important to decide if the patient needs also a liver transplant or not. If TPN has caused irreversible liver failure, then in addition to the intestine the patient will need also a liver transplant. Different parts of the intestine can be transplanted, and the following are the most commonly used type of surgeries, with the description of the organs transplanted.


Gennaro Selvaggi, M.D.
Assistant Professor of Clinical Surgery
Division of Liver and GI Transplantation