Intestinal transplantation is a surgical treatment for intestinal failure. It is one of the most rarely performed transplant procedures performed, exclusively involving the transplantation of donor small bowel to a recipient, with an ileostomy formation.
Due to the high risk of complications with the procedure, it is usually reserved for patients with intestinal failure who are unable to be sustained on total parenteral nutrition (TPN) due to complications of TPN treatment 1,2.
With continued improvements in donor selection, organ preservation, and operative techniques, studies report improvements in outcomes from intestinal transplants to be comparable with those from lung transplantation 7.
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Indications
There are two main patient groups that are candidates for small bowel transplantation:
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commonly due to previous surgical bowel resection
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impaired motility
impaired absorption despite sufficient gut length
Contraindications
untreated systemic or local infections
severe cardiac or pulmonary failure
malignancy (relative contraindication) 2
Surgical technique
Both live donor and cadaveric operations are performed depending on whether intestinal transplant is being performed in isolation or combination with other visceral transplants.
Live donor intestinal transplants
between 150-200 cm of ileum, including 20-25 cm of ileocecal valve/terminal ileum, harvested from a donor
end-to-side anastomosis of donor ileocolic artery and vein to recipient aorta and inferior vena cava (IVC) respectively
proximal anastomosis of donor ileum and recipient bowel or stomach
Bishop-Koop ileostomy formation
Cadaveric intestinal transplants
the intestinal graft can either have venous drainage via the IVC or via portal system (superior mesenteric vein)
arterial anastomosis to abdominal aorta, usually infrarenal
intestinal anastomosis as for live donor
Combined intestinal-liver transplants
concomitant liver failure related to TPN
hypercoagulable states causing intestinal failure that are correctable with liver transplantation
arterial anastomosis between a patch of donor aorta including the celiac axis and SMA origin to recipient aorta
donor-recipient portoportal venous anastomosis
cavocaval venous anastomosis
Roux-Y-choledocho-enterostomy for biliary drainage
Multivisceral transplants
used in patients with invasive abdominal malignancies requiring multiorgan curative surgical resection