Small bowel transplant
Introduction
The bowel
The bowel (intestine) is a long muscular tube in your abdomen (tummy). It moves partly digested food from the stomach to the anus and absorbs nutrients into your bloodstream.
When the intestine is not functioning as it should, you can become dehydrated and malnourished.
A small bowel (intestinal) transplant is an operation to replace a diseased or shortened small bowel with a healthy bowel from a donor.
Why a small bowel transplant is needed
A small bowel transplant is an option for children and adults whose bowel has stopped working properly and who are being fed by total parenteral nutrition. Parenteral nutrition is where liquid nutrition is given through a drip. For more information see the paragraph titled 'What is TPN?' below.
A small bowel transplant may be considered when the person has developed complications from TPN or is unable to tolerate this form of feeding. See When should it be done for more information.
How common is it?
In the UK, small bowel transplants were first performed in adults at Addenbrooke’s Hospital, Cambridge in 1987 and in children at the Children’s Hospital in Birmingham in 1993.
As of September 2009, a total of 91 bowel transplants had been performed:
- 67 in Birmingham Children’s Hospital
- 16 at Addenbrooke’s in Cambridge
- 5 at the John Radcliffe Hospital in Oxford
- 3 at King's College Hospital in London
Outlook
After receiving a small bowel transplant, patients can be moved from total parenteral nutrition to a normal diet fed through the mouth.
However, a transplant is complicated and difficult surgery that can take up to 12 hours. In the past, there were high rates of rejection of the new organ, but the introduction of more advanced immunosuppressant drugs over the last 15 years has greatly improved survival rates.
Immunosuppressant drugs (which weaken your immune system) are given during and after your transplant and must be taken for life, so your body will not reject your new bowel.
You will need to have regular blood tests and will be routinely seen at the transplant centre for the rest of your life.
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When should it be done?
What is TPN?
Total parenteral nutrition, or TPN, provides liquid nutrition through a catheter (fine tube) that is inserted into a vein in the arm, groin, neck or chest. It is often given overnight.
Long-term TPN may be recommended for children, although it can result in complications including liver disease, bone disorders or catheter-related infections. TPN can also damage the veins used to administer the nutrition.
TPN is the only alternative to a small bowel transplant.
When a small bowel transplant is needed;
Most patients with short gut syndrome (where there is not enough bowel to absorb nutrients) will need some parenteral nutrition (feeding via a catheter) and will be able to manage well.
However, if complications from parenteral nutrition develop, or if the person can no longer tolerate this form of feeding, then a small bowel transplant may be considered.
Complications can include:
- liver disease
- infection of the intravenous line (drip), which can spread through the bloodstream
- problems with venous access (a device fitted under the skin to allow access to the bloodstream without repeatedly puncturing the blood vessels)
A combined liver and small bowel transplant or multiple organ transplant (multivisceral transplant) is performed on patients who have developed liver disease or who have large tumours that can only be removed by transplanting several organs.
Underlying diseases
Small bowel transplant patients may have either a tumour or short gut syndrome. Short gut syndrome can be caused by:
- volvulus (twisting of the bowel)
- gastroschisis (a birth defect where some of a baby's bowel develops outside the body)
- necrotising enterocolitis (where part of the tissue of the bowel dies)
- Crohn's disease
- an injury
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Preparation
If you are being considered for a small bowel transplant, you will be referred for a transplant assessment. Tests are carried out to find out whether a transplant really is the best treatment for you.
Transplant assessment
You will need to stay in hospital for three to five days for the assessment. Tests may include:
- an X-ray of your digestive tract
- a barium enema (a special type of X-ray used to examine the large bowel, where liquid barium sulphate is introduced into your bowel)
- an endoscopy (where the inside of your body is examined using a long, thin tube with a camera on the end)
- a CT scan (where X-rays create detailed images of the inside of your body)
- an ultrasound scan of your circulatory system (this scan uses high-frequency sound waves to create an image)
- blood tests for liver function, electrolytes, kidney function and antibodies to certain viruses
During the assessment you will have the chance to meet members of the transplant team and to ask any questions. The transplant co-ordinator (the person organising your transplant, who you will have most contact with) will talk to you and your family about what happens and the risks involved in a small bowel transplant.
When the assessment is complete, it will be decided whether a small bowel transplant is the best option for you.
Your transplant team
Your transplant team will include:
- surgeons
- anaesthetists
- an intensive care specialist
- a transplant nurse
- physiotherapists
- psychologists
- a transplant
co-ordinator
Why you might be unsuitable for a small bowel transplant
You may be considered unsuitable for a small bowel transplant if:
- You have not complied with previous advice or been reliable. For example, you have not given up smoking despite advice to do so, you have a poor history of taking prescribed medication or you have missed hospital appointments.
- Previous surgery and complications relating to the abdomen (tummy) mean that the operation is technically impossible because there is no space left in the abdomen for the transplanted organs.
The waiting list
Once you are on the active waiting list, the transplant centre may give you a pager so you can be contacted at short notice.
The length of time you will have to wait will depend on your blood group, donor availability and how many other patients are on the list (and how urgent their cases are).
While you wait, you will be cared for by the doctor who referred you to the transplant centre. Your doctor will keep the transplant team updated with changes to your condition. Sometimes, another assessment is necessary to make sure you are still suitable for transplant.
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How is it performed?
A small bowel transplant is complicated surgery and can take up to 12 hours.
Depending on the cause of your bowel failure, it may be recommended that you have one of the following:
- Small bowel transplant, which is recommended for patients with bowel failure who do not have liver disease.
- Combined liver and small bowel transplant, which is recommended for patients with bowel failure who also have end-stage liver disease.
- Multivisceral (multiple organ) transplant, which is not a commonly performed operation, but may be recommended for patients with multiple organ failure. The diseased stomach, pancreas, duodenum, liver and small bowel are removed and healthy donor organs transplanted.
During surgery
After removing your diseased bowel, your blood vessels are connected to the blood vessels of the transplanted bowel to supply it with blood. The transplanted bowel is then connected to your digestive tract.
The surgeon will make an ileostomy (an opening so the end of the small bowel can be passed through your abdominal wall). After the operation, the ileostomy allows body waste to pass out of your body into a pouch and lets the transplant team assess the health of your transplanted bowel.
Depending on your health and the success of the operation, the ileostomy may be closed a few months after the operation and the bowel reconnected. However, this is not always possible.
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Risks
Better anti-rejection drugs, refined surgical procedures and a greater understanding of the body's immune system have increased the number of successful bowel transplants and improved survival rates.
However, complications can include:
- rejection of the donor organ (see below)
- infection
Also, taking immunosuppressant medication can make certain types of cancer more likely.
What is rejection?
Rejection is a normal reaction of the body. When a new organ is transplanted, your body’s immune system sees it as a threat and makes antibodies against it, which can stop it from working properly.
Immunosuppressant drugs (which weaken your immune system) are given during and after your transplant and must be taken for life, so your body will not reject your new bowel.
If rejection does happen, there is a risk that the bacteria found in the small bowel can get into your bloodstream.
After surgery you will be closely monitored by the transplant team to reduce this risk.
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Recovery
Immediately after the transplant you will be taken to the intensive care unit.
You will be carefully monitored so the transplant team can check that your body is accepting the new organ. This monitoring will include regular X-rays and bowel biopsies (where tissue samples are taken).
The transplant team can determine whether your body is rejecting the bowel from your biopsy results. If it is, additional treatment will be given to reverse the process.
The transplant team will also begin to wean you from total parenteral nutrition. Over time, you will move from taking liquid nutritional supplements through a feeding tube to eating a normal diet fed through the mouth.
Follow-up appointments
You will normally be discharged from hospital four to six weeks after surgery, although in some cases it could be longer. You will be asked to stay near to the transplant centre for one month.
During the second month, you will need to visit every week for four weeks. After that, for the rest of your life, you will have a blood test every six weeks and will be seen at the transplant centre every three months.
How long your recovery takes depends on your case and whether you had an isolated small bowel transplant or a multivisceral (multiple organ) transplant.
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