Small Bowel Transplantation

Intestinal transplantation is gradually becoming a therapeutic intervention rather than an experimental procedure. In the long term, the best outcome for patients with intestinal failure remains total parenteral nutrition, but where this is unlikely to allow long-term survival because of loss of venous access sites or severe cholestasis, intestinal transplantation should be considered. The technical aspects of the procedure are well described and advances in recent years in both immunosuppression and antimicrobial therapy have led to improved outcomes, particularly in the larger centers. Graft monitoring and the profound sepsis that accompanies graft dysfunction due to bacterial translocation remain major challenges, whereas the issues of denervation, lymphatic disruption, graft-versus-host disease (GVHD), and nonphysiological venous drainage have not proved to be major problems. Whether intestinal transplantation will become an alternative for the stable patient on total parenteral nutrition rather than a salvage procedure for when total parenteral nutrition fails remains to be seen.

Transplantation - total parenteral nutrition - intestine - immunosuppression

REFERENCES

• 1 Micklewright A, Elia M, Meadows N et al.. Nutrition: reading the BANS (British Artificial Nutrition Survey).  Nursing Times. August 20-26, 1997;  93 67-68
• 2 Lennard-Jones J E. Indications and need for long term parenteral nutrition; implications for intestinal transplantation.  Transplant Proc. 1990;  22 2427-2429
• 3 Middleton S J, Pollard S G, Friend P J et al.. Assessment of adult small bowel transplantation in England.  Br J Surg. 2003;  90 723-727
• 4 Bianchi A. Intestinal loop lengthening-a technique for increasing small intestinal length.  J Pediatr Surg. 1980;  15 145-151
• 5 Pollard S G. Small bowel transplantation. In: Forsythe JLR Transplantation Surgery-A Companion to Specialist Surgical Practice. London; WB Saunders 1997: 229-251
• 6 Ballinger W F, Christy M G, Ashby W B. Autotransplantation of the small intestine: the effect of denervation.  Surgery. 1962;  52 151-164
• 7 Olivier C, Rettori R, Camilleri J P. Interruption of the lymphatic vessels and its consequences in total homotransplantations of the small intestine and right side of the colon in man.  Lymphology. 1972;  5 24-31
• 8 Collins B H, Bollinger R R. The mucosal barrier. In: Grant DR, Wood RFM Small Bowel Transplantation. London; Edward Arnold 1994: 53-69
• 9 Rosemurgy A S, Schraut W H. Small bowel allografts: sequence of histologic changes in acute and chronic rejection.  Am J Surg. 1986;  151 470-475
• 10 Iwaki Y, Starzl T E, Yagihasi A et al.. Replacement of donor lymphoid tissue in small bowel transplants.  Lancet. 1991;  337 818-819
• 11 Pollard S G. Economics of small intestinal transplantation. In: Bodger D, Daly M, Heatley RV Clinical Economics in Gastroenterology. Malden, MA; Blackwell Science 2000: 250-264
• 12 Abu-Elmagd K, Reyes J, Bond G et al.. Clinical intestinal transplantation: a decade of experience at a single centre.  Ann Surg. 2001;  234 404-416