Introduction: Small for size syndrome and lower limits of donor-recipient body weight ratio (DRWR) are established in liver transplantation. Ideal donor in intestinal transplantation (ITX) is considered to be 50 to 80% of recipient body weight. Loss of abdominal domain and difficult abdominal closure is a serious complication after ITX. DRWR 50-80% does not always permit easy abdominal closure. We report our single center experience of using DRWR < 50%.

Method: Retrospective review of single center experience of ITX from 2011 to 2016 using  prospectively maintained database. DRWR  calculated with donor weight from UNET divided by pre-transplant recipient weight, as percentage. Cases with DRWR < 50% included in final analysis. Primary outcomes were patient and graft survival; secondary endpoints included autonomy from parenteral nutrition (PN) and abdominal closure.

Results: There were 55 ITX without inclusion of liver during study period. DRWR < 50% was identified in 29 ITX (52.7%) in 27 patients. There were 25 ITX with colon, ITX with kidney 3, and ITX with pancreas 1. Median DRWR was 34.1% (20.3 to 49.5%). DRWR was 20-29% in 7, 30-39% in 11 and 40-49% in 11 recipients. Time on the waitlist was a median of 97 days (15 to 294). Donor age was 4.7 years (0.2 to 11.7) and body weight was 20.0 kg  (4.9 to 34.0). Donors were local/regional in 3 cases and national in 26 of 29 ITX. Cold ischemia time was 7h 20 minutes (281 - 626 minutes). Vascular extension grafts from the same donor were used in all cases. Abdominal wall was closed primarily in 23 cases (79.3%) and required creation of skin flaps in 6 ITX. There was no graft vascular thrombosis after ITX. One year patient and graft survival was 86.2% and 75.9% respectively. Death and graft loss were unrelated to donor size. PN was weaned off in 24 patients (82.8%) at a median 32 days (10-122 days) after ITX. In 5 cases PN could not be weaned due to early mortality (1), acute rejection (ACR) and graft enterectomy (2) and other ITX complications (2). 4 patients required PN > 60 days due to ACR (3) and intestinal leak (1). All 20 patients currently alive with mimimum f/u of 7 months after ITX are nutritionally independent and well.   

Conclusion: ITX using small donors (DRWR < 50%) seems acceptable practice with no impact of donor size on surgical complications, nutritional autonomy and patient and graft survival. Abdominal closure was easier in this cohort compared to our own historic controls and reported literature.