Patients with poor intestinal function who cannot be maintained on intravenous feedings are potential candidates for transplantation. Sometimes, most of the bowel has been surgically removed to treat the intrinsic disease. This produces ‘short-gut syndrome’, which is the most common cause of intestinal failure. Sometimes, the entire intestine is present, but it is unable to absorb enough fluids and nutrients.
Intestinal rehabilitation is the first step to ensure that all possible remedies have been tried. This includes a multidisciplinary approach to patient management involving the expertise of nutritionists, pharmacists, gastroenterologists, pediatricians .
Common indications for intestinal transplantation include:
- Short-gut syndrome caused by volvulus, gastroschisis, trauma, necrotizing enterocolitis, ischemia, Crohn’s disease¸ radiation enteritis
- Poor absorption caused by microvillus inclusion disease, secretory diarrhea, autoimmune enteritis
- Poor motility caused by pseudo-obstruction, aglionosis (Hirschprung’s disease), visceral neuropathy
- Tumor such as desmoid tumor, familial polyposis (Gardner’s disease)
Most children and adults do well on total parenteral nutrition (TPN), and transplantation may not be indicated for these patients. In some of these patients appropriate managements and intestinal salvage operations like exploration and adhesionolysis and STEP procedures can restore intestinal integrity and lead to good absorption. Transplantation, however, is a potentially life-saving option for patients with intestinal failure in whom salvage surgery has failed or who cannot tolerate TPN. Because patients’ survival rates are better after isolated bowel transplants, this is the preferred type of transplant. Combined intestinal-liver transplants or cluster transplants are options for patients who developed liver failure on TPN or for patients who have large, local tumors that can only be removed by removing several organs.