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Small bowel transplantation: procedure, prognosis
Medical expert of the article
Last reviewed: 07.07.2025
Small bowel transplantation is indicated for patients with malabsorption syndromes associated with bowel diseases (gastroschisis, Hirschsprung disease, autoimmune enteritis) or bowel resection (mesenteric thromboembolism or disseminated Crohn's disease), with a high risk of death (usually due to congenital enteropathy such as inclusion disease) or with complications of total parenteral nutrition (TPN) (liver failure, recurrent sepsis, complete venous outflow obstruction). Patients with locally invasive tumors that cause obstruction, abscesses, fistulas, ischemia, or hemorrhage (usually due to desmoid tumor associated with hereditary polyposis) are also candidates for transplantation.
Grafting from brain-dead, cardiac-active cadaveric donors is performed in combination with other organs, as the small intestine may be transplanted alone, with the liver, or with the stomach, liver, duodenum, and pancreas. The role of living related donors in small intestinal allografts is currently undetermined. Transplant procedures vary among centers; immunosuppressive therapy also varies, but typically includes antilymphocyte globulin followed by high-dose tacrolimus and mycophenolate mofetil as maintenance therapy.
Endoscopy is performed weekly to detect rejection. Symptoms and signs of rejection include diarrhea, fever, and abdominal colic. Endoscopy reveals mucosal erythema, edema, ulceration, and exfoliation; the changes are unevenly distributed, difficult to detect, and must be differentiated from cytomegalovirus enteritis by identifying viral inclusion bodies. Biopsy reveals malformed villi and inflammatory infiltrates in the lamina propria. Treatment of acute rejection involves high-dose glucocorticoids, antithymocyte globulin, or both.
Surgical complications occur in 50% of patients and include anastomotic leakage, bile leakage and strictures, hepatic artery thrombosis, and lymphatic ascites. Nonsurgical complications include graft ischemia and graft-versus-host disease caused by gut-associated lymphoid tissue transplantation.
By the third year, more than 50% of transplants survive when transplanting only the small intestine, and patient survival is about 65%. When transplanting in combination with the liver, the survival rate is lower, since the procedure is more traumatic and is performed on recipients with a more severe initial condition.
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