Section: Surgical Oncology Curriculum: Curriculum, page 73

General

Historically challenging
- Stimulates a strong graft rejection response
  - Small intestine contains large amounts of lymphoid tissue
- Ischaemia and rejection increase intestinal permeability
  - Allow translocation of bacteria from the lumen
- Operation often complex
Graft rejection and infection remain major problems
- Results obtained are inferior to those obtained after other types of organ transplantation

Indications

Indicated for intestinal failure requiring TPN
- Short gut, or intestinal dysfunction caused by:
  - Intestinal atresia
  - Necrotising enterocolitis
  - Volvulus
  - Disorders of motility
  - Mesenteric infarction
  - Crohn’s disease
  - Trauma
  - Desmoid tumours
Indications
- Recurrent line complications - sepsis or clots.
- TPN associated liver failure (SB transplantation is combined with liver transplantation)
- Frequent episodes of severe dehydration despite intravenous fluid administration in addition to parenteral nutrition

May be carried out as an isolated procedure (highest survival)
- Performed together with a liver transplant
- Or as a component of a multivisceral transplant
Deceased donor transplant
- Comprises the entire small bowel
  - Not ascending colon
- SMA of the graft (with an aortic patch) is anastomosed to the recipient aorta
- SMV is anastomosed to the IVC or to the side of the Portal Vein
- Proximal end of SB graft anastomosed to the recipient jejunum or duodenum
- Distal end
  - Anastomosed to right colon (with loop ileostomy)
  - Or Direct end ileostomy
- Draining gastrostomy and feeding jejunostomy inserted
½ of patients on long-term TPN also require liver transplant due to cholestatic liver disease
- Do both en-bloc

1-year graft survival rate 65% 2009 - latest data suggests up 90% at 1 year
- For both isolate SB transplantation and for combined with liver
3 years, the graft survival rate is around 45%
Survival better after isolated SB transplantation than after combined liver
- Loss of the graft usually equates with death
Mortality due to sepsis and multi-organ failure
- Risk of infection heightened by the additional requirements for immunosuppression to control graft rejection
- Also accounts for the relatively high incidence of lymphoproliferative disease (10%)
Because of the large amount of donor lymphoid tissue transplanted, GVHD may be an added complication
Despite the hazards, small bowel transplantation offers pts with IF a chance to lead an active life, free from long-term nutritional support