Small Bowel Transplantation

01 Overview

Small bowel (intestinal) transplantation is a less common procedure reserved for patients with irreversible intestinal failure who can no longer be sustained safely on long-term parenteral nutrition.

02 Anatomy

The transplant may involve isolated small bowel or be combined with the liver and other viscera, with vascular anastomoses to the recipient's aorta and vena cava or portal system, and construction of a stoma for graft surveillance.

03 Physiology

The transplanted intestine must restore absorptive and motility function despite lymphatic and neural disruption, and its dense lymphoid tissue makes it particularly susceptible to rejection compared with other solid organs.

04 Indications

Indications include:

• Irreversible intestinal failure with loss of vascular access for parenteral nutrition
• Recurrent life-threatening catheter-related sepsis
• Parenteral nutrition-associated liver disease
• High risk of death from the underlying intestinal condition

05 Contraindications

Contraindications include:

• Active malignancy
• Severe uncorrectable cardiopulmonary disease
• Multiple organ failure precluding safe surgery
• Lack of adequate support for intensive follow-up

06 Donor Assessment

Donor selection considers bowel length and quality, size matching with the recipient, and absence of intestinal or systemic disease that would compromise graft function.

07 Recipient Assessment

Recipients are evaluated for nutritional status, vascular access options, and liver function, and the extent of remaining bowel informs the choice between isolated intestinal or combined liver-intestinal transplantation.

08 Surgical Technique (Summary)

The procedure involves vascular reconstruction to establish arterial inflow and venous outflow for the graft, restoration of bowel continuity, and creation of a stoma to allow direct endoscopic monitoring for rejection.

09 Immunosuppression (Overview)

Intestinal transplantation generally requires more intensive immunosuppression than other solid organs, often with induction therapy and multi-agent maintenance, reflecting the graft's high immunogenicity.

10 Complications

Recognised complications include:

• Acute rejection
• Graft-versus-host disease
• Infection and sepsis
• Anastomotic leak
• Chronic allograft enteropathy

11 Follow-up

Close follow-up includes frequent endoscopic biopsy surveillance, nutritional monitoring, and infection screening, particularly in the early post-transplant period when rejection risk is highest.