Small intestine transplantation: procedure, forecast

Small bowel transplantation is indicated in patients with malabsorption syndrome associated with bowel diseases (gastroschisis, Hirschsprung's disease, autoimmune enteritis) or with intestinal resection (mesenteric thromboembolism or common Crohn's disease), with a high risk of death (usually due to congenital enteropathy such as inclusive disease) or who have complications of total parenteral nutrition (TPN) (liver failure, recurrent sepsis, total impairment of venous outflow). Transplant candidates are also patients with local invasive tumors that lead to obstruction, abscess, fistula, ischemia or hemorrhage (usually due to a desmoid tumor associated with hereditary polyposis).

Taking a graft from donor corpses with death of the brain and working heart is carried out in conjunction with other organs, as the small intestine can be transplanted isolated, together with the liver or with the stomach, liver, duodenum and pancreas. The role of living donor-relatives of the small intestinal allograft is not yet defined. In different medical centers the procedure of transplantation is carried out in different ways; immunosuppressive therapy is also prescribed differently, but usually it includes antilymphocytic globulin with the subsequent administration of high doses of tacrolimus and mycophenolate mofetil as maintenance therapy.

Endoscopy is performed weekly to detect rejection. Symptoms and objective signs of rejection include diarrhea, fever, and abdominal colic. Endoscopy reveals mucosal erythema, edema, ulceration, exfoliation; the changes are uneven, they are difficult to detect and must be differentiated from cytomegalovirus enteritis by detecting inclusions of viral bodies. During biopsy, deformed villi and inflammatory infiltrates are identified in the lamina propria of the mucous membrane. Treatment of acute rejection consists in the administration of high doses of glucocorticoids, antitimocytic globulin or both.

Surgical complications are noted in 50% of patients and consist of leakage at the site of anastomosis, bile flow and strictures, hepatic artery thrombosis and development of lymphatic ascites. Non-surgical complications include transplant ischemia, graft versus host disease, caused by transplantation of enteric-associated lymphoid tissue.

By the third year, more than 50 % of transplants survive when transplanting one small intestine, and the survival rate of patients is about 65%. With transplantation in combination with the liver, the survival rate is lower, since the procedure is more traumatic and is performed by recipients with a heavier initial state.

[1], [2], [3], [4]