Small Bowel Patient Selection Criteria

Background

Small bowel/intestinal transplantation, combined liver/intestinal transplantation, and multivisceral transplantation are operations that are reserved for life-threatening conditions, but no longer considered investigational.  Worldwide, from the early 1980s until mid 2003, 61 centers had performed 989 transplants upon 923 patients.  (433 isolated small intestinal, 386 liver/intestinal, and 170 multivisceral). Sixty one percent of all transplants have been performed upon children. In this era, one-year survival has remained between 65 and 70% and five-year survival is between 40 and 50%. When reserved for patients with no possibility of long-term survival without transplantation, the procedure should be strongly considered.

Factors governing success of the procedure will include the general health of the recipient before transplant, the size of the center, the experience of the physicians within that center with small bowel or liver transplantation and/or related procedures, and recent advances in surgical technique, graft monitoring techniques, immunosuppressive regimens, and antiviral therapies.  The average length of stay varies from 55 days for small intestinal transplantation to 72 days for multivisceral transplantation. Success can be monitored by outcome-measures that include cost of the procedure and the morbidity and mortality of the patients undergoing the procedure.

Indications

Isolated small intestinal transplantation is an operation reserved for patients with irreversible short bowel syndrome (or intestinal failure despite intact intestinal length) associated with life-threatening complications due to either parenteral nutrition or the underlying disorders themselves. When prospects for weaning from parenteral nutrition are nil, or patients have experienced multiple serious episodes of septicemia, progressive loss of vascular access, are at risk for serious morbidity and mortality from disease itself, or are at risk for progressive cholestasis associated with  parenteral nutrition, isolated small intestinal transplantation may be considered.

When candidates have suffered irreversible liver damage (usually associated with prolonged parenteral nutrition) in addition to irreversible intestinal failure, liver/small intestinal transplantation should be considered.  If the candidate’s disease process is one which renders gastroduodenal function unacceptable, or when localized tumors or other causes of vascular occlusion seriously compromise the arterial blood supply to stomach, liver, small bowel, and pancreas, multivisceral transplantation may be performed.

Specific Indications

1. Surgical short bowel syndrome due to:
   • a. Volvulus
   • b. Gastroschisis
   • c. Necrotizing enterocolitis
   • d. Hirschsprung’s Disease
   • e. Congenital atresias
   • f. Crohn’s Disease
   • g. Trauma
   • h. Mesenteric vascular insufficiency
   • i. Localized intra-abdominal tumors (such as desmoid tumors or inflammatory pseudotumor)
   • j. Other causes of surgical short bowel syndrome
2. Secretory diarrhea associated with uncorrectable malabsorption
   • a. Microvillus inclusion disease
   • b. Tufting enteropathy
   • c. Intestinal pseudo-obstruction
   • d. Other life-threatening diarrheal disorders uncorrectable by medical or surgical means short of transplantation
3. Liver failure in association with intestinal failure
   • a. TPN-associated liver failure
   • b. Other causes of liver failure (such as primary sclerosing cholangitis or biliary atresia) in association with intestinal failure
4. Other Consortium-approved indications for transplantation

Contraindications

1. Active chemical dependency, including illegal narcotic usage (i.e. marijuana), not consistent with screening criteria in Substance Dependence Addendum
2. Active infection outside the hepatobiliary system limiting survival
3. Disseminated, non-resectable malignancy
4. Insufficient venous patency to guarantee central venous access
5. Severe dysfunction of other organ systems (cardiac, pulmonary, vascular, renal, neurologic), rendering transplantation risk unacceptable
6. Other life-threatening, uncorrectable illnesses not referable to the gastrointestinal system
7. Unstable, uncontrollable psychiatric illness
8. Proven non-compliance

Reference

“Intestinal Transplant Registry” David Grant MD. URL--http://www.intestinaltransplant.org/