Intestine Transplantation

Organ Transplant

Types of Procedures

Intestine transplantation comprises 3 types of operative procedures that are adapted to the needs of the patient. These procedures include isolated small bowel transplantation, a composite graft of the liver and small bowel, and a multivisceral transplant including the small bowel with liver, stomach, and/or pancreas.

Isolated Intestine transplantation

Isolated intestine transplantation is indicated for patients with irreversible intestinal failure requiring permanent TPN to meet nutritional needs. Criteria for timely transplantation include the diagnosis of intestinal failure with deteriorating liver function secondary to TPN cholestasis, limited central line access, and multiple episodes of line sepsis.

Combined Small Bowel-Liver Transplantation

Combined small bowel-liver transplantation is recommended for patients with irreversible failure of both the liver and small bowel. In this situation, the patient has intestinal failure as well as severe hepatic dysfunction, usually from TPN-induced cholestasis, as evidenced by cirrhosis and associated symptoms of end-stage liver disease.

Multivisceral Transplantation

Multivisceral transplantation is considered when patients have irreversible failure of 3 or more abdominal organs including the small bowel. The most common indications for multivisceral transplantation are total occlusion of the splanchnic circulation, extensive GI polyposis, hollow visceral myopathy or neuropathy, and some abdominal malignancies.^[50]

References

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Cite this: Intestine Transplantation - Medscape - Jun 01, 2002.

Table 1. Indications for Intestinal Transplantation
Pediatric Indications Volvulus Gastroschisis Necrotizing enterocolitis Intestinal atresia or stenosis Trauma Hisrchsprung disease Chronic intestinal pseudo-obstruction Adult Indications Crohn's disease Trauma Vascular insufficiency: superior mesenteric artery thrombosis, mesenteric vein thrombosis Familial polyposis Gardner's syndrome Desmoid tumor Radiation enteritis Budd-Chiari syndrome

Table 2. Patient Evaluation for Small Bowel Transplantation*
Component of Evaluation	Tests and Procedures
Physical Examination	Complete physical examination and review of systems
Medical and Surgical History	Neonatal history (infants and children) Complete review of all medical and surgical problems
Gastroenterology (GI) Assessment	Gastroenterology consultation Upper and lower GI barium studies Gastric emptying study (if indicated) Endoscopy (if indicated) Motility testing (if indicated) Absorption testing (D-xylose, fecal fat) Abdominal ultrasound Stool cultures
Hepatic Function Assessment	*Laboratory Tests* Serum: bilirubin, alkaline phosphatase, AST, ALT, GGTP, albumin, ammonia, alpha-fetoprotein, prothrombin time, partial thromboplastin time, *Diagnostic Procedures* Liver ultrasound of hepatic vessels Liver biopsy (if indicated)
Venous Access Assessment	Ultrasound of great vessels for patency Number and placement of Broviac lines Number of line infections and organisms
Nutritional Assessment	*Nutritional Status* Height, weight Anthropometric measurements Caloric intake *Nutritional support* TPN Enteral feeds Oral intake history Oral intake aversion history/behaviors *Laboratory Tests* Electrolytes, creatinine, BUN Triglycerides Zinc, trace elements, vitamin A, D, E, K, B₁₂, thiamine
Infectious Disease Assessment	Immunization history *Laboratory Tests* Hepatitis screen HIV CMV: IgG, IgM EBV: IgG, IgM Herpes zoster: IgA, EIA Measles, mumps, and rubella titers Cultures: blood, urine, quantitative stool
Pulmonary Assessment	Pulmonary consultation (if indicated) Assessment for pulmonary complications: Bronchopulmonary dysplasia Hepatopulmonary syndrome Cystic fibrosis
Cardiac Assessment	Cardiology consultation Echocardiogram Electrocardiogram Chest X-ray
Anesthesiology Assessment	Anesthesiology consultation Anesthesia history Surgical procedures Drug allergies
Developmental Assessment	Consultations are requested based on assessment and may include: Occupational therapy Physical therapy Speech therapy Child development Child Life
Psychosocial Assessment	Psychiatry/Psychology consultation Social Work consultation Clinical Nurse Specialist consultation
Educational Needs Assessment	Clinical Nurse Specialist consultation
Financial Needs/Assessment	Transplant Financial Coordinator consultation

AST = aspartate aminotransferase, ALT = alanine aminotransferase, GGTP = gamma-glytamyl-transpeptidase , CMV = cytomegalovirus, EBV = Epstein-Barr virus

Table 3. Discharge Medications
Medication	Dose	Route & Frequency
Tacrolimus	1 mg	Oral, twice daily
Prednisone	5 mg	Oral, daily
Mycophenolate mofetil	100 mg	Oral, twice daily
Bactrim	60 mg	Oral, Monday, Wednesday, Friday
Mycostatin	5 cc	Oral, 4 times daily
Prilosec	10 mg	Oral, twice daily
Actigal	120 mg	Oral, twice daily
Vitamin K	5 mg	Oral, daily
Multivitamin	1 cc	Oral, daily
Phenobarbital	20 mg	Oral, twice daily
Bicitra	50 mEq	Gastrostomy tube, twice daily
Imodium	1 mg	Gastrostomy tube, twice daily
Zosyn	900 mg	IV, 4 times daily for 14 days
Cytogam	1.5 gm	IV, weekly for 4 doses
Zenapax	12 mg	IV, every 2 weeks for 2 more doses
Benefiber	2 tblsp.	Add to every 1 liter of enteral feeding

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