Intestinal Transplant

Intestine Transplant Guide

Read in detail or skim through one of the most detailed guides on an intestine transplant.

1. Indications for Intestinal Transplantation

 
We will reiterate what we always do. If you see the signs of this disease in yourself or someone you know, resist the need for panicking and seek medical help as soon as possible. People with bowel failure who have developed complications from TPN (total parenteral nutrition) or cannot seek it are advised to undergo this type of organ transplant.

TPN is required when a person’s bowel is unable to absorb any nutrients from the food they eat. TPN occurs when a drip is inserted into a vein to absorb the necessary nutrition required by the body to sustain itself.

One major limitation of TPN is that it can only be given in a large vein. This is a problem as there are only a total of six large veins, to begin with. Insertion of drips into these veins can damage them permanently.

2. Who might need intestinal transplantation?

 
People who become dependent on TPN for a long time can suffer and will, therefore, require a small intestine transplant. Children, especially, will develop serious infections or liver problems if they are kept on TPN for an irreversibly long time.

3. What is intestinal failure?

 
When one’s gut loses the ability to absorb water, macronutrients, micronutrients and electrolytes, it is considered as an intestinal failure (IF).

Not being able to absorb all the above elements will affect the quality of life immeasurably.

Acute IF (Phase 1 and Phase 2) is the initial phase of the disease and may last from weeks to months.

4. What are the causes of intestinal failure?

Before diving into the causes, it is important to assert that they are divided into categories such as congenital/acquired, GI or systemic, benign or malignant.

The following gastrointestinal conditions can become the root causes of intestinal failure:

1. Crohn’s disease: Prolonged inflammation can damage your intestines and may require the surgical removal of parts of your intestines.

2. Celiac disease: Advanced forms of celiac disease cause chronic inflammation that result in poor nutrient and fluid absorption.

3. Motility problems: Treatment for rare and advanced motility problems, such as gastro paresis, may require the surgical removal of a portion of your small intestine.

4. Radiation: People who undergo radiation treatment for gastrointestinal cancer end up with narrowing (strictures) and scar tissue (adhesions). This can end up causing intestinal failure too.

5. Short bowel syndrome: People who have had half or more of their intestines removed may find that the remaining portion is incapable of meeting their body’s needs.

5. How is intestinal failure managed?

By a surgeon and their team who specializes in these types of organ transplants. As you may have gathered by now, this infrequently-performed surgery requires strategic planning and risk assessment.

This, accompanied with anesthetic and nutritional expertise will increase the chances of survival and success.

This transplant should not be taken up and accepted by a faint-hearted surgeon who only has the slightest idea of what they are doing.

6. How is an intestinal transplant performed?

 
It is performed by using precision and laser-sharp focus.

The small bowel transplant takes about 8 hours or more in which the surgeons carefully remove the diseased small intestine and replace it with a healthy one.

Note that the healthy small intestine is and will always be screened for any anomalies or infections before it is used for transplantation.

After the removal of your diseased bowel, your blood vessels will be connected to the blood vessels of the transplanted bowel. The latter will then be connected to your digestive tract or whatever is left of the bowel.

According to the rules of an ileostomy, your surgeon will divert a small part of your small bowel through an opening they will make in your abdomen, called the stoma.

After the operation, the digestive waste of your body will pass through the stoma and into an external pouch. This will allow your transplant team to assess the health of your transplanted bowel.

If everything goes as planned, your ileostomy may be closed and your bowel reconnected a few months after the operation. This, however, will not always be possible. Therefore, in such a case, hoping for the best is the most practical approach you can take.

Remember that an intestinal transplant is challenging and difficult to orchestrate. Hence, becoming overly-optimistic about your recovery is impractical and ill-informed.

Give your body and your mind time to recover. As you have read, even the surgeon and their team will have to plan beforehand how to approach this surgery in order to make it successful.

7. Types of intestinal transplant

There are three types of intestinal transplant that a potential patient should have general information about. Either way, your doctor will be able to suggest the best type of intestinal transplant which you should opt for to prolong and improve the quality of your life.

1. Isolated intestinal graft:

This is the most basic type of intestinal transplant treatment. In this type of transplant, only the jejunum (the second section of the small intestine) and the ileum (the final section of the small intestine) are transplanted. This is done when there is no sign of advanced liver disease. However, a liver will also need to be transplanted if there are signs of liver dysfunctions.

2. Combined intestinal-liver graft:

This is a treatment option for when a patient has both end-stage liver disease and intestinal failure. Both may be caused after complications from TPN (Total Parenteral Nutrition).

3. Multi-visceral graft:

The inclusion of stomach, pancreas, duodenum and/or colon are composed of the multivisceral graft as at this point, the intestinal failure manages to compromise other parts of the digestive system such as motility syndromes, not-yet metastasized intra-abdominal tumors, etc.

8. Treatment of intestinal transplant

 
In a world where there are types of intestinal transplants, there are types of intestinal transplant treatments as well. They are:

1. Isolated intestinal graft:

This is the most basic type of intestinal transplant treatment. In this type of transplant, only the jejunum (the second section of the small intestine) and the ileum (the final section of the small intestine) are transplanted. This is done when there is no sign of advanced liver disease. However, a liver will also need to be transplanted if there are signs of liver dysfunctions.

2. Combined intestinal-liver graft:

This is a treatment option for when a patient has both end-stage liver disease and intestinal failure. Both may be caused after complications from TPN (Total Parenteral Nutrition).

3. Multi-visceral graft:

The inclusion of stomach, pancreas, duodenum and/or colon are composed of the multi0visceral graft as at this point, the intestinal failure manages to compromise other parts of the digestive system such as motility syndromes, not-yet metastasized intra-abdominal tumors, etc.

9. Cost of intestinal transplant surgery

 
In India, the cost of intestinal transplant surgery is 30 lakh right off the bat.

And, did you know that the first-ever successful intestinal transplant was done in India at Medanta-The Medicty to a 30-year old male by a team of 30 doctors? This was back in 2013 so it can be surmised that since then, we have come a long way when dealing with this obstacle-ridden organ transplant.

10. Care after intestinal transplant

Right after the fragile surgery, you will need to protect your incision from infection. Your transplant team may also advise you on staying close to their transplant centre for at least three months if you live in a different city.

During this time, you will have to visit your chosen transplant centre as when required as biopsies and lab tests may be performed on you. The surgeon-in charge will not only search for any signs of infection but also make sure that you are able to eat and drink properly.

It may take time to become healthy again. It could be 3 months or more. But, at the end of the day, endeavor to achieve complete gastrointestinal rehabilitation.

10. Care after intestinal transplant

 
Right after the fragile surgery, you will need to protect your incision from infection. Your transplant team may also advise you on staying close to their transplant centre for at least three months if you live in a different city.

During this time, you will have to visit your chosen transplant centre as when required as biopsies and lab tests may be performed on you. The surgeon-in charge will not only search for any signs of infection but also make sure that you are able to eat and drink properly.

It may take time to become healthy again. It could be 3 months or more. But, at the end of the day, endeavor to achieve complete gastrointestinal rehabilitation.

11. What are the risks of an intestinal transplant?

 
While there are heightened risks attached to the process of an intestinal transplant, better anti-rejection medication, a more thorough understanding of the human immune system and the growing expertise of the surgeons contribute to the success of such surgeries.

Nevertheless, you and your family members have every right to know the risks that are associated with intestinal surgery:

● Problems related to breathing and the heart
● Infection in the small bowel – such as an infection by the cytomegalovirus (CMV)
● Blood clots (thrombosis)
● Post-transplant lymph proliferative disorder (PTLD) – where the Epstein-Barr virus infects white blood cells. This can lead to abnormal growths throughout the body and multiple organ failures, if not treated right away.
● Rejection of the donor organ (when one’s immunity system rejects the new organ, thus making antibodies to stop it from working properly)
● Increased risk of infections, certain types of cancer, kidney problems. These risks can be attributed to the long-term use of anti-rejection medication.
● Graft versus host disease (GvHD) in which the immune cells that were transplanted with the new organ fight against the host’s cells.

12. How to choose a transplant centre?

 
While it may seem hard, your doctor will always be with you when choosing the right transplant centre.

Of course, you can also always choose one that aligns well with your life insurance company’s policies.

However, the reputation, the experience level of the surgeons, the annual survival rates reported by the transplant centre and the added benefits before, during and after the transplant surgery count significantly.

13. What you can expect?

 
Before the procedure

After your doctor proclaims that you fit as a candidate for the transplant, you will undergo a series of tests and scans which will determine the risks and benefits that you will receive from the surgery.

After this evaluation, you will be placed on the waiting list in hopes that you will find a living or cadaver donor soon.

As this transplant is fairly uncommon, the wait time is short but the requirements of the organ required are exclusive.

While you wait, your condition will be managed medically and your TPN status will be updated by using weekly results from your lab tests.

During the procedure

You will be unconscious throughout the surgery as you will be given general anesthesia. Expect weariness, grogginess and soreness when you wake up from this arduous operation which takes 8-10 hours, sometimes even more.

After the procedure

You will be taken to the Intensive Care Unit (ICU) to recover. After this, you will be constantly monitored by your surgeon and their transplant team for any signs of complications and infections.

Expect to be discharged from the hospital after around 4 to 6 weeks.

If, at any point, you start feeling the mental stress from the surgery, talk to your friends and family as they shall provide you with all the support you will need during this uncomfortable time.

14. Results

Intestinal transplant survival rates
Over the years, the number of patients that have survived has increased because of advancements in medical science. Currently, the survival rate of intestinal transplant is 70% and in some cases, greater.

One can say that we have come a long way after realizing that the first intestinal transplant was attempted in 1964.

15. Diet and nutrition after intestinal transplant

Your assigned nutritionist will make sure to coach you on how you and your family can enforce food safety at home. Nevertheless, only eat food that is well-cooked and served hot to you. Ask your family members to practice immense hygiene when cooking for you.

Cross-contamination of food can pose a great risk for someone in your condition.

Do not consume raw or undercooked foods of animal origin. Raw or undercooked eggs are also a big No-No. Eating soft cheeses is also not recommended.

Such dietary restrictions may sound suffocating but please know that they were put in place to benefit you in the long run.

16. Exercise tips for transplant patients

 
For the first three months, resist vigorous exercise and heavy lifting. The silver lining is that it is safe to go swimming after three months have passed your surgery.

What one should prioritize more is setting up a regulated exercise routine that should constitute lots of walking.

It’s important to keep your body up and active. Lounging around will result in you gaining weight which can also be a complication on its own.

Deep breathing and yoga postures that do not trouble your incision are also recommended.

Before you adopt ANY exercise routine, make sure that you talk to your transplant surgeon and their team.