By: Rodrigo Vianna and Thiago Beduschi
The first isolated intestinal transplant was described almost 50 years ago and it has been 30 years since the first multivisceral transplant was performed. Even though there has been remarkable progress after four decades, intestinal transplantation remains a rare event and is only performed by a handful of centers throughout the world. Improvements in surgical techniques, critical care, immunosuppressive drugs, and immune-monitoring combined with a better understanding and management of the complications have resulted in excellent outcomes in the modern era, even comparable to other solid organ transplants.
In the last decade, new indications have come along with improvements in outcomes. Other than the traditional patient with short-gut syndrome and life-threatening complications from the total parenteral nutrition (TPN), indications now include:
• Complex porto-mesenteric thrombosis (where liver transplant is not technically possible)
• Slow growing and non-resectable intra-abdominal tumors (neuroendocrine/ desmoid tumors)
• Gastrointestinal pseudo-obstruction (and other severe dysmotility disorders)
• Abdominal catastrophes (trauma, open abdominal cavity, multiple enteric fistulas)
• Quality of life
Peri-operatory mortality is rare in experienced hands and hospital stays have been decreasing drastically, with several patients leaving the hospital in less than three weeks with no central lines and complete enteral autonomy.
Most of the patients achieve enteral autonomy in two to three weeks after the transplant and do not require any additional nutrition or hydration other than by mouth.
Intestinal transplantation has proved to be cost effective when compared to TPN. After two and half years, transplant becomes cheaper than all the costs related to parenteral nutrition. Quality of life is another point in favor of transplant. Patients report going back to their regular activities. Freedom from lines and their complications is one of the highlights for patients.
Intestinal and multivisceral transplantation is not free of complications. One of the main factors affecting the final outcome is the patient condition at the time of the surgery. Patients coming from home perform much better than patients coming from the hospital at the time of transplant.
For this reason, early referral to a specialized intestinal transplant center is fundamental for better outcomes. It is common to be referred patients who already have limited vascular access, TPN induced liver disease and multiple infections. In some cases, complete lack of central venous access can preclude the transplant.
Intestinal and multivisceral transplantation has now evolved to be a valid therapy for complex patients, restoring the physiology of the abdominal cavity, the ability to eat and at the same time eradicating the baseline disease.