A small bowel (intestinal) transplant is an operation to replace a diseased or shortened small bowel with a healthy bowel from a donor.
Why a small bowel transplant is needed
A small bowel transplant is an option for children and adults whose bowel has stopped working properly and who are being fed by total parenteral nutrition (TNP). Parenteral nutrition is where liquid nutrition is given through a drip.
A small bowel transplant may be considered when the person has developed complications from TPN or is unable to tolerate this form of feeding.
Read more about when a small bowel transplant is needed.
Before having a small bowel transplant, you will need a transplant assessment. This involves tests and conversations with a transplant team to find if you are suitable for the procedure.
If you are suitable, you will be placed on an active waiting list and may be contacted at any time by the transplant team.
How long you have to wait will depend on your blood group, the availability of donors and how many urgent cases are on the list.
Read more about preparing for a small bowel transplant.
A small bowel transplant is a complicated and difficult surgery that takes on average around 8-10 hours.
During the procedure the surgeon will remove the bowel and connect the transplanted bowel to your blood vessels and digestive tract. They will also create an opening so the small bowel can be passed through the abdominal wall (ileostomy) to allow waste to pass out of your body into a pouch.
After the transplant operation, patients can be moved from total parenteral nutrition (TNP) to a normal diet fed through the mouth.
Read more about how a small bowel transplant is performed.
Getting back to normal
You will have to take medicine to weaken your immune system, known as immunosuppressants, for the rest of your life to prevent your body rejecting the new organ.
You will need to have regular blood tests and will be routinely seen at the transplant centre for the rest of your life.
Immediately after the transplant you will be taken to the intensive care unit and carefully monitored so the transplant team can check your body is accepting the new organ.
The transplant team can determine whether your body is rejecting the bowel from your biopsy results. If it is, additional treatment will be given to reverse the process.
The transplant team will also begin to wean you from total parenteral nutrition (TPN). Over time, you will move from taking liquid nutritional supplements through a feeding tube to eating a normal diet fed through the mouth.
You will normally be discharged from hospital four to six weeks after surgery, although in some cases it could be longer. You will be asked to stay near the transplant centre for one month.
During the second month, you will need to visit every week for four weeks. After that, for the rest of your life, you will have a blood test every six weeks and will be seen at the transplant centre every three months.
For the first 4-6 weeks after the transplant, it is common to experience some pain, although medication should be available for this.
How long your recovery takes depends on your case and whether you had an isolated small bowel transplant or a multivisceral (multiple organ) transplant.
Few boys have faced as many trials as Aaron Gray. He received a liver and small bowel transplant when he was just three and has also had two heart operations.
Family life for Catriona Gray and her partner William, who live in Peebles, Scotland, was turned upside down when it was found that Aaron, their first child, had been born with an acute heart condition that needed immediate surgery.
The operation saved his life, but while he was recovering Aaron caught an infection which destroyed most of his small intestine. At five weeks old it was likely he would die. "We were told to prepare ourselves for the worst," says Catriona.
Aaron pulled through but suffered acute liver damage. Aged only seven months he needed a new liver and small bowel. Aaron finally left hospital for the first time when he was 13 months old, but his heart was too weak to undergo transplant surgery and his future looked bleak.
"It was a worrying time. We feared the worst," says Catriona. "Then, at last, we had some good news. Aaron's liver started to repair itself. His jaundice went and he was the healthiest he had ever been. He'd defied all the odds stacked against him."
In summer 1999, when he was almost three, Aaron was declared fit enough for open heart surgery. However, he again fell victim to a severe post-operative infection. His jaundice returned, his liver was suffering and by January 2000 he was in urgent need of a transplant. Then came the agonising wait for a donor.
The call came at the end of May. The family were rushed by air ambulance from Scotland to Birmingham for the operation. A liver and small bowel had been donated by the parents of a 10-year-old boy and were successfully transplanted into Aaron.
He improved rapidly. Within two weeks of the transplant the yellowness of jaundice had gone and Aaron's appetite returned, along with his health.
"Aaron now lives a wonderful, normal life and can eat for Scotland and loves his veggies. He has a strong, outgoing personality without which I'm sure he wouldn't have made it through these past years," says Catriona. "He is an inspiration to us all.”
If you are being considered for a small bowel transplant, you will be referred for a transplant assessment. Tests will be carried out to find out whether a transplant is the best treatment for you.
You will need to stay in hospital for three to five days for the assessment. Tests may include:
- blood tests for liver function, electrolytes, kidney function and antibodies to certain viruses
- diagnostic imaging – which could include a chest X-ray, a CT scan of the abdomen and an ultrasound scan of your liver
- a barium enema (a special type of X-ray used to examine the large bowel, where liquid barium sulphate is introduced into your bowel)
- an endoscopy (where the inside of your body is examined using a long, thin tube with a camera on the end) to examine your bowel
- a lung function test
During the assessment you will have the chance to meet members of the transplant team and ask questions. The transplant co-ordinator (the person organising your transplant, who you will have most contact with) will talk to you and your family about what happens and risks involved in a small bowel transplant.
When the assessment is complete, it will be decided whether a small bowel transplant is the best option for you.
Why you might be unsuitable for a small bowel transplant
You may be considered unsuitable for a small bowel transplant if:
- you have not complied with previous advice or been reliable – for example, you have not given up smoking despite advice to do so, you have a poor history of taking prescribed medication or you have missed hospital appointments
- previous surgery and complications relating to the abdomen (tummy) mean that the operation is technically impossible because there is no space left in the abdomen for the transplanted organs
The waiting list
Once you are on the active waiting list, the transplant centre may give you a pager so you can be contacted at short notice.
The length of time you will have to wait will depend on your blood group, donor availability and how many other patients are on the list (and how urgent their cases are).
While you wait, you will be cared for by the doctor who referred you to the transplant centre. Your doctor will keep the transplant team updated with changes to your condition. Sometimes, another assessment is necessary to make sure you are still suitable for transplant.
There may be different types of transplant surgery recommended depending on the cause of your bowel failure.
Procedures that may be used are described below:
- Small bowel transplant – recommended for patients with bowel failure who do not have liver disease
- Combined liver and small bowel transplant – recommended for patients with bowel failure who also have end-stage liver disease
- Multivisceral (multiple organ) transplant – may be recommended for patients with multiple organ failure, although it is not commonly used. The diseased stomach, pancreas, duodenum, liver and small bowel are removed and healthy donor organs transplanted
A small bowel transplant is complicated surgery performed under general anaesthetic. The procedure takes around 8-10 hours on average, although it can take longer.
After removing your diseased bowel, your blood vessels are connected to the blood vessels of the transplanted bowel to supply it with blood. The transplanted bowel is then connected to your digestive tract, or to what is left of the bowel.
The surgeon will make an ileostomy (an opening so the end of the small bowel can be passed through your abdominal wall). After the operation, the ileostomy allows body waste to pass out of your body into a pouch and lets the transplant team assess the health of your transplanted bowel.
Depending on your health and the success of the operation, the ileostomy may be closed a few months after the operation and the bowel reconnected. However, this is not always possible.
Read more information about recovering from a small bowel transplant.
A small bowel transplant may be considered for people with bowel failure who develop complications from total parenteral nutrition (TPN).
Bowel failure is when a person's bowel is not able to absorb enough nutrients from food. It is most often caused by either short gut syndrome or a non-functioning bowel.
Short gut syndrome can be caused by:
- volvulus (twisting of the bowel)
- gastroschisis (a birth defect where some of a baby's bowel develops outside the body)
- necrotising enterocolitis (where part of the tissue of the bowel dies)
- extensive surgery to treat Crohn's disease or a tumour by removing part of the bowel
- an injury
Most people with short gut syndrome (where there is not enough bowel to absorb nutrients) will need some parenteral nutrition and will be able to manage well.
However, if someone is on total parenteral nutrition (TPN) and complications develop, then a small bowel transplant may be considered.
Total parenteral nutrition (TPN)
Total parenteral nutrition, or TPN, does the job of the small bowel by providing a person's full nutrition in liquid form. It is given through a fine tube (catheter) inserted into a vein in the arm, groin, neck or chest. It is often given overnight.
However, complications can develop from TPN which in some cases can be life-threatening. These include:
- liver disease
- infection of the intravenous line (drip), which can spread through the bloodstream
- problems with venous access – running out of suitable veins to insert the fine tubes for TPN (catheters)
A combined liver and small bowel transplant or multiple organ transplant (multivisceral transplant) is performed on patients who have developed liver disease or who have large tumours that can only be removed by transplanting several organs.
As with all surgery, there are risks when having a small bowel transplant.
Risks of a small bowel transplant
Better anti-rejection drugs, refined surgical procedures and a greater understanding of the body's immune system have increased the number of successful bowel transplants and improved survival rates.
However, complications of a small bowel transplant can include:
- breathing difficulties
- heart abnormalities
- blood clots (thrombosis)
- rejection of the donor organ (see below)
Taking immunosuppressant medication can also make certain types of cancer more likely and may increase the risk of kidney problems.
What is rejection?
Rejection is a normal reaction of the body. When a new organ is transplanted, your body’s immune system sees it as a threat and makes antibodies against it, which can stop it from working properly.
Immunosuppressant drugs (which weaken your immune system) are given during and after your transplant and must be taken for life, so your body will not reject your new bowel.
If rejection does happen, there is a risk that bacteria found in the small bowel can get into your bloodstream.
After surgery you will be closely monitored by the transplant team to reduce this risk.