Small Bowel Transplant

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What is a small bowel transplant?

A small bowel transplant is a surgery done when the small intestines stop working properly, seriously threatening a person’s life. Surgeons replace missing or damaged parts of the intestines with healthy intestines from another person. This includes the small intestine and at least part of the large intestine as well. 

This surgery is considered for children who have intestinal problems because they were born with certain conditions, had surgeries, or face other issues that make it difficult for their intestines to function properly. 

What is the small bowel? 

The small bowel, also called the small intestine, is an important part of the human body’s digestive system. The small intestine is a long, tube-shaped organ connecting the stomach and the large intestine (colon). The small intestine is very important for absorbing nutrients and helping us digest the food we eat.

The small intestine has three sections:

  • Duodenum: The first section of the small intestine, which connects directly to the stomach. 
  • Jejunum: The middle section of the small intestine, where most nutrients are absorbed.
  • Ileum: The last section of the small intestine, which connects to the large intestine. 

When most of the small intestine is damaged or removed due to medical conditions, surgery, or injury, individuals may have trouble absorbing nutrients, leading to poor nutrition and other health complications. In some severe cases, a small bowel transplant might be considered to restore correct digestive function and improve overall health.

Why might a child might need a small bowel transplant?

A child might need a small bowel transplant if their small intestines do not work properly as a result of medical conditions, in order to support the child’s growth and daily function. Some common reasons why a child might require a small bowel transplant include:

  • Short bowel syndrome: This is one of the most common reasons for a small bowel transplant in children. Short bowel syndrome occurs when a large part of the small intestine has been removed due to surgery, developmental problems, or injury. The remaining intestine might not be enough to properly absorb nutrients, leading to malnutrition, dehydration, and other complications.
    • Necrotizing enterocolitis: Necrotizing enterocolitis is a serious gastrointestinal disease that primarily affects premature infants. It involves inflammation and damage to the intestines, which can lead to death of the tissue (called necrosis). In severe cases, parts of the intestine may need to be removed, causing short bowel syndrome.
  • Intestinal atresia or stenosis: An infant may be born with these conditions. They are caused by incorrect formation of parts of the small intestine, affecting proper nutrient absorption. Surgery to correct these issues may sometimes lead to short bowel syndrome.
  • Motility disorders: Some children may have conditions that affect proper movement of the intestines, leading to chronic bowel dysfunction and malabsorption. 
  • Tumors or trauma: Rarely, tumors in the abdomen or traumatic injuries to the abdominal area might result in the need for a small bowel transplant.
  • Intestinal failure: Children with intestinal failure cannot absorb enough nutrients from a regular diet. This can be caused by different conditions, including those listed above, and might require a small bowel transplant to improve the child’s quality of life and prevent health complications.
  • Recurrent central line-associated bloodstream infections: Many children with non-functioning intestines need intravenous nutrition delivered through a central venous line. Infections in these lines are a severe health risk, so a small bowel transplant is a potential solution to free the patient from required intravenous nutrition.
  • Loss of vascular access: If a child's central veins become clotted due to a central line used to deliver nutrition, they might lose access to these veins. In such cases, a small bowel transplant may be needed to ensure the child receives adequate nutrition.

A small bowel transplant can be a complex and challenging procedure, typically considered when other treatments and interventions cannot improve a child's condition. The decision to perform a small bowel transplant is made by a team of medical professionals, considering factors such as the child's overall health, underlying condition, and potential benefits and risks of the procedure.

What are the symptoms of intestinal failure?

Intestinal failure in children can have different symptoms depending on the underlying cause and the severity of the condition. Common symptoms of intestinal failure in children include:

  • Failure to thrive: One of the hallmark signs in infants and young children is inadequate growth and weight gain. Children with intestinal failure may fall behind in height and weight for their age group.
  • Chronic diarrhea: Frequent, watery stools are a common symptom. The diarrhea can lead to fluid and electrolyte imbalances.
  • Malnutrition: Insufficient absorption of nutrients can result in malnutrition, which may manifest as weakness, fatigue, muscle wasting, and developmental delays in young children.
  • Abdominal pain: Children with intestinal failure may experience abdominal discomfort, cramping, or pain, particularly after eating.
  • Liver problems: Prolonged intestinal failure can affect the liver, potentially leading to liver disease and jaundice.
  • Delayed development: Children with chronic intestinal failure may experience developmental delays, both in physical and cognitive functions.

How are decisions made about donor intestines?

A nonprofit scientific organization maintains the national waiting list for donor organs. Their goals are fairness to all and good outcomes for as many people as possible. Patients are treated equally, regardless of ethnicity, gender, or economic status.

Patients are evaluated by their transplant center. Depending on how sick patients are and how likely it is that they can be successfully treated with transplantation, they are matched by this organization to donor organs as they become available. Your child’s gastrointestinal doctor will be able to provide more information about the transplant process and the options for your child.

How is a small bowel transplant performed?

Your child will be admitted to the hospital. Surgeons will remove the diseased or nonfunctioning intestines. Healthy donor intestines will be placed into your child’s abdomen and will be connected to your child’s own healthy intestines. The surgeon will also make sure blood vessels from the donor intestine match up to your child’s blood vessels—this is very important because it helps the new intestines get enough blood. 

Your surgeon may create an ostomy during the small bowel transplant. An ostomy is a surgical opening in the abdomen. The opening of the ostomy on the skin is called an intestinal stoma. Through this opening, a part of the transplanted intestines will be attached to a bag that collects bowel contents. An ostomy helps doctors monitor the health of the intestines. Your child may have the ostomy for a short period of time until the doctors think the intestines have healed and are healthy. 

After surgery, your child will go to the intensive care unit to be watched closely and will start taking special medications to try to keep the new intestines healthy. 

What is rejection?

Your child's body is pretty amazing. It has a defense system (called the immune system) that can recognize things that are not supposed to be there. Sometimes, the body can start attacking transplanted tissues like intestines because it thinks the new tissues are a foreign invader. When the body does attack the new tissue, it is called "rejection." Your child is given special medications after a small bowel transplant to try to prevent this from happening. 

To watch for rejection, doctors use a special tool called an endoscope. An endoscope is a thin tube with a tiny camera at the end. Doctors can put an endoscope into your child's body through the mouth, anus, or ostomy. With this camera, they can see the intestines and even collect tiny pieces of the tissue to make sure they are healthy. This can help catch rejection early and take steps to stop it.

What is life like after a small bowel transplant?

After a small bowel transplant, your child can live a normal life. There will be some changes such has taking daily medications to prevent rejection and regular doctor visits and endoscopies to monitor health of the intestines. Most patients no longer require intravenous nutrition and can have their central line removed. 

What about multivisceral transplants?

Sometimes, when a child's other organs are also having problems or are damaged, doctors might decide to do a transplant where they replace more than one organ at the same time. This can include organs like the stomach, small intestine, large intestine, pancreas, and liver. This procedure is more complex, so your doctor will have a special conversation with you if this is something your child might need.

Authors: Tebyan Rabbani, DO and Ke-You (Yoyo) Zhang, MD
Editor: Christine Waasdorp Hurtado, MD
September 2023

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North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
The Association of Pediatric Gastroenterology and Nutrition Nurses
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Foundation
The NASPGHAN Council For Pediatric Nutrition Professionals
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