Bowel Transplant

It is a complicated and highly specialised operation that is not commonly performed, although the number of procedures carried out has increased in recent years.

Currently, around 15-20 small bowel transplants are performed each year in the UK.

These procedures are carried out at four specialist centres – Birmingham Children’s Hospital, Addenbrooke’s Hospital in Cambridge, John Radcliffe Hospital in Oxford and King's College Hospital in London.

Why small bowel transplants are carried out

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 (TPN). This is where a person requires all their nutrition to be given through a drip into a vein because their bowel is unable to absorb nutrients from any food they eat.

While many people needing TPN can have this treatment at home without experiencing any significant problems, the long-term use of TPN can lead to serious complications such as liver disease and repeated infections.

A small bowel transplant may be considered when the person has a serious problem with their bowel, but have developed complications from TPN or are unable to tolerate this form of feed

How it is carried out

There are different types of small bowel transplant operation that may be recommended, depending on your individual circumstances.

The main types of transplant procedure are:

• small bowel transplant only – recommended for people with bowel failure who do not have liver disease
• combined liver and small bowel transplant – recommended for people with bowel failure who also have advanced liver disease
• multiple organ (multivisceral) transplant – although it's not often carried out, this can be recommended for people with multiple organ failure, and involves transplanting the stomach, pancreas, duodenum (the first section of small bowel), liver and small bowel

What happens during surgery

A small bowel transplant is a complicated and highly specialised operation. It is performed under general anaesthetic and takes around 8-10 hours to complete, although it can take longer.

After removing your diseased bowel, your blood vessels are connected to the blood vessels of the transplanted bowel, in order 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 form an ileostomy (where part of the small bowel is diverted through an opening in the tummy, called a stoma). After the operation, the ileostomy allows digestive waste to pass out of your body into an external pouch, and lets the transplant team assess the health of your transplanted bowel.

Depending on your health and the operation's success, the ileostomy may be closed a few months after the operation and the bowel reconnected. However, this is not always possible.

Getting ready

Before having a small bowel transplant, you will need a transplant assessment. This involves tests and conversations with a transplant team to check if you are suitable for the procedure.

If you are suitable, you will be placed on a national waiting list until suitable organs from a recently deceased donor become available. You may be contacted at any time by the transplant team, day or night.

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. On average, people wait just under six months for a small bowl transplant.

In some cases, it may be possible for a family member to donate a section of their bowel for transplantation, without you needing to be placed on the waiting list.

The operation

A small bowel transplant is a complicated and difficult operation that takes, on average, around 8-10 hours and is carried out under general anaesthetic.

During the procedure, the surgeon will remove the bowel and connect the transplanted bowel to your blood vessels and digestive tract. They will also form an ileostomy, where part of the small bowel is diverted through an opening in the tummy, called a stoma.

The stoma will allow digestive waste to pass out of your body into an external pouch, and lets the transplant team easily assess the health of your transplanted bowel. Although it is not always possible, the ileostomy may be reversed a few months later.

After the operation

Recovering from a small bowel transplant can take a long time, and you'll probably need to stay in hospital for at least four to six weeks.

While in hospital, you will receive medication to reduce the risk of your body rejecting the new organ; these are known as immunosuppressants. You will be slowly weaned from TPN to eating a normal diet.

After leaving hospital, you'll need to continue taking immunosuppressant medication and have regular check-ups for the rest of your life.

Recovering from the operation

Immediately after a small bowel transplant, you will be taken to the intensive care unit (ICU) and carefully monitored, so the transplant team can check your body is accepting the new organ. 

While in the ICU, you will have various tubes in your veins to provide medications and fluids, and you will be attached to monitoring equipment.

You may also have regular bowel biopsies, where tissue samples are taken using the opening in your tummy created by the surgeon. Alternatively, you may have an endoscopy, where a long, thin tube with a camera on the end is inserted into the opening in your tummy, to examine the inside of your bowel.

The transplant team can determine whether your body is rejecting the bowel from your biopsy results. If it is, additional treatment with medications to suppress your immune system (immunosuppressants) will be given.

Once you have started to recover, you will usually be transferred to a specialist transplant ward, where you will continue to be given painkillers, immunosuppressant medication and nutrition through a tube into a vein (parenteral nutrition).

Over time, the vast majority of people are able to move from parenteral nutrition to eating a normal diet fed through the mouth.

Leaving hospital

How long it takes to recover from a small bowel transplant depends on whether you also had any other organs transplanted at the same time. Overall, the recovery period is generally longer than for most other types of organ transplant.

On average, people who have a small bowel transplant are discharged from hospital after around four to six weeks.

If you live a long distance from the hospital, you may need to stay in nearby hospital-provided accommodation for a month or two after you are discharged, so you can be monitored carefully and treated quickly if any problems develop.

After leaving hospital

On leaving hospital, you will be given immunosuppressant medication to help prevent your body rejecting the transplant. This medication will need to be taken for the rest of your life.

For the first few weeks or months after leaving hospital, you will need to continue having regular blood tests and endoscopies, but these will be carried out less often over time. Eventually, you may only need to see your surgeon once year and have blood tests every few months.

Although it can take a long time to make a full recovery from a small bowel transplant, and there is a risk of potentially serious complications, the aim of the operation is to eventually allow you to live as normal a life as possible – including working, enjoying hobbies and living independently.

Outlook

Although medication and regular check-ups will be needed indefinitely, a small bowel transplant can allow you to live as normal a life as possible – including working, enjoying hobbies and living independently.

However, due to the risks of surgery and the general poor health of people who are considered for a small bowel transplant, some people will die within a few years of their operation.

Current figures for transplants carried out in the UK between January 1998 and December 2013 show that:

• after 90 days – 84% of adults and 88% of children are still alive
• after one year – 76% of adults and 72% of children are still alive
• after five years – 62% of adults and 51% of children are still alive

However, the outlook for small bowel transplants carried out now is likely to be better than these figures suggest, as medical knowledge and techniques are constantly improving.

Risks

As with all types of surgery, there are risks associated with having 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 in recent years.

However, potentially serious complications can still occur, such as:

• heart and breathing problems
• infection of the small bowel – such as an infection by the cytomegalovirus (CMV)
• blood clots (thrombosis) 
• post-transplant lymphoproliferative disorder (PTLD) – where the Epstein-Barr virus infects white blood cells, which can lead to abnormal growths throughout the body and multiple organ failure, if not promptly treated
• rejection of the donor organ (see below)
• problems associated with the long-term use of anti-rejection medication – such as an increased risk of infections, kidney problems and certain types of cancer

Due to these risks and the overall poor health of people who are considered for a small bowel transplant, some people will die within a few years of the procedure. However, the majority of adults and children who have the operation will live for at least another five years.

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, which can stop it from working properly.

This is also known as graft versus host disease (GvHD), and it can occur within a few weeks of a transplant or, less commonly, a few months or even years later.

Immunosuppressant medications that weaken your immune system are given during and after your transplant and must be taken for life, to reduce the risk of your body rejecting your new bowel.

As well as stopping the donated organ working properly, rejection can sometimes mean that bacteria found in the small bowel can get into your bloodstream and cause a serious widespread infection. You will be closely monitored by the transplant team after surgery to reduce this risk. 

In some cases where the transplant fails, you may be put on the waiting again for another transplant.