About Intestinal Transplant

Intestinal transplant is a surgical procedure aiming to resolve intestinal failure as well as manage other complications related to parenteral nutrition (PN). Conditions that may generate a need for intestinal transplant which may be detected at birth or during its development over time.

Need for Intestinal Transplant

Various acute and chronic ailments may affect the functioning of the intestinal and may require intestinal transplants. Some of the conditions are listed below:

• TPN related complications
• Parenteral nutrition-induced liver disease: Liver failure is one of the worst complications induced by parenteral nutrition. It is responsible for a large number of deaths caused by the failure of the intestine.
• Central venous catheter (CVC) related thrombosis of 2 or more central veins: If a patient loses access to one or more central veins from thrombosis (or clotted veins) secondary to a parenteral nutrition line, he/she may be at risk of not being able to access a central line for hydration and nutrition.
• Frequent episodes of central line sepsis: This could include 2 or more episodes per year of bloodstream infection secondary to an infection of a central venous line requiring hospitalization.
• Underlying disease/condition with an increased risk of morbidity
• Desmoid tumors linked with familial adenomatous polyposis.
• Congenital mucosal disorders.
• Ultra-short bowel syndrome (duodenostomy, gastrostomy, residual small bowel <10 cm in infants and <40 cm in adults).
• Intestinal failure
• Intestinal failure due to intolerance to parenteral nutrition.
• Short Bowel Syndrome (SBS): SBS is a malabsorption disorder caused due to the surgical removal (resection) of large sections of the intestine.
• Motility disorders may also known as Chronic Intestinal Pseudo-obstruction (CIPO). The length and anatomy of the bowel may be preserved, but the function (the way the small bowel moves) is impaired.
• Intra-abdominal non-metastasizing tumors
• Crohn’s Disease
• Ischemia
• Motility Disorder
• Trauma
• Tumor
• Volvulus

Type of Intestinal Transplant

There are different types of intestinal transplants suggested for a patient, depending upon the severity of the condition and the overall health status of the patient.

• Intestine only
• Modified multi-visceral transplant, which includes all organs except the liver
• Combined liver and intestine with pancreas transplant
• Full multi-visceral transplant including the pancreas, intestine, liver, stomach, and duodenum
• Multi-visceral transplants are considered for patients whose underlying condition significantly compromises other sections of the digestive system, as listed above.

Pre- Intestinal Transplant evaluation

Before undergoing transplant, you may need to undergo rigorous evaluation, which includes:

• CT scans of the head, chest, and abdomen
• Blood test
• Stress test
• Pulmonary function testing
• Heart catheterization
• Endoscopy
• X-rays of the upper GI tract
• X-ray of small bowel
• Motility studies

General health exam: This usually includes a physical examination and cancer screening tests to evaluate your overall health.

Blood tests: There are different blood tests that you may need to undergo to know about gene compatibility.

Imaging tests: Various tests like CT scan, MRI, or PET scan may be recommended to look for any abnormality in the organs.

Social and psychological evaluation: These evaluations are done to assess your overall stress, financial issues, and support by your friends and family.

Ultrasound: Ultrasound is done with the help of sound waves creates a picture of the internal organs, and it gives the inside picture of the organ. Endorectal ultrasounds are commonly performed to find in case of cancer and how deeply rectal cancer has grown. It also helps plan treatment.

Colonoscopy: Colonoscopy helps the doctor to look inside the entire colon for any abnormality. In this procedure, a long, flexible tube (colonoscope) is inserted into the rectum. There is a tiny video camera at the tip of the tube that gives the pictures.

Waiting Period

There are more patients in need of an intestinal transplant than the bowel donated. Hence, the waiting list is long in India. While being on the waiting list for organ, your doctor will start the other treatment and plan a treatment that will keep you in stable condition and prepare you for your upcoming transplant procedure. Keep your doctor informed about any changes your experience about your health and get a consultation.

The Intestinal Transplant process

Complications of Intestinal Transplant

As with every surgical procedure, the risk of complications is there, and intestinal transplant is also not an exception. However, it is not mandatory that a patient develops such complications, but it is good to be aware of them. Below-mentioned are some of the common complications linked with intestinal Transplant:

• Surgical Complications: Certain complications may occur during or shortly after the surgery, such as:
• Wound infection
• Blood clot in the artery or vein of the lungs, heart, spleen, pancreas, or liver.
• Bile leakage from the bile ducts
• Uncontrollable bleeding
• Infection: You will be prescribed immunosuppressants to suppress the action of the immune system to aid the adjustment of the new organ in the body. However, taking immunosuppressants may expose you to various infectious diseases.
• Rejection: Sometimes, your new organ may not be accepted by the body and hence may not be able to function appropriately. Our immune system recognizes the foreign organisms or particles such as viruses or bacteria, and it might not accept the new organ as well, leading to chances of rejection.
• Anti-rejection medications side effects: You will be prescribed various anti-rejection medications for the proper functioning of the liver and overall health. These medicines can behave certain major side effects such as:
• Weight gain
• High blood pressure
• Diabetes
• Damage to kidneys
• Cholesterol imbalance
• Thrombosis: It is the clot that forms in the artery or vein of the new intestine. It leads to the stoppage of the blood supply to the intestine.
• Bleeding: There is a high risk of internal bleeding linked with major surgeries. This may call for blood transfusion, and another surgery may be required to stop the bleeding.
• Leak: Sometimes, the leak may occur at a point where your new intestine has been attached to your own organ. You may need to undergo an operation to stop this leak.

Post-intestinal Transplant Procedure

After the surgery is completed, you will be taken to a recovery room for a few hours, where you will be under observation. Once the doctor feels you are in stable condition, you will be shifted to the intensive care unit (ICU), where you are observed closely for several days, and your vitals will be monitored.

Frequently blood samples will be taken to check the new bowel. The doctors will also keep a check that other organs like the lungs, kidney, and circulatory system are all working well. Anti-rejection medicines will be administered and watched closely to be sure that the patients are getting the right dose and mixing the right medicines. You will initially be started on a liquid diet, and gradually you may have a regular diet with no restrictions.

You may have to stay in hospital for 4-6 weeks. When your doctor feels you are stable, you will be shifted to a normal ward. Gradually, you will be able to walk and move around for a long duration. The doctor will then guide you how to take care of yourself when you go home.

Life after Intestinal Transplant

An intestinal transplant can improve the quality of life of the patients significantly. However, there are certain measures and practices that you need to follow to live a normal and healthy life.

• Frequent and regular follow-ups: You may have to have frequent follow up with your doctor for the initial months after your transplant. They will keep a check on your body's response to transplant and any complications which may arise.
• Hygiene and lifestyle: Following good hygiene practise and staying active is an excellent contributory factor for your recovery. Live a healthy lifestyle by engaging yourself in any form of physical activity, avoiding smoking, eating a balanced diet, etc.
• Immunosuppressants: As our body have tendency to reject the foreign body or object. You might have to take immunosuppressant medicines to avoid the possibility of rejection.

Success rate and life expectancy of an intestinal transplant

With improvement in medicine, the life expectancy of patients undergoing an intestinal transplant is also progressing. In comparison to the last decade, patient's life expectancy has improved.

• Success rate – 70%
• Life expectancy

Increased lifespan for 1 year: 85%

Increased lifespan for 3 years: 70%

Choosing the ideal intestinal transplant center

It is crucial to learn about different transplant hospitals and centers before finalizing the one. Here are a few things to keep in mind while choosing a right transplant hospital/center:

• Consult more than 1 doctor and talk to patients who have undergone bowel transplants in the hospital and know about their experience.
• Whether the hospital/center has expertise in living or deceased donor transplants.
• The reputation of the center/hospital and its mortality rate for patients who had transplant.
• If the hospital/center is covered under the insurance policy.
• Total-experience of the hospital/center in dealing with transplant cases.

Cost analysis of Intestinal Transplant

Living with a medical condition that badly affects your life is an extremely painful experience both for the patient and his family. Getting an intestinal transplant can certainly improve the quality of life of the patient. The average cost of intestinal transplants in India varies between 30 lakh approximately. It is important to check with the insurance company if the transplant cost is covered in your current plan. Certain factors that will affect the cost are:

• Infrastructure and location of hospital
• Length of stay in hospital
• The expertise of surgeons, their team, and use of advanced technology
• Any health complications
• Recovery and rehabilitation
• Post-transplant medications

A patient who travels away from home to hospitals for transplant also needs to keep the cost of stay near the hospital in the new city. The cost of staying may also adds up over the course of a few months.