Intestinal and Multivisceral Transplantation - Indications, Contraindications, and Procedure

Introduction:

Intestinal and multivisceral transplant procedures were carried out as interventional procedures for various disorders. This procedure has now become one of the life-saving procedures. The recipient (person who receives the organ) and the donor (person who donates the organ) are evaluated and if they are medically fit to carry out the donation and receive organs. Though complications are associated with this procedure, efficient management of risks and complications has paved the way to successful transplants.

What Is Intestinal and Multivisceral Transplantation?

Transplantation of intestines and organs like the stomach, spleen, pancreas, small and large intestines, and kidneys is called intestinal and multivisceral transplantation. An appropriate approach to the procedure is selected based on the clinical condition of the donor and the recipient.

What Are the Indications of Intestinal and Multivisceral Transplantation?

The indications vary from adults to children.

Commonly it is indicated when there is intestinal failure leading to multi-organ dysfunction.

• Multiple infections.

• Frequent dehydration even on administering IV (intravenous fluids).

• Blockage of blood vessels.

1) In Adults, Intestinal and Multivisceral Transplantation Are Indicated in the Following Conditions:

• Short Bowel Syndrome - A syndrome in which the small intestines are short, and food absorption is decreased.

• Abdominal Cancers - Cancers that affect various abdomen organs can involve the stomach, intestines, liver, pancreas, gallbladder, and rectum.

• Trauma - Trauma to the intestinal region due to major road traffic accidents or stabbing with sharp objects.

• Inflammatory Bowel Disease - Inflammation of the entire or a part of the digestive tract.

• Radiation Enteritis - Inflammation of the intestines due to continuous or frequent radiation exposure.

2) In Children, Intestinal and Multivisceral Transplantation Are Indicated in the Following Conditions:

• Volvulus - Intestine twisting around itself and causing an obstruction.

• Necrotizing Enterocolitis is a lethal condition affecting premature babies with inflamed intestines.

• Intestinal Atresias - It is a defect seen in newborns with an intestinal blockage.

• Short Bowel Syndrome - A condition in which the intestines are short, thereby decreasing the absorption of nutrients.

• Gastroschisis - A condition in which a hole in the abdominal wall of the belly through which internal organs appear outside the body. It is seen in newborns.

• Intestinal Dysmotility Diseases - Diseases in which normal intestinal movement is hampered.

What Are the Contraindications of Intestinal and Multivisceral Transplantation?

Contraindications are similar to those followed for organ transplantation. The following are the various contraindications:

• When the disease is not treatable with transplantation.

• Local infections when not treatable.

• Lack of family support.

• Alcohol addiction.

What Should Be Done Before the Intestinal and Multivisceral Transplantation Procedure?

Proper medical history of the donor and the recipient is taken, and certain lab investigations are advised.

• HLA Typing (Human Leukocyte Antigen) - A blood test used to match the donor and the recipient.

• Blood Cross Matching - A test to check harmful interactions between the donor and the recipient.

• CBC (Complete Blood Count) - This blood profile is obtained to check for the values of each component in the blood.

• Pre Albumin - Prealbumin is a protein made in the liver. The levels of this protein are evaluated too.

• Blood Coagulation Panel - This blood test measures blood's ability to clot.

• CT (Computed Tomography) Enterography - Imaging test to visualize small intestines.

• Duplex Ultrasound Scan - Examines blood flow in blood vessels.

• Angioplasty - A procedure to stretch a narrowed blood vessel.

How Is Intestinal and Multivisceral Transplantation Procedure Performed?

The surgical procedure can be performed in various approaches -

1. Isolated intestine transplant procedure.

2. Combined liver intestine transplant procedure.

3. Multivisceral transplant procedure.

4. Living-donor small-bowel transplant procedure.

1) Isolated Intestine Transplant-

Donor Procedure - The intestines are isolated from the other organs. Their blood vessels are ligated and put on a laparotomy pad (an absorbent pad used in surgical procedures to absorb excess blood fluids and obtain a clear view). Usually, the pancreas is transplanted along with intestines from the same donor. But the back table procedure is carried out in cases where that does not happen.

Back-Table Procedure - In cases where the pancreas is not required to be transplanted, a back-table procedure is performed in which the blood vessels of the pancreas are separately ligated and sutured.

Recipient Procedure - The technique of vascular reconstruction is carried out in recipients in either of the following ways -

• Mesenteric Vascular Reconstruction - Usually indicated in patients with intestinal motility disorder. The blood vessels of the donor's intestines are then anastomosed with that of the recipients. Mesenteric blood vessels are sutured in place with an extension graft which can be used to make a connection between the donor and the recipient's organs.

• Systemic Vascular Reconstruction - Usually indicated in patients with short bowel syndrome. This procedure attaches the grafts to the inferior vena cava and aorta (major blood vessels). Following a maintained blood flow, the intestines are sutured.

2) Combined Liver–Intestine Transplant:

• Donor Procedure -The liver and intestine are separated from the donor as a single unit along with its critical structures.

• Back-Table Procedure - All the blood vessels and the important structures are identified and ligated.

• Recipient Procedure - The isolated structures are then anastomosed to the recipient's inferior vena cava and aorta (major blood vessels).

3) Multivisceral Transplant - Including other organs like the stomach, kidney, and spleen along with the liver and intestines is a multi-visceral treatment.

4) Living-Donor Small-Bowel Transplant: Surgical Procedure - about 150 cm or part of the donor's intestine is isolated, and the remaining open ends are attached and sutured. This isolated segment is then sutured to the recipient depending on the anatomy.

What Is Expected After the Surgery?

It is a life-saving procedure where the outcomes can vary from patient to patient.

Recovery: The patient is expected to be hospitalized for nearly a month after the surgical procedure. The condition of the patient and the emerging risks are monitored by the healthcare professional team.

Medications: The patient is supposed to take medications and continue them for the rest of their life.

• Anti-infective Drugs - The body is weakened as the immune system is weakened. Hence it is necessary to take anti-infective drugs.

• Anti-rejection Drugs - Immunosuppressant drugs decrease the immunity to prevent donor organ rejection.

What Complications Are Associated With Intestinal and Multivisceral Transplantation?

• Rejection - When the recipient's body cannot take up the organ and shows various reactions against it, it is said that the body has rejected it.

• Graft Versus Host Disease - Maintenance therapy includes tacrolimus and prednisolone. It occurs when the donor cells recognize host cells as foreign antigens and start attacking them. Management includes increasing immune-modulating drugs along with stem cell therapy.

• Posttransplant Lymphoproliferative Disorder - There can be a great neoplastic proliferation of the lymphocytes that can make the patient's condition critical. It can be managed by Immunosuppression therapy and antiviral therapy.

• Infections - Bacterial to viral infections are the expected complication in organ transplantation.

• Post-Surgical Complications - These can occur immediately after surgery, like fluid leaks, clots in blood vessels, and bleeding. They can be managed with or without surgery.

Conclusion:

Intestinal and multivisceral transplantation is a procedure carried out to treat certain disorders. It has recently emerged as a life-saving procedure increasing life expectancy. Though there are multiple complications associated with this procedure, proper management ensures a positive treatment outcome.