Multi-Organ Transplant

Small Bowel Transplant - Patient Information

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The Multi Organ Transplant Program of the Toronto General Hospital began performing small bowel transplants in January 2000. Depending on the medical diagnosis, the patient may require a small bowel transplant alone, a small bowel and liver transplant, or a small bowel, liver, pancreas and stomach transplant (also known as a multi-visceral, or cluster transplant). We have done 10 small bowel transplants to date, the latest being in November 2006.

Indications
Small bowel transplantation can be considered when patients with poor intestinal function do not respond to standard therapy, which usually includes parental nutrition (TPN). Patients may require a small bowel transplant alone, a small bowel and liver transplant or a small bowel, liver, pancreas and stomach transplant (also known as a multi-visceral or cluster transplant). The Hepatologist and surgeon will decide on which transplant would be most suitable.

Some of the signs and symptoms of small bowel failure are:

	Persistent diarrhea
	Dehydration
	Muscle wasting
	Poor growth
	Frequent infections
	Weight Loss
	Fatigue

Conditions that can lead to intestinal failure include:

Short Gut Syndrome: this is when most of the intestine has been surgically removed because of poor circulation, infection, trauma, tumour, or disease.
Poor Absorption: even though the entire intestine is present, it is unable to absorb fluids and nutrients properly.
Poor Motility: the small bowel is unable to contract its muscles normally so that it can move food through the intestinal tract.

There are three general types of small bowel failure.

	Small bowel alone
	Small bowel and liver
	Cluster transplant (small bowel, liver, pancreas, and stomach)

Types of Failure		Examples
Changes in Small Bowel Structure		Intestinal Atresia
		Gastroschisis
		Necrotizing Enterocolitis
		Microvillus Atrophy
		Psuedoobstruction
		Crohn's Disease
		Gardner's Syndrome
		Radiation Enteritis
		Unresectable tumour
Blood Supply to the Small Bowel		Superior Mescenteric Vein Thrombosis
		Superior Mescenteric Artery Thrombosis
		Volvulus
		Trauma
Other		Severe secretory diarrhea
Other		Malabsorption Syndrome

Assessment
Pre-transplant evaluation consists of a variety of medical tests and interviews with members of the transplant team. This process is essential in determining a patient's suitability for small bowel transplant. During the evaluation process the potential candidates and their family will be provided with information to assist them in making informed decisions about the operation and post-operative period. The patient and their family are encouraged to ask questions of the team members and meet the candidates awaiting transplant as well as those having received a previous transplant if possible.
The workup process typically involves the following tests, but may require additional testing if other health issues are of concern:

	Bloodwork
	Chest X-Ray
	Abdominal Ultrasound
	CT Scan
	Gastroscopy
	ECG
	2D Echocardiogram
	Stress Test
	Cystoscopy
	Urinalysis

The Transplant Team Members who consult on small bowel transplant evaluation are:

	Hepatologist
	Small Bowel Transplant Surgeon
	Gastroenterologist
	Primary Care Nurse Practitioner
	Enterostomal Therapist
	Anesthetist
	Transplant Coordinator
	Social Worker
	Psychiatrist / Psychiatric Nurse
	Physiotherapist
	Nutritionist

Waiting List
There are generally less than 5 patients on the waiting list for small bowel transplant within our program. The waiting period for a donor varies in length because the donor pool is limited and the selection criteria for a matching donor are strict. Wait time is dated from the time you are approved as suitable to be listed. The transplant team works with the candidates primary health care team to provide ongoing monitoring and assessment to ensure ongoing suitability for transplant.

Surgery
Small Bowel transplant surgery is a complex procedure and may take up to 16 hours. Once the donor’s organs are determined to be suitable, the recipient is taken to the operating room and placed under anaesthetic. The operation consists of removal of the diseased small bowel, attaching the new small bowel, creation of an ileostomy and placement of a feeding tube. If additional organs are required they will be removed and the new organ is attached. The abdomen is then closed and the patient is taken to the Intensive Care Unit for the initial recovery period. A large abdominal incision is held together with staples.

Recovery
Small bowel transplant recipients can expect to be in the hospital for several weeks after surgery. After the transplant procedure, patients will be on a ventilator to assist with breathing and are closely monitored in the ICU. Once stabilized, the ventilator is removed and the patient is then transferred to the Multi Organ Transplant Unit. Patient care following transplantation focuses on:

	Monitoring for Rejection
	Adjusting Immunosuppressive Therapy
	Education and Teaching
	Rehabilitation
	Support

Discharge & Follow-up
Discharge planning begins well in advance and patients meet with a social worker during their initial assessment to address these issues early. The program's Patient Resource Coordinator assists in assessing patients' readiness for discharge and ensuring patient teaching is complete. Patients will return to the Ambulatory Care area regularly after the initial postoperative period, with the frequency of clinic visits reduced as the patient's condition permits. During clinic appointments, patients are seen by their Transplant Coordinator, and Transplant Physician. Communication with the patient's family physician and other specialists is an important component of follow-up care. Patients keep in contact with their transplant team through our patient voicemail system, Easy Call. The Multi Organ Transplant Program's team approach ensures that patients receive comprehensive follow-up care after transplantation and throughout their lives post-transplant.

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