Small bowel transplantation has become the treatment of choice for patients with chronic gut failure whose illness cannot be maintained on home parenteral nutrition. Outcomes have improved as a result of refinements in patient selection, surgical techniques, and the prevention, diagnosis, and treatment of graft rejection. Early listing is important because of the shortage of organ donors. Rejection rates are still 50% or more, despite the use of potent immune suppression. Sepsis rates are also higher for patients who have had small bowel transplantation than for those who have received other organs because of bacterial translocation from the gut secondary to preservation injury and graft rejection. Graft and patient survival rates after small bowel transplantation are comparable to rates after lung transplantation. Successful transplant recipients resume unrestricted oral diets.

Small bowel transplantation

Jejunal and ileal absorptive function after a model of canine jejunoileal autotransplantation.

Intestinal transplantation: effects on ileal enteric absorptive physiology.

The role of extrinsic (autonomic) innervation in postprandial contractile activity of the small intestine is unknown. Using a canine model, we investigated the effects of complete extrinsic denervation on the parameters of fasting and postprandial jejunal contractions and their relationship to intestinal transit. Individual contractions were recorded using strain gauge transducers. Spatial and temporal parameters of contractions were analyzed by computer methods. Bolus injection of 14C-polyethylene glycol was used to calculate intestinal transit rates. Statistical comparisons of control and denervated animals were made by nonparametric tests. Extrinsic denervation did not abolish fasting or fed motor activity, but the following effects were observed: (1) the frequency of migrating motor complexes (MMCs) increased; (2) the onset of fed motor activity was delayed, and the duration of fed activity was shortened; (3) frequency, mean amplitude, and mean area of postprandial contractions were decreased; (4) fewer contractions propagated distally, and mean propagation distance was shortened; and (5) intestinal transit was slower for solids, but not for liquids. In the small intestine, extrinsic nerves modulate motor activity, which is under primary control of the intrinsic (enteric) nervous system.

Motor activity and transit in the autonomically denervated jejunum.

The successful development of clinical intestinal transplantation remains an exciting challenge for the transplant surgeon, immunologist, and gastroenterologist. Bowel transplantation was first attempted in 1901 by Carrel who transplanted portions of small intestine into the neck of dogs.' Interest was rekindled in 1959 when Lillehei showed that autotransplantation of the small intestine into the dog was feasible.' Despite recent major improvements in techniques, however, and the introduction of new immunosuppressive regimens which have seen the flourishing of liver, heart, heart/ lung and pancreatic transplant programmes, the clinical results of small intestinal transplantation remain dismal. Two major problems confront us; first, the complex immunological phenomena occurring after small bowel transplantation, which include both classical graft rejection and graft versus host disease, do not appear to be easily controlled by current immunosuppressive protocols, and require elaborate treatment of both graft and host.-' Second, the physiological functions of the graft are severely deranged by the process of transplantation and further immunological damage will not only hamper recovery but destroy the barrier functions so vital to recipient survival. A series of clinical intestinal transplants were performed in the early 1970s by several institutions, with only one survivor beyond two weeks. More recently small intestinal transplants have been carried out in several major transplant centres in Europe and North America and two European recipients have survived beyond six months (personal communication). While small intestinal transplantation remains hazardous, however, it can not be considered a true therapeutic option for patients who are satisfactorily maintained on total parenteral nutrition. The purpose of this review is to summarise the progress made so far and to highlight the areas in which further research is required before small bowel transplantation becomes a practical therapeutic option.

https://gut.bmj.com/content/gutjnl/30/12/1771.full.pdf

Current status of intestinal transplantation.

https://www.gastrojournal.org/article/0016-5085(88)90540-9/pdf

Water, electrolyte, glucose, and glycine absorption in rat small intestinal transplants.

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Water, electrolyte, glucose, and glycine absorption in rat small intestinal transplants.