Small bowel transplantation – the latest developments

Intestinal transplantation has become a routine clinical procedure for selected patients. Over the last 10 years patient survival figures have improved considerably and are now approaching those receiving organs such as liver, lung and heart. Patient selection has improved and immunosuppression has been enhanced by the introduction of lymphocyte modulating antibody therapy combined with less potent maintenance immunosuppression. The indications for intestinal transplantation remain conservative at present and largely reserve this procedure for patients who have life threatening complications of parenteral nutrition or require surgical procedures that make simultaneous or subsequent transplantation advantageous. However, as survival figures improve the indications are beginning to broaden to include consideration of quality of life. Survival after transplantation is approaching that associated with uncomplicated parenteral nutrition and if this trend continues it may replace parenteral nutrition as the treatment of choice for patients with irreversible intestinal failure. This article describes the current indications for intestinal transplantation and the current results of the procedure. Guidelines for referring patients for transplantation assessment and for the management of the sick transplant patient are given. The need to consider referral of patients at an early stage to allow timely assessment for transplantation is also discussed.