Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation represents an important treatment option for patients with intestinal failure. Early attempts were hindered by technical and immunological complications. However, significant developments in immunosuppressive therapy have led to marked improvements in outcomes in recent years. The main indications for intestinal transplantation are life-threatening complications or unacceptable quality of life on total parenteral nutrition (TPN), or following evisceration for extensive intra-abdominal tumours. In suitable patients, in the absence of significant liver disease, an isolated intestinal graft is appropriate. A combined liver and intestinal transplant is indicated in patients with significant liver disease, almost always as a result of long-term TPN. Pathology affecting the foregut may require more extensive grafts, including the stomach, duodenum and pancreas. Multivisceral transplantation is technically demanding. The transplant recipient has frequently undergone multiple previous laparotomies and may present with multiple stomata, fistulae, collections, distortion of intra-abdominal anatomy and significant contraction of the abdominal cavity. The most important early complications are acute rejection and sepsis, which frequently occur together. In the long term, chronic rejection and malignancy are the leading causes of graft loss and mortality and immunosuppression related renal impairment a major source of morbidity. It is hoped that ongoing improvements in intestinal and multivisceral transplantation may eventually justify its use as a primary alternative to long-term TPN.