Advanced Bowel Transplant at Fortis Hospital Bangalore

At Fortis, Bowel Transplants are performed by a remarkable team of determined and skilled experts who are truly committed to making lives better. With a wealth of experience, our multidisciplinary team of Surgeons, Gastroenterologists, Interventional Radiologists, Transplant Hepatologists, Anesthesiologists and critical care Intensivists, and well trained technical and nursing staff make a huge difference in the life of every patient by offering one of a kind of patient care.

The gastrointestinal system:

It is a system of our body which starts from the mouth and ends in the anus. The function of this system is to break down the food we consume; absorb the essentials and discard the wastes. The other organs which form the part of this system are an oral cavity, esophagus, stomach, small intestine, large intestine, pancreas, and liver.

The difference between solid organ and intestine transplants:

The transplant of the liver, pancreas, and kidney is called a solid organ transplant. Whereas, the transplant of stomach, small and large intestine is called hollow viscera transplant. The transplant of the liver along with the pancreas and intestines at the same time is called a multi-visceral transplant.

Short gut syndrome:

The short gut syndrome is a condition in which your body is unable to absorb the proper amount of nutrients from the food due to surgical removal of a portion of the intestine. Surgical removal is usually done in patients with gangrene of the intestine, Crohn’s disease, trauma with extensive injury to the intestine, etc.
In some children, this syndrome can be congenital or conditions (like necrotizing enteritis/Crohn’s disease/long-segment Hirschsprung disease) may develop and damage the intestine which requires a portion of the intestine to be removed in order to save their lives. As the length of the intestine decreases, its capacity to absorb the nutrients also decreases, resulting in Intestinal failure. This mal-absorption of nutrients leads to malnutrition and eventually causes the death of the patient.

Small Bowel/Intestine Transplantation:  

The surgical replacement of the small intestine due to surgical or medical causes of intestinal failure. If patients with intestinal failure are not treated appropriately, they will develop liver and kidney failure. As three intra-abdominal organs fail, they will need multi-visceral transplantation which is a combination of liver, small intestine, and kidney transplantation. To make these types of complex life-saving procedures possible, we have a successful on-going cadaver organ transplantation program at Fortis. Moreover, with expert doctors on board and the latest technologies at our disposal, we optimize the patient care in all the aspects.

Candidates for a small bowel transplant: 

• People with small intestine failure are considered to be candidates for small intestine transplant.

• People who are unable to control their weight by eating regular food by mouth are deemed to have a small intestine failure.

• Individuals who got most of their intestine removed due to gangrene (eg, SMA thrombosis) or who are incapable of absorbing the nutrients from the food they consume (despite having a full length of intestine) and cannot maintain a regular lifestyle (due to tufting enteropathy/long segment

• Hirschsprung disease, mal-absorption syndromes or motility disorders) are the people who will benefit from small bowel transplantation.

Alternatives to small bowel transplant

If an individual has an inadequate length of small intestine, he will not be able to consume food by mouth and thus he cannot survive. To fulfil his energy requirements, the food has to be supplied through a tube inserted in one of the broad veins. This way of feeding is called total parenteral nutrition (TPN).

What is TPN and how is it given? 

Total parenteral nutrition (TPN) is a way of supplying the nutritional needs of the body through the veins in the arms. It delivers a mix of nutrients in liquid form at high concentration and in high calories. Thus, it helps to prevent malnutrition. TPN is given by inserting a thin, flexible tube (central venous line) into one of the larger veins in the neck or groin. By this way of infusing the nutrients intravenously, we will be able to deliver the required calories appropriately.

How is a small intestine/bowel transplant performed?

A small intestine transplant can be performed with either a living donor or a cadaveric donor. In the case of living donor small bowel transplant, a portion of the small intestine, approximately about 200cm, is removed from a willing, matched donor and implanted into the body of the recipient. In the case of a cadaveric donor small intestine transplant, the intestine of a brain-dead donor is used. The entire length of the intestine is used for this procedure. First, the blood vessels are connected to re-establish the blood supply. Once the blood supply is re-established, intestinal anastomosis is done to create a connection and maintain the continuity of the digestive tract. Then the end portion of the intestine is brought out of the abdominal wall as a stoma.  To biopsy the intestine regularly and monitor for evidence of rejection, the stoma can be used. The first stage of the transplant process is evaluation. Thorough diagnosis and examination, the patient’s eligibility for the transplantation is determined. If found eligible, post evaluation, the patient will be registered with the government agency which overlooks the transplant process and waits for a suitable organ to be allocated to the patient.

Surgery – What can you Expect in the Operating Room

To begin with the procedure, you will be given general anaesthesia and placed on a ventilator. Before the surgery, the anesthesiologists will discuss this process in detail with you. By making an incision in your abdomen, your intestine (along with the other organs if a multi-visceral transplant is performed) will be removed by the transplant surgeon and suitable donated organ(s) will be placed. During the operation, you may need a surgical technique called veno-veno bypass to be performed. In that case, your surgeon will make an incision in your underarm or neck or groin and place the catheters. These catheters are linked to a machine which allows the blood to bypass the part of your upper abdomen during the operation. Based on your health condition, the transplant surgeons will conclude if the machine will be needed.

To maintain regular blood flow through your legs and prevent fatal blood clots, special mechanical boots will be used. The procedure will take approximately 6 to 12 hours (or may longer). As you recoup and start to ambulate, you can get rid of these boots. Drains will be placed in your body to help remove fluids and heal you. Everyone who undergoes intestine transplantation will have a stoma at the end of the surgery. A stoma is nothing but a surgically-created opening in the colon or small bowel (colostomy and ileostomy respectively) that helps the transplant team to keep a track of the transplanted organ. The stoma is generally a temporary situation, unless it cannot be reconnected or unless repeated and severe episodes of rejection develop. The stoma will be closed after a certain period of time which varies for each patient (generally 6 to 12 months). A minor operation will be performed to close the stoma and it needs only a few days of hospitalization, if not complicated.

Besides stoma, a tube called “Gastrojejunostomy feeding tube” may be getting out of your skin. During the operation, this tube gets inserted through the skin into the GI tract. The gastric end is shorter and gets terminated in the stomach. It helps with decompressing the stomach and administering medications. The longer end is in the jejunal lumen, and if necessary it is used for supplemental tube feeding. This feeding tube is taken out once reasonable nutritional independence is attained. This gastrojejunostomy tube will not be used in selected cases.

Inpatient Post-Operative Surgical Care

Soon after the surgery, you will be moved to the surgical intensive care unit and monitored closely. Once stabilised, you will be relocated to the transplant floor and your post-transplant care will be discussed.