Intestinal Transplant

Evaluation

If you are referred for an intestinal transplant, you will complete an evaluation process with our transplant team to be sure that intestinal transplant is an appropriate treatment for you. During the evaluation process, your medical history will be recorded and you will complete a thorough medical examination and consultations with our doctors, nurses, dieticians and social workers. You also will have a variety of tests, which may include, but are not limited to:

• Upper gastrointestinal and small bowel X-ray series
• Barium enema
• Endoscopy
• Abdominal CT scan
• Motility studies
• EKG and echocardiography
• Ultrasound of the circulatory system
Blood tests for liver function, electrolytes, kidney function and antibodies to certain viruses
• Additional tests that help determine the success of the transplant

During your evaluation period, our team will provide you with detailed information about intestinal transplant and what to expect after surgery. During this time, you'll have an opportunity to discuss any questions you may have about the procedure.

You also will need to identify a friend or family member as a support person to help you after your transplant. Your support person is very important to your recovery period after you have been discharged from the hospital. They will need to stay with you during this time and accompany you to your follow-up appointments.

Waiting List

After you complete the evaluation process and tests, the results will be carefully reviewed and discussed by the intestinal transplant team and transplant selection committee. They will determine whether you are an appropriate candidate for intestinal transplant.

If you qualify for an intestinal transplant, you will be placed on the intestinal transplant waiting list, which is maintained by the United Network for Organ Sharing (UNOS). UNOS is responsible for deciding how organs will be allocated to people in the United States. Intestines are allocated by wait time, except in some special cases when transplantation may be an emergency. Wait time for all organ transplants depends on the availability of organs and number of people on the waiting list. Intestinal transplant recipients may wait for six months or more to receive a transplant once they are placed on the waiting list.

When an organ becomes available, you will be asked to come to UCSF Medical Center where you will be evaluated by a doctor on the transplant team and undergo a few more tests to be sure that your medical condition has not changed. It is important to remember that occasionally a transplant recipient may be called into the hospital for surgery for a "false alarm," when the organ offered to them is determined unsuitable. In such cases, patients are sent home, but retain their position on the waiting list and will be offered the next available suitable organ.

Procedure

Intestinal transplant is a complex procedure that requires the expertise of specialists trained in performing transplants. The surgery may take up to 12 hours and involves either an isolated intestinal transplant alone, combined liver intestine transplant, or a multi-visceral transplant. Depending on the cause of your intestinal failure and your overall medical condition, your doctor will determine the type of transplant that best meets your needs:

• Isolated Intestinal Transplant — An isolated intestinal transplant involves removing the diseased portion of the small intestine and replacing it with a healthy small intestine from a donor. This type of transplant is considered for patients with complications caused by intestinal failure, but who do not have liver failure.
• Combined Liver Intestine Transplant — A combined liver and small intestine transplant involves removing the diseased liver and intestine and replacing them with a healthy liver and intestine from an organ donor. This type of transplant is considered for patients with intestinal failure who also have irreversible liver failure.
• Multivisceral Transplant — A multivisceral transplant is rarely necessary but may be considered for patients who have multiple organ failure, including stomach, pancreas, liver, small intestine and kidney failure. This type of transplant involves removing the diseased organs and replacing them with healthy organs from a donor.

Intestinal transplant involves removing your diseased small bowel and/or other organs, and replacing them with healthy organs. First your blood vessels are connected to the donor's blood vessels to establish a blood supply to the transplanted intestine. The donor's intestine is then connected to your gastrointestinal tract.

An ileostomy is then created, which is a surgically created opening through which a portion of your small bowel, called the ileum, is brought up through the abdominal wall. After the transplant, this new opening on your abdomen — the ileostomy — allows body waste to pass directly out of the body and empty into a pouch. The ileostomy also allows the transplant team to assess the health of your transplanted intestine. Whether the ileostomy is permanent depends on your medical condition before the transplant. In time, some patients are able to have the ileostomy closed and their intestine reconnected. A feeding tube is also placed into the stomach to help you transition to an oral diet.

Recovery

Care after an intestinal transplant differs slightly for each patient, depending on their medical history, type of transplant and medical condition at the time of their transplant. The length of stay in the hospital varies for each patient, but can last for several weeks or as long as several months.

Immediately after your transplant, you will be taken to the intensive care unit (ICU) where you will be closely monitored. When you are ready, you will be transferred to our transplant ward where you will be monitored and cared for by our team of transplant experts, including doctors, nurses and nurse practitioners, dieticians, pharmacists and social workers. During this time, you will have frequent blood draws, biopsies of the transplanted intestine through the ileostomy and radiologic testing. These tests will help determine the health or your transplanted organ. You also will begin the process of weaning from total parenteral nutrition (TPN) and will slowly start feeding through your feeding tube with a liquid nutritional supplement. Over time, you will start an oral diet.

Discharge

After you leave the hospital, you will need to stay locally if you live more than two hours away, until your doctor determines that you are stable to return home. We maintain listings of hotel and motel accommodations and can help you arrange short and longer-term accommodations. For information regarding hotels, motels and short-term apartment rentals in San Francisco, please visit our campus Housing Office Web site.

During this time, you can expect weekly office visits, frequent biopsies of the transplanted intestine and lab work twice a week. You will stay in close contact with your nurse coordinator and can contact them at any time with questions or concerns regarding your health. Your support person also will need to stay with you during this time to help with your daily activities, taking you to testing and medical appointments.

Medications

After your transplant, your body will think of the transplanted organ as a "foreigner," and therefore your immune system will try to attack it. This is called "rejection". To help prevent rejection from occurring, you will take immunosuppressive medications, which decrease your immune system’s activity so that it won't reject your transplanted organ. The risk of rejection never goes away, so transplant recipients need to take immunosuppressive drugs for life.

Although immunosuppressive medications help reduce your risk of rejection, they also weaken your immune system, putting you at a higher risk for infections. For this reason, you will need to take medications to help prevent bacterial, fungal and viral infections. Some patients also may require blood pressure, diabetes or anti-ulcer medications.

It is important to remember that an organ transplant is not a surgical cure, but rather a life saving therapy that requires medication and close monitoring to be successful.

Risks and Benefits

Over the last several years, success rates for intestinal transplant have improved dramatically. One-year survival rates for patients after intestinal transplant are more than 85 percent, which is comparable to liver transplant patients. Eighty percent of patients who have had an intestinal transplant are able to completely transition from total parenteral nutrition (TPN) to an oral diet and resume normal activities of daily living.

Intestinal transplant does have some risks. The most common complication is rejection of the transplanted organ. During your recovery period, you will be closely monitored for rejection, which is most accurately diagnosed with a biopsy. In most cases, rejection can be treated with strong medications.

Bacterial, fungal or viral infections can develop in people following transplant because immunosuppressive drugs weaken the immune system. You will be given medications to help prevent infections.

Transplant recipients face increased risks for cancer such as skin cancer and lymphoma, a side effect of some immunosuppressant drugs, and should be closely monitored for these conditions.