Paediatric Small Bowel Transplantation

Intestinal transplantation (ITx) is now a well-established treatment for infants and children with intestinal failure (IF), who develop complications related to long-term parenteral nutrition (PN). Transplantation of other organs such as kidney, liver and heart developed during the 1960s but did not reach widespread clinical application until the cyclosporine era of immune suppression in the early 1980s. ITx lagged behind as the intestine was found to be an organ with special problems of its own immunogenicity, its interface with the enteric lumen colonized with bacteria and transfer of a heavy load of immune competent cells of the donor at the time of engraftment. In addition, organ preservation was more fragile and consequences of ischaemic reperfusion injury more severe. At the same time, treatment of intestinal failure with parenteral nutrition (PN) had developed to give children with IF a reasonable quality of life. Long-term PN, however, has its own complications including central venous catheter related sepsis, venous thrombosis and PN associated liver disease. PN therefore is not a lifetime treatment. Sporadic cases of ITx were reported in the 1970s but all recipients died of technical complications, sepsis or rejection. Optimism for success in the cyclosporine era was short-lived as most grafts were lost to rejection. A total of 15 cases were reported between 1985 and 1990 with one long term survivor. This child received a neonatal donor intestine and has survived 19 years post transplant. Introduction of more effective tacrolimus immune suppression by Starzl in 1990 allowed for reports of 60 % 1 year graft survival by 1993. Currently 90 % 1 year survival is reported from some centres.

Parenteral nutrition remains the current standard of care for infants and children with intestinal failure with a systemic co-morbidities. There is no lower age or size limit and a history of multiple previous laparotomies is not a contraindication but both may carry a waiting list mortality risk of nearly 50% in the <10 kg size recipients because of the shortage of size matched donors.