Intestinal Transplant & Multivesicular Transplant:

History of Intestinal Transplantation:

Bowel transplantation was first attempted in humans during the 1960s. At that time, patients were dying of starvation after having a large portion of their bowel removed because of disease or trauma. Parenteral (intravenous) feeding was not yet available, and surgeons hoped that the transplanted bowel would function normally. These first intestinal transplant patients died, however, from technical complications such as: rejection, or infection. Successful intestinal transplants were not performed until the mid-1980s when better immune suppressive drugs became available along with better methods to prevent infections. As a result of these improvements, today almost 1000 patients have been able to stop total parenteral nutrition (TPN), resume a normal diet, and enjoy a healthy lifestyle after intestinal transplantation.

Difficulty in Intestinal Transplant

The intestine has been more difficult to transplant than other solid organs and some of the possible reasons include:

• the large number of white cells in the bowel provides a strong stimulus for rejection
• the large number of bacteria in the gut increases the risk of infection after transplantation

Patients must take anti-rejection drugs to suppress their immune system so their body will accept the transplanted bowel. They must take enough drugs to prevent rejection, but not too many or they may have problems with infection and drug toxicity. Prograf® (FK506, tacrolimus) is the most common anti-rejection drug used in intestinal transplantations.

Success Rate of Transplant

Improved anti-rejection drugs, refined surgical procedures, better prevention of infection, and a greater understanding of immunology have all contributed to successful intestinal transplants. Survival rates are now comparable to, or better than, the results of lung transplantation. Of the surviving patients, three-fourths have stopped total parenteral nutrition (TPN) resuming on a normal oral diet. Because most of the patients in the international Intestinal Transplant Registry have been followed for a brief period time; it will take several years to obtain reliable data on long-term results.

To become the standard treatment for intestinal failure, transplantation must offer better survival, better quality of life, and lower costs than TPN. Considerable progress has been made towards these goals, but further refinements are needed before bowel transplantation becomes a routine surgical procedure.

Types of Transplant

Here are four main types of intestinal transplantation:

  • Isolated intestinal transplantation
  • Liver intestine transplantation
  • Multivisceral transplantation
  • Modified multivisceral transplantation

Types of visceral allografts; intestine, liver-intestine, and multi visceral. Inclusion of the pancreaticoduodenal complex (unshaded organs) is optional with the liver-intestine allograft. A multivisceral graft must include the stomach en bloc with the other visceral organs without (modified) or with (full) the liver. The colon, pancreas and kidney could also be added en bloc to the visceral allograft with the exception of the liver-free visceral allograft when the kidney can only be transplanted separately.

Isolated Intestinal Transplantation: An isolated intestinal transplant refers to a surgical procedure in which a diseased or dysfunctional intestine is replaced with a healthy donor intestine. This type of transplant focuses specifically on the intestine and is considered when other medical interventions have failed to address the underlying condition affecting the organ.

Liver Intestine Transplantation: A liver-intestinal transplant, also known as a combined liver and small bowel transplant, is a surgical procedure in which both the liver and the small intestine (or a portion of it) are transplanted simultaneously from a donor to a recipient. This type of transplant is typically performed in cases where both the liver and small intestine are affected by severe dysfunction or disease, and a combined transplant offers the best chance of successful treatment. The procedure involves removing the diseased or damaged liver and small intestine from the recipient and replacing them with the healthy liver and small intestine from a deceased donor. The transplantation aims to restore normal liver and digestive function in the recipient. Liver-intestinal transplants are complex surgeries that are generally considered for patients with conditions such as intestinal failure, liver failure, or combined liver and intestinal disorders. The success of the transplant depends on various factors, including the compatibility of the donor and recipient, the overall health of the recipient, and post-transplant care and management. After the transplant, recipients usually require lifelong immunosuppressive medications to prevent organ rejection.

Multivisceral Transplantation: A Multivisceral Transplant, also known as a composite visceral transplant or multivisceral organ transplantation, is a surgical procedure in which multiple abdominal organs are transplanted as a cluster from a donor to a recipient. This type of transplant typically involves the simultaneous transplantation of several organs such as the stomach, small intestine, liver, and sometimes other structures like the pancreas and colon. The procedure is usually considered for patients who have complex medical conditions affecting multiple abdominal organs, making individual organ transplants insufficient to address their health issues. Multivisceral transplants are complex and challenging surgeries, often reserved for cases of intestinal failure, tumors, or congenital abnormalities that affect multiple organs in the abdominal cavity. Due to the complexity and risks associated with multivisceral transplantation, it is considered a last resort when other treatment options have been exhausted, and the patient’s survival and quality of life are severely compromised. The success of such transplants depends on various factors, including the compatibility of the donor organs, the recipient’s overall health, and the expertise of the surgical team.

A multivisceral organ transplant is most commonly required for patients dealing with short bowel syndrome and intestinal failure. Various conditions may necessitate this type of transplant, including:

  1. Aganglionosis/Hirschsprung’s Disease
  2. Blocked or obstructed intestines (atresia)
  3. Desmoid tumor with intra-abdominal infiltration
  4. End-stage liver disease (cirrhosis)
  5. Gastroschisis
  6. Gardner’s syndrome
  7. Malabsorption
  8. Massive resection of the intestine
  9. Mesenteric thrombosis
  10. Microvillus inclusion
  11. Necrotizing enterocolitis
  12. Pseudo-obstruction
  13. Short bowel syndrome
  14. Certain trauma victims, who survive acute illness, may develop lingering, debilitating syndromes disrupting abdominal organs. Intestinal failure due to catastrophic accidents (car, sports, etc.) and diseases represents traumatic experiences that could lead to a multivisceral organ transplant.
  15. Volvulus

Modified Multivisceral Transplantation:

A Modified Multivisceral Transplant is a complex surgical procedure involving the transplantation of multiple abdominal organs. This typically includes the stomach, small intestine, liver, and pancreas. The term “modified” indicates that the procedure may involve variations or adjustments based on the specific needs of the recipient or the donor organs available. This type of transplant is usually performed in cases where patients have extensive damage or diseases affecting multiple abdominal organs. Conditions such as extensive tumors, trauma, or certain congenital disorders may necessitate the need for a Modified Multivisceral Transplant. The goal is to replace the damaged or non-functioning organs with healthy donor organs to restore normal digestive and metabolic functions. It’s important to note that this procedure is highly specialized and requires a skilled surgical team. Patients undergoing such transplants typically require careful postoperative care and long-term immunosuppressive medications to prevent organ rejection. The decision to undergo a Modified Multivisceral Transplant is usually made based on a thorough evaluation of the patient’s medical condition and the potential benefits of the procedure. Such transplants involve replacing the entire gastrointestinal system of a patient with new, healthier organs. This comprehensive approach is often necessary to reset the gastrointestinal tract for improved health. It becomes a viable treatment option for individuals who are unable to receive total parenteral nutrition (TPN) or intravenous liquid nutrition.

Costs of Transplant (Medical & Non-Medical Costs)

The cost of a transplant varies depending on location, hospital, organ type, insurance coverage and other factors.

If you are researching or preparing for an organ transplant, contact your health insurance provider and your transplant center’s financial coordinator. They can help to determine costs based on your procedure, transplant center’s policies, and individual insurance coverage.

Below are a few resources which can help you to get an idea of what kind of costs you can expect when undergoing an organ transplant.

Milliman research report – U.S. organ and tissue transplant cost estimates This most recent report from 2020 is a summary of estimated U.S. average costs per member including billed charges and utilization related to the 30 days prior and 180 days after transplant admission for treatment for organ and tissue transplants. This report also includes all billed charges pre- and post-transplant admission. Please note costs reflected in this report are the final billed charges for an organ transplant procedure. Costs to the individual/out-of-pocket costs will be dependent on individual health insurance coverage.

Medicare The Official U.S. Government site for Medicare also provides links and resources for Medicare patients receiving an organ transplant. Learn more about Medicare Part B benefit available for kidney recipients.

Covering transplant costs For more information, details, and links for important insurance-related transplant coverage.

Medical Costs checklist

It’s one thing to say that organ transplants are hard to come by. It’s another thing to consider that an intestinal transplant costs $1,147,300 on average.

Consulting firm Milliman tallies the average costs of different organ transplants in the U.S. And while most are expensive—some are very expensive. A kidney transplant runs just over $400,000. The cost for the average heart transplant, on the other hand, can approach $1.4 million.

Cost is only part of the problem though. Even if the U.S. healthcare system and individual patients are able to pay, availability is extremely limited. More than 116,000 Americans are waiting to receive a transplant, and about 20 die each day during the wait.

Other Medical costs include:

  • Insurance deductibles
  • Insurance co-pays
  • Pre-transplant evaluation and testing
  • Fees for surgeons, physicians, radiologist, anesthesiologist and lab tests
  • Fees for the recovery of the organ from the donor
  • Surgery
  • Follow-up care and testing
  • Additional hospital stays for complications
  • Anti-rejection and other drugs, which can easily exceed $2,500 per month
  • Rehabilitation

Non-medical costs checklist

When planning for a transplant, it’s also important to take into consideration potential non-medical costs. Non-medical costs could include:

  • Food, lodging and long distance phone calls for you and your family
  • Transportation, to and from your transplant center, before and after your transplant
  • Plane travel to get to your transplant hospital quickly
  • Childcare
  • Lost wages if your employer does not pay for the time you or a family member spends away from work
  • If your transplant center is not close to your home, lodging close to the center before and after your surgery. Some centers offer free or low-cost hospitality houses for you and your family.

Post Transplant Complications:

After intestinal transplant the patients may experience postoperative complication(s). The commonest complications include infections, rejection, intestinal ischemia, and leaks from the anastomoses. Because of the high doses of immunosuppressive medications, intestinal transplant recipients are at higher risk of infection compared to other surgery patients. Rejection is another complication in which body reacts against the transplanted intestine. Intestinal ischemia and leak are mostly related to due to surgical technical difficulty in reconnection of the intestine and the vessels. There are treatment options for all of the above-mentioned complications but in some cases they result in graft loss or even death of the patient.