Authors' objectives:

The objectives of this review are to: - Determine the safety, effectiveness and cost-effectiveness of small bowel transplantation for individuals with chronic intestinal failure as compared to total parenteral nutrition. - Identify indications for small bowel transplantation.

Authors' results and conclusions: Survival rates and graft function: The current trend in treating intestinal failure emphasizes a comprehensive multidisciplinary program that provides a continuum of care to maximize intestinal functions, including transplantation, when all standard treatments have failed. The experience in small bowel transplant is limited both worldwide and in Canada. International data shows that during the last decade, patient survival and graft survival rates from small bowel transplant (SBT) have improved, mainly because of improved immunosuppression therapy and early detection and treatment of infection and rejection. The largest intestinal transplant centre reported an overall one-year patient and graft survival rate of 72 per cent and 64 per cent respectively, and five-year patient and graft survival of 48 per cent and 40 per cent respectively. The overall one-year patient survival rate reported for 13 Ontario pediatric small bowel transplants is 61 per cent (isolated small bowel (ISB) 83 per cent, small intestine and the liver (SB-L) 50 per cent, multivisceral (MV) 33 per cent). The majority (70 per cent or higher) of surviving small bowel transplant recipients were able to wean from parenteral nutrition and meet all caloric needs enterally. Growth and weight gain in children after ISB has been reported by two studies, while two other studies reported a decrease in growth velocity with no catch-up growth. The quality of life after SBT was reported to be comparable to that of patients on home enteral nutrition. Survival was found to be better in transplants performed since 1991. Isolated bowel recipients had better survival rates. Adverse Events: Despite improvement in patient and graft survival rates, small bowel transplant is still associated with significant mortality and morbidity including : - Infection with subsequent sepsis is the leading cause of death (51.3 per cent). Bacterial, fungal and viral infections have all been reported. The most common viral infections are cytomegalorvirus (18 to 40 per cent) and Epstein-Barr virus. - Graft rejection, the second leading cause of death after SBT occurred in 10.4 per cent, and was responsible for 57 per cent of graft removal. Most of the acute rejection episodes were mild and responded to steroids and anti-T cell monoclonal anti bodies (OKT3). - Post-transplant lymphoproliferative disease (21 per cent of SBT recipients) accounted for seven per cent of post-transplant mortality. The frequency was higher in pediatric recipients (31 per cent) and adults receiving composite visceral allografts (25 per cent). - Host-versus-graft disease varied widely among centers (zero per cent to 14 per cent). - Surgical complications (85 per cent of SB-L transplants and 25 per cent of ISB transplants) resulted in re-operations in 45 per cent to 66 per cent of patients in a large study.

Authors' recommendations: Intestinal transplant is a high cost, high acuity and low volume procedure. For patients who can no longer continue home enteral nutrition due to life-threatening complications associated with this therapy, small bowel transplant offers the only viable alternative. The majority of patients who survived small bowel transplant were able to discontinue total parenteral nutrition and receive the required nutrients enterally. Limited evidence suggests that the quality of life of these patients is equivalent to that of patients on home pareneteral nutrition. Although much improvement in patient outcomes has been observed since 1995 and better outcomes were reported at more experienced centres, small bowel transplant is still associated with significant patient mortality (overall 37-45% in the 1st year) and morbidity as a result of infection, rejection and post-transplant lymphoproliferative disease. The procedure is also associated with high rates (45%-66%) of re-operations after transplant. These outcomes are inferior to those reported for home enteral nutrition. For the above reasons, home enteral nutrition remains the treatment of choice for individuals with intestinal failure who can tolerate this treatment. There has been no head to head comparison between small bowel transplant and home enteral nutrition because small bowel transplant has only been performed in patients with intestinal failure who could no longer continue total parenteral nutrition. There is no evidence to support small bowel transplantation in patients with intestinal failure who can be treated with parenteral nutrition.

Authors' methods: Systematic review

Project Status: Completed

Year Published: 2003

URL for published report: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_sbtrans_020103.pdf

URL for additional information: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ohtas-reports-and-ohtac-recommendations/small-bowel-transplant

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Medical Advisory Secretariat

Contact Address: Medical Advisory Secretariat, 20 Dundas Street West, 10th Floor, Toronto, ON M5G 2N6 CANADA. Tel: 416-314-1092l; Fax: 416-325-2364;

Contact Name: MASinfo.moh@ontario.ca

Contact Email: MASinfo.moh@ontario.ca

Copyright: Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care