Resumen de Small bowel transplantation: the latest developments

Dunecan Massey, Simon Gabe, Stephen Middleton

• Improvements in survival mean that intestinal transplantation should now be routinely considered for selected patients. Survival has consistently improved since the late 80s. In the best performing centres, survival at 5 years is now similar to that found after liver (alone) and heart transplantation. Patient selection has improved and immunosuppression has been enhanced by the introduction of lymphocyte-modulating antibody therapy combined with less potent maintenance immunosuppression. The indications for intestinal transplantation remain conservative at present and largely reserve this procedure for patients who have life-threatening complications of parenteral nutrition or require surgical procedures that make simultaneous or subsequent transplantation advantageous. As survival figures improve, the indications are beginning to broaden, although caution should be exercised when considering transplantation for quality of life reasons and these alone are rarely sufficient to justify the risk associated with this procedure. In the latest report from the international intestinal transplant registry the survival figures are inferior to those expected for patients on parenteral nutrition. However, in the better performing centres, survival figures are now approaching those found with parenteral nutrition, and patients who are considered as good candidates for surgery might be offered the procedure at an earlier stage if this trend continues. This article describes the current indications for intestinal transplantation and the current results of the procedure, and provides guidelines for referring patients for transplantation assessment and for the management of the sick transplant patient. The need to consider referral of patients at an early stage to allow timely assessment for transplantation is also discussed.