Intestine Transplant in Hyderabad, India |
Types and Cost
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Advanced Centre for Intestine Transplant in Hyderabad, India
We are one of the Advanced Centre for Intestine Transplant in Hyderabad, India, backed up with a state-of-the-art facility that offers comprehensive care for patients with intestinal failure. PACE Hospitals is renowned for its expertise in intestinal transplantation, a complex and life-saving procedure that is often the last resort for patients with short bowel syndrome, motility disorders, and other conditions that prevent the intestine from absorbing nutrients.
Intestine Transplant Team led by highly skilled surgeons, transplant specialists, and nurses, the center provides a multidisciplinary approach to patient care, ensuring the best possible outcomes for even the most critically ill patients. With advanced diagnostic and therapeutic capabilities, the Advanced Centre for Intestine Transplant at PACE Hospitals is a beacon of hope for patients in need of intestinal transplantation, offering them a chance to live a healthy and fulfilling life.
We do not provide the guarantee of obtaining intestine for transplantations. The patient can get registered at PACE Hospitals for the procurement of a matching intestine from cadaver or deceased-donor for transplant. PACE Hospitals keeps greatest effort to ensure the obtainment of intestine but does not provide any guarantee. Intestinal Transplantation will happen as per state and center govt. rules and regulations.
Intestinal transplantation is a procedure developed as a treatment modality for individuals suffering from intestinal failure, particularly associated with a high-risk fatality due to any of the underlying diseases or experiencing various complications due to assisted parenteral nutrition. This is an open procedure performed by a team of surgical gastroenterologists. It is also being increasingly considered as an option for treating any conventionally unresectable abdominal tumors.
Intestinal transplantation aims to be the viable first-line option for intestinal failure. There has been a steady increase in its survival rate with the advent of advanced surgical techniques, improved postoperative care, and immunosuppressive drugs.
Intestinal failure definition
As explained earlier, intestine transplant is primarily intended for patients suffering from intestinal failure. In intestinal failure, the patients are devoid of protein energy maintenance, fluid maintenance, electrolyte maintenance, or micronutrient balance due to various underlying gastrointestinal diseases.
Intestinal failure causes immediate malnutrition, which could cause death if the question of nutrition is solved. In these cases, either parenteral nutrition must be carried out, or the patient must be a recipient of an intestine transplant.
Intestinal failure types
Intestinal failure can be frequently categorised into three types.
- Type 1 intestinal failure: In this type of intestinal failure, self-limitation (cures on its own) is seen and usually appears in the postoperative periods, especially with operation in the ileus.
- Type 2 intestinal failure: Also called acute intestinal failure, it usually appears after an intra-abdominal surgery in metabolically unstable patients presenting with fistulae, hostile abdomens, or adhesions. Usually, the patients suffering from acute traumatic events get type 2 intestinal failure. These events include traffic accidents, surgical procedures associated with anastomotic leaks, other surgical injuries, laparostomy creation (open abdominal wound), etc.
- Type 3 intestinal failure: Also called chronic intestinal failure, it is seen in patients who have progressed to stability and, therefore, require long-term intravenous management of intestinal failure over months to years; it could be reversible or irreversible.
The various diseases that could cause intestinal failure differ in children and adults. They include:
Diseases leading to intestinal failure in adults
- Crohn’s disease (A chronic disease causing inflammation in the digestive tract, in the small intestine)
- Superior mesenteric artery thrombosis (blockage of the superior mesenteric artery, which supplies blood supply to the small intestine and ascending colon)
- Superior mesenteric vein thrombosis (local blood coagulation impairing the superior mesenteric vein, leading to venous engorgement and mesenteric ischemia)
- Trauma (physical injury of the abdomen)
- A desmoid tumour (noncancerous growths in the connective tissue mostly seen in the abdomen and limbs)
- Volvulus (a loop of intestine twisting around itself, causing a bowel obstruction)
- Pseudo-obstruction (a rare condition in which the patients display intestinal obstruction symptoms, but diagnostic tests couldn’t find anything blocking the intestines)
- Massive resection secondary to tumour (Cutting of tumour in the small intestine. Could be due to treatment or biopsy)
- Radiation enteritis (inflammation of intestines seen after radiation therapy)
Pediatric diseases leading to intestinal failure (pediatric intestinal transplant)
- Intestinal atresia (a congenital defect resulting in complete obstruction of the lumen)Gastroschisis (a congenital defect where the intestines extend outside of the baby's body through a hole in the abdomen)
- Crohn’s disease (A chronic disease causing inflammation in the digestive tract, in the small intestine)
- Microvillus involution disease (a rare genetic intestinal disease with the inability to absorb nutrients and severe diarrhoea)
- Necrotizing enterocolitis (a life-threatening condition affecting the neonates with inflammation of the intestine leading to bacterial invasion causing cellular damage and necrosis of the colon and intestine)
- Midgut volvulus (a loop of intestine twisting around itself, causing a bowel obstruction)
- Chronic intestinal pseudo-obstruction (a rare condition in which the patients display intestinal obstruction symptoms, but diagnostic tests couldn't find anything blocking the intestines)
- Massive resection secondary to tumour (Cutting of tumour in the small intestine. Could be due to treatment or biopsy)Hirschsprung disease (a congenital condition of large intestine in which problems are seen with passing stool due to missing nerve cells in the muscles of the infant's colon)
Types of intestine transplant procedures
There are four types of intestinal transplant procedures, and the surgical gastroenterologist selects the appropriate procedure depending on various factors such as:
- The presence of previous abdominal surgeries
- The underlying causative factor of intestinal failure
- The quality of native organs,
- The stage of liver disease (if manifested)
The four main types of intestine transplant procedures include:
- Small bowel transplant
- Liver transplant and small bowel transplant
- Multi visceral transplant
- Modified multi-visceral transplant
- Small bowel transplant: This procedure is performed in people suffering from intestinal failure without any liver disease manifestation. The surgical gastroenterologist secures the arterial supply to the allograft through an anastomosis performed between the recipient’s infrarenal aorta and the donor’s superior mesenteric artery (SMA). Here, the venous drainage is attached either to the inferior vena cava or the recipient’s portal vein (PV) or to the superior mesenteric vein (SMV) seen at the root of the mesentery.
- Liver and small bowel transplant: This procedure is usually recommended for patients suffering from advanced liver disease associated with intestinal failure. In such cases, extensive portomesenteric venous thrombosis (a rare and fatal complication seen after laparoscopic sleeve gastrectomy in the morbidly obese) may be seen. The survival rates have been improved with the inclusion of a liver graft combined with the liver-small bowel transplant.
- Multi-visceral transplant: This procedure is performed in people suffering from multiple organ failure and involves transplanting various visceral organs such as the pancreaticoduodenal complex, the stomach, the liver, and the small bowel.
- Modified multi-visceral transplant: This type of intestine transplant is recommended in patients suffering from multiple organ failure, and in this procedure, the stomach, the pancreaticoduodenal complex, and the small bowel are transplanted. The liver is not transplanted, and this is one of the main differences between a multi-visceral and a modified multi-visceral transplant. In these cases, the recipient has a functional liver coexisting with any pancreatic insufficiency (such as cystic fibrosis, chronic pancreatitis, and type I diabetes mellitus). Usually, patients suffering from intestinal dysmotility (abnormal contraction of the intestinal muscles) with concomitant severe gastroparesis (stomach paralysis) and patients with tumour development either in the mesentery or the duodenum.
While small bowel transplants may be done by obtaining body parts from either cadaveric sources, brain-dead patients, or living donors, the other types of intestinal transplants rely exclusively on cadaveric organ donors.
Nevertheless, in a few cases, small bowel transplants can be carried out from living donors if they are family members. This technique was developed by Gruessner and Sharp in 1997.
Selection of donor for intestine transplant
While most of the intestinal transplantations have been performed using cadaver donors. Very rarely, intestines had been procured from living donors. Theoretically, the mortality for intestinal donors is very minimal (< 1%).
Nevertheless, there are certain selection criteria for the extraction of the potential organ from the cadaveric source. They include:
- The age of the cadaveric source should be below 50 years
- There shouldn’t be any electrolyte abnormality or hemodynamic instability
- The duration of graft ischemia shouldn’t be more than six hours.
While harvesting, the surgical gastroenterologist takes care to avoid any potential damage to the mesenteric vessels, especially during the simultaneous harvest of the liver or pancreas.
Efficacy of intestinal transplant over parenteral nutrition
Despite the option of parenteral nutrition, healthcare providers do opt for intestinal transplants in feasible cases. There are various reasons, such as:
- The sway of parenteral nutrition: During the earlier days, parenteral nutrition (intravenous transmission of nutritional products to patients) was the only option for patients suffering from intestinal insufficiency, with intestinal insufficiency which could occur due to a plethora of factors resulting in progressive malnutrition leading to malabsorption with fluid and electrolyte disorders. Intestinal insufficiency eventually leads to progressive weight loss.
- Limitations of parenteral nutrition: While parenteral nutrition is the primary treatment of choice, it is very expensive, combined with poor quality of life and treatment-specific morbidities. Also, it must be understood that the 5-year survival rate of patients prescribed for parenteral nutrition is less than 80%.
- Intestinal transplantation was developed as a better alternative out of such necessity to overcome these lacunae presented by parenteral nutrition prescribed for patients suffering from intestinal insufficiency.
Although it has a rich developmental history commencing since the 1960s, intestinal transplantation rose to reputation only after the introduction of novel immunosuppressive therapies in the 1990s.
- By the end of 2011, over 2600 patients had undergone intestinal transplantation all over the globe (60% children and 40% adults). The majority of the transplanted patients (65% of children and 80% of adults) were attending treatment at home on waiting lists before their transplantation.
- Although the short-term survival has been greatly improved, the long-term results, on the other hand, haven't demonstrated much progress (the 5-year survival lies in the range of 40–60%).
- Nevertheless, there are still debates in the sphere of the medical fraternity regarding topics such as:
- Definitive indications for transplantation
- Type of graft to choose, etc
Life-threatening indications for intestinal transplantation
An Italian study published in 2011 demonstrated that there are only two factors that could be associated with an increased risk of significant fatality among patients recommended for parenteral nutrition. These were proposed as absolute indications for intestinal transplantation procedures. They are:
- Hepatic insufficiency (also called liver failure, which needs a combined intestinal and hepatic transplantation) and
- Desmoid tumors (also called aggressive fibromatosis, are noncancerous growths of the connective tissue and are a much rarer anomaly).
The development of liver failure (hepatic insufficiency) is gradual in patients being treated with parenteral nutrition for intestinal insufficiency. It partially occurs due to the introduction of triglyceride-rich parenteral nutrition solutions and partially due to the supposedly exclusive intravenous nutrition route because of the patient's malabsorptive state.
Hepatic insufficiency may manifest as hepatic steatosis (triglyceride build-up in the hepatocytes), which can be detected within two weeks of parenteral nutrition. Although reversible in ideal situations, steatosis may develop into steatohepatitis cirrhosis, the initiation in the wake of parenteral nutrition.
- Along with hepatic steatosis, the other principal pathologic lesion in adults is biliary lithiasis (stone formation in the gallbladder, intra- and extra-hepatic bile ducts).
- In infants, the principal pathologic lesion includes intra-hepatic cholestasis (congenital disorders characterized by defective bile export) leading to
choledocholithiasis (gallstones in the common bile duct).
Considerations of a surgical gastroenterologist before conducting an intestinal transplantation
Before the transplant, the surgical gastroenterologist assesses the potential candidate from various medical perspectives to understand the necessity and the longevity of the transplant. Once the patient meets the criteria without presenting any contraindications to the graft, the objective of the pre-transplant assessment is commenced. It extracts the answer to several fundamental questions, such as:
(a) Is intestinal insufficiency permanent?
(b) Is the patient a candidate for an intestinal transplant according to current criteria?
(c) Are there any contraindications to transplantation?
(d) What type of graft to implant?
Goals of a surgical gastroenterologist in performing intestinal transplantation
Through intestinal transplantation, the surgical gastroenterologist aims to Improve the prognosis and quality of life for patients with irreversible intestinal failure.
It's a life-saving therapy for those who can't be treated with conventional therapies. The procedure has shown exceptional growth and improvement in graft survival rates, making it a viable first-line option for patients with severe complications of parenteral nutrition.
Preprocedural assessment of the patient before the surgery
Before the patient is admitted into the transplant ward, the surgical gastroenterologist prescribes various investigations and tests to understand the overall health to assess his/her eligibility for transplant. The common tests include:
- Blood tests (to understand the blood group along with HIV and hepatitis states)
- CT scan of the abdomen, Chest X-ray (to understand diseased parts of the intestine)
- Ultrasound of arms and legs (to understand the venation)
- Ultrasound of the liver (tells liver status)
- Myocardial perfusion scan (also called a nuclear stress test. Tells the flow of blood through the heart muscle.)
- Echocardiogram (ultrasound test depicting the structure and function of the heart.)
- A lung function test (Understanding the lung capacity)
- Sigmoidoscopy or colonoscopy (bowel examinations)
There could also be other tests that depend on the age, gender, and health status of the patient.
Jeevandaan intestinal transplant waiting list
Post assessment, the multidisciplinary team (consisting of anesthetists, transplant surgeons, gastroenterologists, pharmacists, dietitians, and psychiatrists) gathers to discuss the patient’s eligibility for a transplant. Upon confirming and signing the consent form, the patient’s name may be added to Jeevandaan’s waitlist.
Intestines are harvested from donors that have died (usually brain death). Extraction is done in patients with brain injury (stroke, trauma, etc.). In these patients, without a ventilator, survival is abysmal. The organs are retrieved while the heart is still beating. The extracted intestine is placed on ice for transport.
During the Intestinal transplantation surgery
Donor operation
- The donor is given mono- or polyclonal anti-lymphocyte antibodies, graft irradiation, and the intestine is decontaminated.
- Usually, after the dissection of arteries (supra celiac, infrarenal aorta, and superior mesenteric artery), the dissection of veins (superior mesenteric vein, splenic vein, and portal vein) is done.
- Depending on the type of procedure performed, the intestinal procurement is done either with or without simultaneous visceral organ extraction.
Recipient operation
- Systemic draining of the graft (into the infrarenal vena cava) is performed. If proven difficult, portal drainage is done (into a superior mesenteric vein) and can be drained systemically.
- Arterial revascularization is done by arterial anastomosis.
- An aperture in the abdomen is usually created. Intestinal solid waste goes into a bag attached to the outside of the body.
- The aperture called a stoma is temporary. Through this, the surgical gastroenterologist monitors the recipient’s acceptance by measuring the waste that comes out in a 24-hour period. An increase in the volume could either be infection or rejection.
After the Intestinal transplantation surgery
- The patient may be hospitalised for at least a week to recover after the surgery. Immunosuppressants can stabilise the patient.
- Dietary specifications (what and how much to eat and drink) may be discussed with the patient and caretakers.
- The patient may be discharged once the intestine transplant surgery team approves the health.
- Follow-up is compulsory for patients.
The common questions patients may ask after an intestinal transplant
- When can I go home?
- What kind of pain can I expect?
- What are the side effects of intestinal transplants?
- What can I eat and drink after an intestinal transplant?
- When can I go back to work?
- When can I start exercising again?
- When do I need to see my doctor again?
- Do I need any further treatment?
- What is my risk of developing cancer in the future?
- How can I reduce my risk of developing cancer in the future?
- Can I get cancer or infection from a donor?
- Should I continue parenteral nutrition after my operation?
- Will I need an intestinal biopsy?
- How long will the surgery take?
- How long will the wait for an intestine? Etc
Artificial intestine transplant surgery
There may not be sufficient evidence to answer exactly. However, bioengineered intestinal grafts show potential for treating short bowel syndrome, as they can provide a source of transplantable tissue for patients with intestinal failure. Studies have demonstrated the successful generation of functional human intestinal grafts using patient-derived materials in a bioreactor culture system.
Complications of intestinal transplantation
Complications following intestinal transplantation may result in graft failure or death. Graft loss would need parenteral nutrition resuming and considerations of re-transplantation, which has a lower rate of success compared with the initial transplantation. Some of the causes of graft loss or failure include:
- Small bowel transplant rejection (acute and chronic)
- Infections
- Posttransplant lymphoproliferative disorder (PTLD)
- Graft-versus-host disease (GVHD)
- Acute rejection: Small bowel transplant rejection, which can occur in acute (within three months, though it can occur late) and chronic (typically taking months to years) forms. Acute rejection poses a significant hazard, affecting 45% of intestinal transplant patients within the first posttransplant year and hindering graft survival rates.
- Chronic rejection: Chronic rejection occurs in 15% of cases and typically appears 1–5 years following transplantation. The gastroenterologist may recommend immunosuppression to alleviate symptoms, but a retransplant is likely the more durable option.
- Donor-specific antibodies: Donor-specific antibodies have been associated with acute rejection and may be implicated in chronic rejection and graft loss. The 5-year graft survival of less than 30% was noted in patients who developed antibodies, whereas survival rates of more than 80% were observed in recipients without donor-specific antibodies.
- Infections: The use of immunosuppression in small bowel transplantation poses a significant risk of infection. Sepsis remains the most common cause of death and graft failure, accounting for over 50% of cases. Bacterial infection is common in the immediate phase of post-intestinal transplantation, with 2.6 episodes per patient.
- Posttransplant lymphoproliferative disorder (PTLD): The lymphoid and/or plasmacytic proliferations occurring in patients receiving chronic immunosuppression for solid organ transplantation is PTLD. The presence of this disease has led to a significant reduction in patient survival within the first posttransplant year. It can be treated with immunosuppression reduction and chemotherapy regimens.
- Graft-versus-host disease (GVHD): GVHD poses a significant risk of mortality, with reported rates ranging from 14–18%. Risk factors include younger age, multi-visceral transplant recipients, and intraoperative splenectomy.
Life after intestinal transplantation
The quality of life among intestine transplant surgery patients has reported various improved health indices such as:
- Better fatigue control
- Reduction in gastrointestinal symptoms
- Better stoma management/bowel movements
- Ability to holiday/travel but not significantly better eating ability and had worse sleeping patterns.
Various other studies have found that intestinal transplantation recipients have a similar quality of life to those who are stable on parenteral nutrition.
Small bowel transplant life expectancy
Small bowel transplantation can significantly improve life expectancy in patients with short bowel syndrome.
The early experience of small bowel transplantation was laden with high rates of graft failure and mortality. Recent advances in immunologic suppression have made small bowel transplant procedures a more attractive therapeutic option in patients with intestinal failure. Many transplantation programs now achieve 1-year graft and patient survival rates in excess of 80%.
Although patient survival continues to improve after intestinal transplantation (currently reported as 80 and 54% at 1 and 5 years, respectively), the pretransplant mortality remains higher than any other group awaiting solid-organ transplantation.
Small intestine transplant success rate
The success rate of small intestine transplants varies. One-year patient survival rates are approximately 64-80%, with 5-year survival rates ranging from 29-54%. The success rate depends on factors such as the type of transplant (isolated small bowel, small bowel-liver, or multivisceral), patient age, and the presence of concomitant liver failure. Complications such as infections, intestinal transplant rejection, and post-transplant lymphoproliferative disease can affect the success rate. Despite improvements, small intestine transplant is still associated with significant mortality and morbidity.
Frequently Asked Questions (FAQs) on Intestinal transplantation Procedure
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What are the signs of intestinal failure?
In patients suffering from intestinal failure, the nutrients needed to grow and thrive obtained from food cannot be absorbed. The nutrients needed to grow and thrive. Due to the above conditions, the intestinal failure symptoms are presented with gastroenterological undertones such diarrhoea, gas, bloating, feeding intolerance, oral aversion, vitamin and mineral deficiencies, poor growth, dehydration, etc.
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Is there any provision for intestine transplant?
Yes, intestinal transplantation is a viable treatment for patients with irreversible intestinal failure. It's indicated for patients who can't be weaned from parenteral nutrition and have severe complications. The procedure has shown exceptional growth and improvement in graft survival rates, mainly due to better outcomes seen in the first year of transplantation.
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What are the four major components of an intestinal transplant?
Before the transplant, the surgical gastroenterologist assesses the potential candidate from various medical perspectives to understand the necessity and the longevity of the transplant. The four major components of an intestinal transplant which is necessitated before the commencement of an intestinal transplant include – the permanency of the intestinal insufficiency, the eligibility of a candidate for an intestinal transplant, the presence of any contraindications to transplantation, and the type of graft to implant.
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Is intestine transplant a difficult surgery?
Yes. Intestine transplant is a complex and difficult surgery. In this challenging surgery, multiple organs and vital connections are involved, and any wrong direction could catastrophically induce the failure of the surgery or worse - even death. The procedure is complicated, lasting 8-12 hours, and requires a skilled surgical team. Complications are frequent, especially early on, but recent results show improvements in rejection control and viral infections, making it a life-saving therapy.
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How does intestinal failure affect the body?
Intestinal failure occurs when the body is unable to absorb enough nutrients and fluids to maintain life and growth. This can lead to malnutrition, dehydration, and other complications. The condition may result from short bowel syndrome, congenital issues, or surgical resection of the small bowel. Intestinal failure can disrupt normal physiological processes, impacting growth and development, and may require parenteral nutrition for survival. Complications include liver disease, bacterial overgrowth, catheter-related infections, and loss of venous access.
Can you get a large intestine transplant?
Yes, the large intestine can also be transplanted, but since it is not life-threatening, it may not be done as frequently as a small intestine transplant. It is also used as an alternative in oesophageal replacement. With a complete evaluation of preoperative, intraoperative, and postoperative, as well as long-term outcomes, the healthcare team proceeds with the transplant.
Can the small intestine be transplanted?
Yes. Small intestine be transplanted. It is used during the cases of intestinal failure or in the failure of parenteral nutrition. There are various diseases that could induce intestinal failure. A few of them include Crohn’s disease, superior mesenteric artery thrombosis, superior mesenteric vein thrombosis, physical trauma, volvulus, desmoid tumor, etc.
How long do intestinal transplants last?
The longevity of intestinal transplants can be influenced by many factors. Nevertheless, there has been an overall good response for intestinal transplants. The statistics from the American Institute - of Scientific Registry of Transplant Recipients (SRTR) depicted that 83% died after one year after transplantation, and 70% survived even after three years.
What is the success rate of intestinal transplants?
Various studies were performed to understand the efficacy of intestinal transplants. Although the short-term survival has been greatly improved, the long-term results, on the other hand, haven't demonstrated much progress (the 5-year survival lies in the range of 40–60%). On the other hand, the International Registry for Intestinal Transplantation depicts an improvement in patient survival rates, with a 55% graft survival rate and a 69% 1-year patient survival rate since 1995.
When was the first intestinal transplant?
Although unpublished data, the intestinal transplant in humans was first performed in Boston by Dr. Deterling in 1964. Nevertheless, in 1967, Dr. Lillihei and coworkers were the first surgical team to reportedly perform a human intestinal transplant.
What is the quality of life after intestinal transplant?
The quality of life after intestinal transplant has been reportedly improved. As such, total parenteral nutrition is no longer needed; the patients can enjoy the freedom of being not tethered to a bed with intravenous attachment apart from relishing the taste of their favorite foods once again. Nevertheless, care must be taken to understand which foods to eat/reject at the doctor’s discretion.
What is the cost of intestine transplant in Hyderabad, India?
On average, the intestine transplant cost in Hyderabad, India can range from ₹ 22,50,000 to ₹ 48,50,000 (approximately US$ 30,000 to US$ 58,000). The cost of intestinal transplantation in India can vary depending on several factors, including the patient condition, age, associated conditions, hospital, the complexity of the procedure, insurance or corporate approvals.
It is important to note that the cost of intestinal transplantation can vary significantly based on the patient's specific medical condition and the hospital's pricing structure. Some of the healthcare provider may offer financing options or work with insurance providers to help cover the cost of the transplant.
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