Intestinal Transplant
Also covered as: intestinal failure · necrotizing enterocolitis · bladder outlet obstruction · posterior urethral valves · oligohydramnios · inguinal hernia · umbilical hernia · wound dehiscence
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Surgical Management
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Renal transplantation: Cincinnati Fetal Center
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Dr. Maria Alonso, Intestinal Transplant Surgeon, presents on renal transplantations. She discusses general surgical needs, gastrostomy tube, peritoneal dialysis catheter, hemodialysis catheter, extra peritoneal approach, extra vesicle re im
video13:51 · Nov 2018
Renal transplantation: Fetal Genitourinary Disease 2015
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Dr. Maria Alonso, Intestinal Transplant Surgeon, presents on renal transplantations. She discusses general surgical needs, gastrostomy tube, peritoneal dialysis catheter, hemodialysis catheter, extra peritoneal approach, extra vesicle re-im
video13:44 · Jan 2019
Evidence & Research
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Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
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Audio Journal with Dr. Von Allmen about using Corticosteroids After Hepatoportoenterostomy for Bile Drainage, Dr. Whit Holcomb about surgical site infections (SSI) are an important source of morbidity and mortality. and feasibility and safe
podcast44:19 · Dec 2020
In-Depth Reviews
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Intestinal Failure with Dr. Brad Warner
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Discussion with Dr. Brad W. Warner about intestinal failureWhat is intestinal failure?An umbrella term for when the small bowel is unable to digest and absorb an adequate amount of nutrients to sustain a patient through enteral means alone.
podcast52:46 · Dec 2020
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Intestinal failure occurs when the small intestine cannot absorb sufficient nutrition to support the patient enterally . Prognosis depends on residual bowel length and anatomy: neonates with ileocecal valve require 10–15 cm for salvageability, versus 15–20 cm without [e296-c3, e296-c4]. Adults with <50 cm face 40% mortality at 5–10 years . Adaptation occurs over 1–2 years post-resection . Medical management centers on TPN optimization (100–120 kcal/kg/day, lipid reduction strategies to mitigate cholestasis) and maximizing enteral tolerance [e296-c9, e296-c12]. Breast milk is preferred for neonates due to growth factors and oligosaccharides . Surgical intervention—STEP or Bianchi lengthening—is indicated when enteral progress plateaus, with dilated loops >4–5 cm, or recurrent sepsis [e296-c18, e296-c22, e296-c26]. STEP is now dominant but can cause dysmotility and may require revision [e296-c26, e296-c27, e296-c29]. Teduglutide (GLP-2 analog) reduces adult TPN requirements by 1–2 L/week but remains unapproved in U.S. children due to malignancy concerns [e296-c35, e296-c36]. Small bowel transplant achieves 50–60% five-year survival but demands intensive immunosuppression [e296-c38, e296-c39]. Multidisciplinary teams and ethanol line locks have improved outcomes [e296-c40, e296-c41].
- Residual bowel <50 cm in adults carries 40% 5–10 year mortality; neonatal salvageability threshold is 10–15 cm with ileocecal valve, 15–20 cm without [e296-c3, e296-c4, e296-c5].
- STEP lengthening is now preferred over Bianchi (easier, less vascular risk) but can redilate and cause dysmotility; redo STEP outcomes are inferior [e296-c26, e296-c27, e296-c29].
- Teduglutide reduces adult TPN by 1–2 L/week in RCTs but is not approved for U.S. children due to proliferation-related malignancy concerns [e296-c35, e296-c36].
- Lipid reduction (1 g/kg/day 2–3×/week) and fish oil–based emulsions (Omegaven, SMOF) mitigate TPN cholestasis; breast milk optimizes neonatal adaptation [e296-c12, e296-c13, e296-c14, e296-c15].
- Small bowel transplant achieves 70–80% one-year and 50–60% five-year survival but requires industrial-strength immunosuppression due to graft immunogenicity [e296-c38, e296-c39].
For patients & families
When a child's intestine cannot absorb enough nutrition from food alone, doctors call this intestinal failure . The amount of intestine a baby has matters — physicians estimate that newborns with at least 10–15 centimeters of small intestine (when certain structures are present) may eventually manage without IV nutrition, though outcomes vary widely [e296-c3, e296-c6]. After intestine is lost, the remaining bowel adapts over about one to two years . During this time, doctors carefully balance IV nutrition (TPN) with gradually increasing amounts of food by mouth or feeding tube [e296-c8, e296-c9]. Breast milk is considered the best choice for babies because it contains natural growth factors that help the intestine adapt . Sometimes the intestine becomes too dilated and stops working well, requiring surgery to reshape or lengthen it [e296-c22, e296-c26]. A medication called teduglutide has helped some adults reduce their need for IV nutrition, though it is not yet approved for children in the United States [e296-c35, e296-c36]. When other treatments do not work, intestinal transplantation may be considered, with about 50–60% of patients surviving five years after transplant . Teams of specialists — surgeons, nutritionists, pharmacists, and others — work together to give these children the best chance .
When a child's intestine cannot absorb enough nutrition from food alone, doctors call this intestinal failure . The amount of intestine a baby has matters — physicians estimate that newborns with at least 10–15 centimeters of small intestine (when certain structures are present) may eventually manage without IV nutrition, though outcomes vary widely [e296-c3, e296-c6]. After intestine is lost, the remaining bowel adapts over about one to two years . During this time, doctors carefully balance IV nutrition (TPN) with gradually increasing amounts of food by mouth or feeding tube [e296-c8, e296-c9]. Breast milk is considered the best choice for babies because it contains natural growth factors that help the intestine adapt . Sometimes the intestine becomes too dilated and stops working well, requiring surgery to reshape or lengthen it [e296-c22, e296-c26]. A medication called teduglutide has helped some adults reduce their need for IV nutrition, though it is not yet approved for children in the United States [e296-c35, e296-c36]. When other treatments do not work, intestinal transplantation may be considered, with about 50–60% of patients surviving five years after transplant . Teams of specialists — surgeons, nutritionists, pharmacists, and others — work together to give these children the best chance .
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Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.
host_summaryDaniel von Allmen2:48 ↗
The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.
host_summaryDaniel von Allmen3:32 ↗
High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.
host_summaryDaniel von Allmen4:01 ↗
Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.
host_summaryDaniel von Allmen4:39 ↗
Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.
host_summaryDaniel von Allmen4:55 ↗
Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.
opinionDaniel von Allmen5:31 ↗
The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.
host_summaryDaniel von Allmen7:11 ↗
Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).
clinicalDaniel von Allmen9:09 ↗
The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.
clinicalDaniel von Allmen10:09 ↗
A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.
host_summaryWhit Holcomb11:20 ↗
Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
host_summaryWhit Holcomb13:49 ↗
The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.
host_summaryWhit Holcomb14:20 ↗
Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
host_summaryWhit Holcomb14:48 ↗
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
clinicalWhit Holcomb16:30 ↗
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
opinionWhit Holcomb17:03 ↗
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
clinicalWhit Holcomb18:16 ↗
A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.
host_summaryWhit Holcomb20:35 ↗
Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
host_summaryWhit Holcomb22:42 ↗
In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).
host_summaryWhit Holcomb23:14 ↗
Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
host_summaryWhit Holcomb24:35 ↗
Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
host_summaryWhit Holcomb24:55 ↗
The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.
host_summaryWhit Holcomb25:20 ↗
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
opinionWhit Holcomb26:33 ↗
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
clinicalWhit Holcomb27:00 ↗
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
opinionWhit Holcomb27:22 ↗
Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.
opinionWhit Holcomb27:52 ↗
Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
host_summaryWhit Holcomb29:19 ↗
If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.
opinionWhit Holcomb29:45 ↗
A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant.
host_summaryAaron Lipskar31:31 ↗
Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy.
host_summaryAaron Lipskar32:58 ↗
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