Right in the Gut

Bowel Transplants, Once Viewed as Nearly Impossible, Are Increasingly Saving Lives

Organ transplants, once-exotic procedures carried out at the edge of medicine, have become almost commonplace. Surgeons have succeeded with, and in some cases nearly perfected, the harvest and implanting of kidneys, hearts, livers, pancreases, corneas, bone marrow, even skin and lungs.

But one of the most difficult challenges in transplant science is in the gut. More specifically, the small intestine.

Every known pathogen "lives in a big cesspool in your intestinal tract," said Thomas Fishbein, 41, of Georgetown University Hospital, one of the few surgeons who perform transplants of the small intestine, also known as the small bowel.

"On top of that, what's in your bowel?"

When transplant patients receive this highly infectious organ, they are also taking powerful immune-suppressing drugs to prevent organ rejection. In other words: Insert dirty organ, turn off immune system.

"That is a very deadly combination," Fishbein said.

Though experimental small bowel transplants were done as early as the 1960s, until the last few years the operation was reserved for patients near death, surviving on intravenous nutrition and out of other options. But rejection rates are down and the survival rate is improving. About 150 bowel transplants are now done worldwide each year.

In a paper he published last year in the journal Transplantation, Fishbein estimated that 90 percent of his patients were alive three years after transplant surgery, about the same percentage as for kidney transplants. Based on a review of the most recent government data, he said, about 60 percent of patients are still alive after five years.

Because the procedure is so new, long-term survival rates are not available. The longest-surviving bowel recipient, a French girl who received her organ when she was 5 months old, has lived for 15 years, according to the girl's surgeon, Olivier Goulet of the Necker Hospital in Paris.

Fishbein said he believes small intestine transplant is in transition from a frontier technology designed to rescue the dying to an accepted primary treatment for a variety of serious bowel conditions, including Crohn's disease, tumors, blood clots and traumatic injuries from gunshots or car accidents.