Unique problems but now standard treatment for small bowel insufficiency Intestinal transplantation is the logical alternative to definitive parenteral nutrition in patients with chronic intestinal failure after conditions such as necrotising enterocolitis or midgut volvulus. Long term parenteral nutrition is associated with complications such as liver impairment and local and systemic infections. But since its introduction in the late 1960s, parenteral nutrition has improved greatly, especially with the development of long term home parenteral nutrition, and, as a result, interest in small bowel transplantation has waned. The evolution of the procedure, first reported in experimental animals by Alexis Carrel in 1902,1 has therefore taken longer than that of other solid organ transplants. However, recent advances in immunosuppression and the monitoring of rejection have brought small bowel transplantation into the realms of standard treatment for certain conditions.

Several features of the small bowel make it unique among transplantable organs: the large amount of lymphoid tissue contained in the mesenteric lymph nodes, Peyer's patches, and lamina propria; its heavy colonisation with microorganisms; and the expression of great quantities of class II antigens on the surface of epithelial cells. These features may contribute respectively to graft versus host disease, graft rejection, and sepsis.

Difficulties in transplanting …