Intestine

transplantation

Intestine transplantation, intestinal

transplantation, or small bowel
transplantation is the surgical replacement
of the small intestine for chronic and acute
cases of intestinal failure. While intestinal
failure can oftentimes be treated with
alternative therapies such as parenteral
nutrition (PN), complications such as PN-
associated liver disease and short bowel
syndrome may make transplantation the
only viable option. One of the rarest type of
organ transplantation performed, intestine
transplantation is becoming increasingly
prevalent as a therapeutic option due to
improvements in immunosuppressive
regiments, surgical technique, PN, and the
clinical management of pre and post-
transplant patients.
 Intestine transplantation

Resected diseased ileum. The prior removal of

sections of small intestine for treatment of
precursor conditions is the primary cause of
short bowel syndrome (SBS), the leading cause
of intestinal transplantation.

ICD-9-CM 46.97

[edit on Wikidata]

History
Intestine transplantation dates back to
1959, when a team of surgeons at the
University of Minnesota led by Richard C.
Lillehei reported successful
transplantation of the small intestine in
dogs. Five years later in 1964, Ralph
Deterling in Boston attempted the first
human intestinal transplant, albeit
unsuccessfully. For the next two decades,
attempts at transplanting the small
intestine in humans were met with
universal failure, and patients died of
technical complications, sepsis, or graft
rejection. However, the discovery of the
immunosuppressant ciclosporin in 1972
triggered a revolution in the field of
transplant medicine. Due to this discovery,
in 1988, the first successful intestinal
transplant was performed in Germany by
E. Deltz, followed shortly by teams in
France and Canada. Intestinal
transplantation was no longer an
experimental procedure, but rather a life-
saving therapy. In 1990, a newer
immunosuppressant drug, tacrolimus,
appeared on the market as a superior
alternative to ciclosporin. In the two
decades since, intestine transplant efforts
have improved tremendously in both
number and outcomes.[1][2]

Pre-transplant diagnoses and

short bowel syndrome
Failure of the small intestine would be life-
threatening due to the inability to absorb
nutrients, fluids, and electrolytes from
food. Without these essential substances
and the ability to maintain energy
balances, homeostasis cannot be
maintained and one's prognosis will be
dismal. Causes of intestinal failure may be
clinically complex, and may result from a
combination of nutritional, infectious,
traumatic, and metabolic complications
that affect ordinary anatomy and
physiology.[3] Many underlying conditions
that serve as precursors to failure are
genetic or congenital in nature. For
example, severe inflammation, ulceration,
bowel obstruction, fistulation, perforation,
or other pathologies of Crohn's disease
may severely compromise intestinal
function.[4] Despite the danger these
conditions may pose in themselves, they
may lead to even further, more serious
complications that necessitate
replacement of the diseased intestine. The
single leading cause for an intestinal
transplant is affliction with short bowel
syndrome, oftentimes a secondary
condition of some other form of intestinal
disease.[5][6] Short-bowel syndrome was
the cause for 73% of American intestinal
transplantations in 2008, followed by
functional bowel problems for 15% and
other causes representing 12% of cases.[7]
Natural SBS is mercifully rare, estimated to
be 3 per 100,000 births.[8] Surgical removal
is the most common cause, performed as
a treatment for various
gastroenterological and congenital
conditions such as Crohn's disease,
necrotizing enterocolitis, mesenteric
ischemia, motility disorder,
omphalocele/gastroschisis, tumors, and
volvulus.[9]

Alternative treatments
Prescription parenteral nutrition formulation.

Regardless of the underlying condition, the

loss of intestinal function does not
necessarily necessitate a transplant.
Several conditions, such as necrotizing
enterocolitis or volvulus, may be
adequately resolved by other surgical and
nonsurgical treatments, especially if SBS
never develops. An individual can obtain
nutrients intravenously through PN,
bypassing food consumption entirely and
its subsequent digestion. Long-term
survival with SBS and without PN is
possible with enteral nutrition, but this is
inadequate for many patients as it
depends on the remaining intestine's ability
to adapt and increase its absorptive
capacity.[3] Although more complicated
and expensive to perform, any person may
receive PN. Although PN can meet all
energy, fluid, and nutrient needs and can be
performed at home, quality of life can be
significantly decreased. On average, PN
takes 10 to 16 hours to administer but can
take up to 24. Over this time frame, daily
life can be significantly hindered as a
consequence of attachment to the IV
pump.[5][10] Over long periods of time, PN
can lead to numerous health conditions,
including severe dehydration, catheter-
related infections, and liver disease.[2][11]
PN-associated liver disease strikes up to
50% of patients within 5–7 years,
correlated with a mortality rate of 2–
50%.[11]

Another alternative treatment to transplant

for patients with SBS is surgical bowel
lengthening via either serial transverse
enteroplasty (STEP) or the older
longitudinal intestinal lengthening and
tailoring (LILT) technique. Although both
procedures contribute to an approximate
70% increase in length, STEP appears
somewhat more favorable in terms of
lower mortality and progression to
transplant.[12] Nevertheless, a positive
reception to either procedure may reduce
the level of PN required, if not negate its
required use altogether.[8][13]

Indications
There are four Medicare and Medicaid-
approved indications for intestine
transplantation: a loss of two of the six
major routes of venous access, multiple
episodes of catheter-associated life-
threatening sepsis, fluid and electrolyte
abnormalities in the face of maximal
medical therapy, and PN-associated liver
disease. Transplants may also be
performed if the growth and development
of a pediatric patient fails to ensue, or in
extreme circumstances for patients with
an exceptionally low quality of life on
PN.[14][15] A multidisciplinary team
consisting of transplant surgeons,
gastroenterologists, dieticians,
anesthesiologists, psychiatrists, financial
representatives, and other specialists
should be consulted to evaluate the
treatment plan and ensure transplantation
is the patient's best option. Psychological
preparations should be made for the
transplant team and patient as well. Early
referral requires trust between all parties
involved in the operation to ensure that a
rush to judgment does not lead to a
premature transplant.[11][16]

Other absolute contraindications to

receiving an intestinal transplant include
the presence of systemic and untreated
local infections, malignant cancer, severe
neurological impairment, and severe
cardiac and/or pulmonary disease. These
criteria are similar to established
guidelines for transplants of other organ
types.[17] HIV infection is a relative
contraindication for intestine
transplantation; desperate terminal
patients may accept a transplant from a
HIV-positive donor if they are willing to
expose themselves to HIV.[14]

Transplant types
There are three major types of intestine
transplants: an isolated intestinal graft, a
combined intestinal-liver graft, and a
multivisceral graft in which other
abdominal organs may be transplanted as
well. In the most basic and common graft,
an isolated intestinal graft, only sections
of the jejunum and ileum are
transplanted.[18] These are performed in
the absence of liver failure. In the event of
severe liver dysfunction due to PN, enzyme
deficiencies, or other underlying factors,
the liver may be transplanted along with
the intestine. In a multivisceral graft, the
stomach, duodenum, pancreas, and/or
colon may be included in the graft.
Multivisceral grafts are considered when
the underlying condition significantly
compromises other sections of the
digestive system, such as intra-abdominal
tumors that have not yet metastasized,
extensive venous thrombosis or arterial
ischemia of the mesentery, and motility
syndromes.[11][17]

Pre-operative period
Donated intestines, like all organs, should
be matched to a recipient prior to recovery,
as to prepare him or her and minimize the
time the organ spends outside the body.[5]
Potential recipients are placed on the
International Intestinal Transplant Registry
(ITR), where they contribute to the world's
growing understanding of intestine
transplantation. Before a transplant may
be performed, an organ must first be
located. In the United States, the matching
of all organs is coordinated by the United
Network for Organ Sharing (UNOS). The
standard intestinal donor is deceased with
a diagnosis of brain death.[19] In terms of
transplant outcomes, brain-dead donors
are highly preferable to donors who have
suffered cardiopulmonary death. If
respiration can be assisted by a ventilator,
brain-dead donors may exhibit
maintainable cardiac, endocrine, and
excretory function. If appropriately
managed, the continuation of blood flow
and bodily metabolism allows for healthier
organs for procurement and additional
time to prepare recipients for
transplant.[20] Furthermore, terminal ileum
recovery from living donors is possible.,[21]
and a laparoscopic technique is being
developed to harvest limited sections of
small bowel from living donors.[22] When
determining potential donor-recipient
matches, important characteristics include
donor size, age, tissue quality, and ABO
and histo-compatibility.[11][21] If the
intestine is too large, it may be not
transplantable into young or small
patients. Ideally, intestines should be
selected from donors of lighter weight
than the proposed recipients to ensure
simple closure of the abdominal wound.[23]
If a patient is too young or too old, they
may not be hardy enough to survive the
operation and recovery period.[11] If the
donor and recipient organs do not meet
compatibility requirements, the threat of
organ rejection by the body is all but
certain.

Organ rejection is the unfortunate

circumstance of the host immune system
recognizing the transplanted organ as
foreign. This is the most notable
complication facing transplant recipients.
Through T-cell receptors, T-lymphocytes
are able to distinguish between self and
non-self by recognizing human leukocyte
antigens (HLA) bound to the major
histocompatibility complex (MHC) protein
located on the surface of organ cells.
Once identified as foreign, the immune
system proceeds to destroy the
transplanted tissue. The panel reactive
antibody (PRA) test measures the
proportion of the population to which a
recipient will react via pre-existing
antibodies to various HLA antigens; in
other words, how likely a patient is to
acutely reject their new transplant.
Therefore, it is essential that HLA and PRA
statuses are tested for and demonstrate
low immunoreactivity of the patient to the
graft.[2][21][24] In some cases, a recipient
may suffer from graft-versus-host disease,
in which cells of the transplanted organ
attack the recipient's cells.[25]

To ensure proper histocompatibility, tissue

quality, and safety from infection, blood
work should be collected and tested in the
laboratory. In addition to HLA and PRA
typing, the complete blood count (CBC),
coagulation profile, complete metabolic
panel, and ABO blood group determination
tests should be performed for both the
donor and recipient.[2] ABO-incompatible
grafts can sometimes be performed on
very young pediatric patients, as their
immune systems have not fully developed
and for whom waiting list mortality
remains high.[14] Additionally, blood serum
should be tested for the presence of
viruses, including HIV, hepatitis B and C,
cytomegalovirus (CMV), and Epstein-Barr
virus (EBV) antibodies to prevent
infection.[24] Particularly in the
immunocompromised system
necessitated by the transplant, these
viruses can wreak havoc on the body and
become extremely dangerous, even fatal.
Even with healthy physiological levels, ABO
and HLA compatibilities, and no signs of
bacterial, viral, and fungal infections, organ
transplantation is not without extrasurgical
risk.[2]
Waitlist and donation
outcomes
A major challenge facing the intestinal
transplant enterprise is meeting the need
for transplantable intestines, particularly in
the United States where the majority of
intestinal transplants take place.[9] There
exists a narrow timeslot between
procurement and transplantation that any
organ remains viable, and logistical
challenges are faced regarding bringing
organ and recipient together. During
procurement, organs that are being
recovered are cooled and perfused with
preservation solution. This slows organ
activity and increases the time they remain
viable for transplant.[2] Although chilling
and perfusion may extend intestinal
lifespans by several hours, failure is still
imminent unless transplanted. This
duration between the cooling of the organ
during procurement and the restoration of
physiological temperature during
implantation is the cold ischemic time. Due
to the sensitivity of the intestine to
ischemic injury, many potential donor
intestines are lost to the events following
brain death and trauma. Furthermore,
irreversible intestinal damage is seen after
approximately only 5 hours of cold
ischemia in the form of mucosal damage
and bacterial translocation outside the
gastrointestinal tract. Therefore, ensuring
cardiac survival and nearby donor-recipient
proximity before procurement are essential
so organs do not wait too long outside the
body and without blood flow.[11] Not only
is there a lack of transplantable intestines,
but a deficiency in the number of centers
possessing the capability to carry out the
complicated transplant procedure as well.
As of 2005, there were only 61 medical
centers in the world capable of executing
an intestinal transplant.[9] Furthermore,
many young, small children, particularly
those weighing less than 5 kg, cannot find
a transplant due to the lack of size-
matched donors.[8]

Despite these challenges, obtaining an

intestine for transplant is rather probable
in the United States. In 2008, there were
212 people on the U.S. intestinal transplant
waitlist, 94% of whom were U.S. citizens.[7]
Regardless of transplant type, over half of
new registrants are 5 years of age or
younger. Adults compromise the next
largest cohort, followed by pediatric
patients aged 6 and older. In 2008, the
ethnic composition of the intestinal
transplant waitlist was 65% White, 18%
Black, 16% Hispanic, 1% Asian, and 0.5%
other or mixed race, resembling the
demographics of the American general
population at the time aside from a below-
average Asian cohort. ABO blood types
also matched the general population, with
31% A, 14% B, 5% AB, and 50% O.[7] In
2004, the average waiting period to receive
a transplant was 220 days,[21] with a
median of 142 days in 2008.[7] The rate of
waitlist additions has shifted from year to
year; gains increased until 2006 (with 317
added), but then decreased in 2012 (to
124 added).[26] In 2007, only 9% of patients
on the U.S. waitlist died while waiting for a
transplant.[7] Waitlist mortality peaked
around 2002 and was highest for liver-
intestine (pediatric) patients. Deaths
among all pediatric groups awaiting
intestine-liver transplants have decreased
in the years leading up to 2014 whereas
adult intestine-liver deaths have dropped
less dramatically. The decrease in recent
years is likely due to improved care of
infants with intestinal failure and
subsequently a decrease in referrals for
transplant.[26] Although many
improvements have been made in the
States, outcomes everywhere still
demonstrate much room for improvement.
Worldwide, 25% of pediatric patients on
the waitlist for an intestinal transplant die
before they can receive one.[8]
Procurement protocol
Following matching of the organ, the
complicated procurement of the small
bowel can be performed by a team of
abdominal transplant surgeons. Once a
donor has been selected and approved for
donation, several pretreatments may be
initiated to destroy microorganisms and
immune cells. The donor intestine must be
decontaminated with several antibiotics,
including neomycin, erythromycin,
amphotericin B, and cephalosporin.[18]
They may also be treated with anti-
lymphocyte antibodies (anti-thymocyte
globulin, alemtuzumab), irradiation
directed against excessive mesenteric
lymphatic tissue, and have their bowel
irrigated.[17]

Once donor preparation is accomplished,

procurement can begin by utilizing the
same standard techniques for all
abdominal organ procurements. The team
exposes the abdominal cavity and inserts
two cannulae for the infusion of University
of Wisconsin organ preservation solution
into the aorta and inferior mesenteric vein.
As the abdominal organs are cooled in
situ, the surrounding tissue is dissected so
that they may be quickly extracted. In the
next step, the aorta is cross-clamped,
cutting off blood supply to the organs.
Once blood and oxygen supply to an organ
is cut off, organ death will approach
swiftly unless steps are taken to preserve
them until transplant. Organs are therefore
fully drained of blood, flushed with cool
preservation solution, and removed from
the body.[2][18] In an isolated intestinal
transplant, the colon will be detached from
the small intestine. The cecum and
ascending colon are devascularized, while
care is taken to preserve major
vasculature in the ileum. The jejunum will
be separated from the duodenum while
preserving the vasculature of the jejunum,
ileum, mesentery, and the pancreas. If
healthy, the pancreas can oftentimes be
retrieved as an additional isolated
procurement. The intestinal allograft, when
ready to be extracted, is attached by the
mesenteric pedicle, where the vessels
converge out of the intestinal system. This
pedicle will be stapled closed, and can be
separated from the body via a transverse
cut to create a vascular cuff. The
complete intestinal allograft can then be
removed and wrapped in a surgical
towel.[18] The protocols for combined liver
and multivisceral procurements are far
more complicated and meticulous than
isolated intestine alone.
Transplantation protocol

Isolated intestine transplant diagram.

First, any abdominal scar tissue from

previous surgeries must be removed. The
aorta and vena cava are dissected in
preparation for vascular anastomosis,
followed by dissection of the proximal and
distal ends of the digestive tract.
Anastomosis is then performed to
revascularize the graft. Arterial vessels are
connected to the abdominal aorta, below
the kidneys. However, venous drainage, or
the reattachment of the transplanted
organ to the venous system, may be
performed differently depending on the
unique intra-abdominal vasculature of the
recipient. The graft is usually drained
systemically into the infrarenal vena
cava,[15] but may also be drained portally
into the hepatic portal or superior
mesenteric vein.[17] The graft is then
reperfused with blood and any bleeding is
stopped before the proximal and distal
ends of the transplant bowel are
connected to the original digestive tract. A
loop ileostomy is then created as to
provide easy access for future endoscopic
observation and biopsies. A gastronomy
or jejunostomy feeding tube may be placed
before the abdominal wall is closed.[2]

When a liver is being transplanted in

conjunction with the intestine, the recipient
must first have their own liver removed.
Following this, the aorta, cava, and portal
veins of the donor and recipient are
anastomosed. The graft is then flushed
before the caval clamps are removed. The
intestine is then reconstructed as in an
isolated intestinal transplant, before being
connected to the bile duct servicing the
new liver.[17] Multivisceral transplants are
especially difficult and susceptible to
complications because all organs must
survive a conjoined procurement,
transport, and transplantation. All three of
these measures are tailored to the
individual needs of the recipient.[18]
Preservation of the native spleen,
pancreas, and duodenum during a
multivisceral transplant can reduce the risk
of additional complications related to
these structures.[11]

Post-operative period
Following the procedure, the patient is
actively monitored in an intensive care unit
(ICU). Broad-spectrum antibiotics are
administered, bleeding monitored, and
serum pH and lactate levels measured for
evidence of intestinal ischemia. The
patient's immune system is strongly
modulated immediately post-operation.
The initial phase of treatment consists of
the administration of tacrolimus with
corticosteroids to suppress T-lymphocyte
activation. Next, various assortments of
interleukin-2 (IL-2) receptor antagonists
(daclizumab, basiliximab), anti-
proliferation agents (azathioprine,
mycophenolate mofetil), and the drugs
cyclophosphamide and sirolimus are
administered on an individual patient basis
to further suppress the immune system.[11]
The bioavailability of these drugs is
dependent on intestinal surface area and
transit time, and therefore the length of the
allograft determines the
immunosuppression regiment.[2]
Intravenous administration of
prostaglandin E1 is occasionally
performed for the first 5 to 10 days
following transplant to improve intestinal
circulation and a potential dispensing of
immunosuppressive effects.[2][11] The gut
is selectively decontaminated against
high-risk flora and preventative care is
taken against CMV and fungal
infections.[11]

It is ideal to commence enteral nutrition as

early as possible following
transplantation. Therefore, a feeding tube
connecting to the stomach or jejunum is
quickly placed to facilitate
rehabilitation.[11] If gastrointestinal
function is restored, a diet can be
reestablished and cautiously advanced as
tolerated. Most patients are weaned from
PN within 4 weeks of transplantation, and
nearly all are free from additional enteral
supplementation by one year.[14] Evidence
for the restoration of function includes
decreasing gastrostomy tube returns and
increasing gas and enteric contents in the
ileostomy.[2] Routine surveillance
endoscopy and biopsies via the ileostomy
should be performed with decreasing
frequency over several months to observe
signs of rejection, ideally before clinical
symptoms present themselves. Should the
patient continue to perform well through
the first post-transplant year, the ileostomy
would generally be closed. Should
rejection be suspected in the future,
endoscopies would be performed and an
appropriate antirejection therapy will be
tailored. The median time for hospital
discharge varies between procedures. The
median times for isolated intestine,
intestine-liver, and multivisceral
transplants are 30, 60, and 40 days post-
operation respectively.[14] Within the first
several months, carbohydrate and amino
acid absorptive capacity should normalize,
followed by the absorptive capacity for
fats. Once enteral nutrition is capable of
providing all nutritional needs, PN can be
discontinued.[2] Nearly all patients with a
successful transplant are free of PN within
one year.[14]

Biological complications
Intestinal transplantation is the least
performed type of transplant due to a
number of unique obstacles. The most
major of these is the profound
immunosuppression required due to the
ability of the intestine to elicit strong
immune responses. Because of exposure
to a wide range of gut flora and material
consumed by the body, the intestinal
epithelium possesses a highly developed
innate immune system and antigen-
presenting abilities. Immunosuppression is
the primary determinant of outcome in
small bowel transplantation; the risk for
graft rejection is increased by under-
immunosuppression and for local and
systemic infection with over-
immunosuppression.[11] Ensuring an
appropriate dose of immunosuppressant
can therefore be difficult, especially as
both ciclosporin (14–36%) and tacrolimus
(8.5–22%) have generally low
bioavailabilities.[27] A major problem due to
immunosuppression in intestinal transplant
patients is post-transplant
lymphoproliferative disorder, in which B-
lymphocytes excessively proliferate due to
infection by EBV and result in infectious
mononucleosis-like lesions.[7] Intestinal
transplant recipients are also at risk for
chronic renal failure because calcineurin
inhibitors are toxic to the kidneys. A
transplant recipient must remain on
immunosuppressants for the rest of his or
her life.[14]

Intestinal transplants are highly

susceptible to infection even more so than
the standard immunocompromised
recipient of other organs due to the great
composition and variety of the gut flora.[11]
A complex assortment of microorganisms
inhabits the human digestive tract, with
concentrations of up to 104–107 CFU/mL
in the jejunoileum and 1011–1012 CFU/mL
in the colon.[28] While suppression of the
immune system may prevent immune
attack on the new allograft, it may also
prevent the immune system's ability to
keep certain gut microbial populations in
line. Despite pre and post-decontamination
of the transplant, recipients are at risk of
local and systemic infection by both
natural and external flora. The common
symptom of graft dysfunction, whether
due to infection, rejection, or some other
condition, is diarrhea.[15]

Transplant outcomes and

impact
Intestinal transplant outcomes have
improved significantly in recent years.
Despite mild incongruities in survival rate
percentages between centers in North
America, Europe, Australia, and elsewhere,
intestinal transplantations mostly
approach survivorship rates of lung
transplantation.[11] At one-year, graft
survival rates for isolated intestine
currently waver around 80%, and 70% for
intestine-liver and multivisceral. Over the
same time period, patient survival for
isolated intestine patients may even
exceed 90%, while the more complicated
multiorgan transplants do not show any
increase in patient survival when
compared to patients surviving with the
intestinal graft alone.[14] The five-year
survival rate for patients and transplants
ranges from 50 to 80% (overall mean 60%),
depending on underlying disease and
presurgical morbidity. Very young (<1 year)
and very old (>60 years) patients receiving
a transplant have pronounced rates of
mortality.[14][15] After 4 years, pediatric
survival significantly worsens compared to
adults.[14]

Several factors relating to superior patient

and graft prognosis have proven to be
statistically significant. Patients who have
been admitted for transplant directly from
home rather than the hospital, younger
patients over one year of age, those
receiving their first transplant, those
receiving transplants at experienced
transplant centers, and who receive
antibody or sirolimus-based induction
therapies have increased rates of
survival.[9][15] Furthermore, underlying
etiology,[29] the presence of comorbidity,
the frequency of previous surgery,
nutritional status, and the level of liver
function have been found to affect patient-
graft survival .[30] Patients with a pre-
transplant diagnosis of volvulus were
found to possess a lower risk of
mortality.[29] As of 2008, the longest
recorded surviving transplant survived for
18 years.[14] Between 1999 and 2008, 131
retransplant procedures were performed in
the United States.[7]

The improvement to quality of life

following an intestinal transplantation is
significant. Of living patients 6 months
after transplant, 70% are considered to
have regained full intestinal function, 15%
are at partial function, and 15% have had
their grafts removed.[9][14] For those with
full function, enteral nutritional autonomy
is high.[7] The ability to resume regular
activities such as the ability to consume
food and exert control over digestive
function is certainly a welcome return for
patients. The low quality of life induced by
intestinal failure is oftentimes further
supplemented by significant psychosocial
disability and narcotic dependence.
Following transplantation, these have been
found to generally decrease.[15] According
to surveys comparing patients who have
undergone transplants and those that have
not, there seems to be a remarkable
improvement for transplant recipients in
such areas as anxiety, depression,
appearance, stress, parenting,
impulsiveness, optimism, medical
compliance, and the quality of
relationships.[14][15][31]

Financial considerations
Receiving an organ transplant of any kind
is a highly significant investment
financially, but a successful, well-
functioning transplant can be very cost-
efficient relative to alternate therapies.
Total charges to maintain PN at home can
reach upwards of $150,000 a year, even
though the actual cost of nutrition is
typically only $18 to $22 a day.[5][14] This
excludes the cost for additional home
support, equipment, and the care of PN-
related complications. The cost involved in
undergoing intestinal transplantation,
including the initial hospitalization for the
transplant, can range from $150,000 to
$400,000, and reoccurring hospitalizations
are common up through the second year.
Two to three years post-transplant, the
financial cost of transplantation reaches
parity with PN and is more cost-effective
thereafter.[11][14]

References
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External links
Crohn's and Colitis Foundation of
America
Transplant Living
 Partnering With Your Transplant Team
by UNOS
Intestinal Transplantation at eMedicine
Intestinal Transplant for Crohn's Disease,
WebMD
Cleveland Clinic Intestinal Transplant
Program
Intestinal Transplantation at UCSF
Intestinal Transplantation at Duke
Pediatric Intestine Transplants at
Children's Hospital of Pittsburg

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