Early risks of a bowel transplant

Nearly all patients will need a blood transfusion within the first week of surgery.

With any operation, there is a risk of bleeding. When this happens during the operation, the surgeon can usually stop it with extra stitches or special medications. Sometimes, it may necessary to return to the operating theatre for more surgery to stop the bleeding, as well as having a blood transfusion. Bowel transplant surgery is major surgery, so the risk of bleeding is high.

Your own blood that is lost during the surgery will sometimes be collected, washed, and transfused during the operation to help reduce the need for a blood transfusion. However, you will commonly require a blood transfusion as well.

Patients who take blood-thinning medications (for example, warfarin) have a higher risk of bleeding.

If your risk of severe bleeding is high, the transplant team may ask radiology doctors to block off the blood supply to your bowel just before the transplant surgery starts. This can reduce blood loss.

A blood transfusion carries risks such as fluid overload or (very rarely) disease transmission. Your bowel transplant team will discuss these with you and will give you a leaflet that explains these in more detail.

Rejection happens in up to a third of patients during the first year after a transplant.

Rejection is when your body’s immune system starts to ‘attack’ your new bowel transplant or any other organs transplanted. It happens when your immune system recognises the organ(s) as coming from a different person and thinks it isn’t supposed to be there.

'Rejection' can be a very upsetting word, but in this medical sense, it does not usually mean that the bowel transplant will not work again. Most episodes of rejection can be successfully treated.

After a bowel transplant, patients need to take powerful medications ('immunosuppressants') to help stop rejection happening. Even if you take your anti-rejection medications carefully, rejection can still occur. This is why your transplant team will closely monitor your health and organ function after your transplant.

The highest risk of rejection is in the first 6 months after the transplant. After this, as long as patients remember to take their prescribed immune suppression, at the correct dosage, rejection is less common.

Approximately 80 in 100 patients who experience acute rejection will need higher-dose steroids as treatment.

The other 20 in 100 patients might need more than one course of steroids or require more powerful anti-rejection treatment. On occasion, antibodies that attack the transplanted organ can develop. This type of rejection may need treatment with stronger medications and other treatments.

> Learn more about rejection

Commonly, patients will require extra antibiotics or antiviral medications for an infection within the few weeks of bowel transplant surgery.

Infections are very common after a bowel transplant, in part because you will be given immune suppressing medicines. These medicines reduce the risk of you rejecting your bowel, but they will also dampen down your immune system’s ability to fight infections.

Most infections can be successfully treated with antibiotics or antiviral medications. Infections can occur in your chest, abdomen (tummy), urine, around the plastic tubes inserted through your skin, or in your surgical wound. More serious infections can spread to your blood stream.

> Learn more about the risk of infections

About 30 out of 100 patients who have had a bowel transplant will need to go back to theatre for more surgery within the first few weeks. There are many reasons for needing more surgery, including bleeding, concerns about infected fluid around the bowel, or worries about the blood supply to the transplanted organ(s).

Whenever bowel is joined together, there is a risk of that join failing and coming apart. Sometimes, this can be treated using telescopes (endcoscopy), but if this is not possible or if you are very unwell, you might need to go back to the operating theatre.

Sometimes, if there are worries about infected fluid around the transplant or in the wound, you may also need further surgery. Infected fluid can often be drained by inserting a small tube through your tummy skin. This is done by radiology doctors.

Collections of tissue fluid (lymphatic fluid, also known as chyle) can also form within the tummy. These can sometimes be treated with insertion of drains under local anaesthetic by X-ray doctors (radiologists).

This occurs in up to 10 in 100 patients. The treatment for this depends on the size of the clot, and whether or not the function of the transplant is affected.

If the blood clot is large, or is interfering with the function of the transplant, you may need another operation to remove the clot or other forms of treatment.

Sometimes the clot is so large that the function of the transplant is permanently damaged and the transplant needs to be removed completely. Another transplant might be needed to fix the problem.

If the clot is small or the transplant is functioning well, blood-thinning medications can be given and no surgery is needed.

Up to 1 in 100 of all bowel transplants do not work. This is called primary non-function (PNF). This complication might be due to a large blood clot that forms in the transplant soon after the surgery that stops the transplant working. Sometimes severe rejection can occur very soon after the transplant and the bowel transplant never works.

You might need another transplant as an emergency, depending on the cause of your original bowel disease.

About 4 or 5 in 100 patients experience deep vein thrombosis.

Blood clots can form within the deep veins of the leg. These clots can break off and travel in the bloodstream to the lungs, causing lung and heart problems. Blood clots in the deep leg veins are called a deep vein thrombosis (DVT). If they travel to the lungs it is called a pulmonary embolus (PE).

How your care team aim to prevent DVT:

• You will be encouraged to get out of bed as soon as you can after a transplant to reduce the risk of these blood clots forming.
• Blood-thinning medication is may be given to patients after a transplant to reduce the risks of DVTs and PEs. However, these blood thinners can increase the risk of bleeding after surgery so a balance needs to be found.

Heart problems or a stroke affect 1-3 in 100 patients. A stroke happens when there is a problem with the blood supply to the brain.

Cardiovascular (heart) problems can occur soon after a transplant. This is the same for any type of surgery. Heart problems can be an irregular heart rhythm, or a heart attack. This may need specialist input from other doctors and additional medications. The risks of these complications are higher if you have had similar problems in the past.

A stroke can happen if the heart stops functioning briefly, or if blood clots form within the heart or brain. Bleeding within the brain might also damage the brain.

This happens when the immune system (white blood cells) in the donated organ(s) starts to ‘attack’ your body. It can be thought of as the opposite of rejection – instead of your body’s immune system attacking the donor organs it is the donor’s immune system attacking you.

This is rare in those who have had a bowel transplant alone (1 in 100), but is more common if a liver has been transplanted as well as the bowel (9 or 10 in 100).

It is a serious condition, that can rarely lead to death.

It can cause a rash, so it is important to let your transplant team know if you have a new rash anywhere on your body.

This might happen in about 1 in every 200 attempted bowel transplant operations. Sometimes the transplant operation can start, but the surgeon is unable to finish it. This is uncommon.

Reasons might include:

• Serious anaesthetic complications that mean it would be dangerous to proceed with surgery (for example, reactions to the anaesthetic or other medications, or serious heart problems)
• Major bleeding that cannot be controlled
• Severe diseases of the arteries or veins that mean that connecting them to the bowel transplant is dangerous
• Serious problems with the blood flow within the bowel transplant that mean the transplant has to be removed during the same operation
• New information about the deceased donor or bowel transplant that was not available before the operation started (for example, finding a cancer in the donor)
• Discovering unexpected cancer

Sadly, there is a small chance that a patient having a bowel transplant may not survive to the end of the operation. This risk is low, but might occur in up to 1 in 100 patients. This could be due to massive bleeding, or severe heart, lung, or brain problems during the surgery.

Fewer than 1 in 1000 patients will get cancer from a donated organ.

It is very rare for cancer to be transmitted with the donated bowel transplant. Donors are screened as carefully as possible, to minimise the risk of transmitting any disease. Although extremely rare, donor-transmitted cancer has been known to occur on a very small number of occasions.

You may be offered a transplant from a donor known to have had cancer. This will only happen if the transplant team think that the risk of the donor’s cancer having spread to the bowel is low. This will be discussed in detail with you.

This happens in fewer than 1 in 1000 patients.

It is rare to get a serious infection such as hepatitis B, hepatitis C or HIV from a bowel transplant. It is more common that less serious infections such as cytomegalovirus (CMV) or Epstein-Barr virus (EBV) are passed on – these infections are usually able to be treated.

> Learn about the risks from a donated bowel

> Learn more about infections