Medical Policy

This document addresses small bowel, small bowel/liver and multivisceral transplantation. A small bowel transplant, also known as intestinal transplant, is typically performed on individuals with short bowel syndrome or intestinal failure. In some instances, short bowel syndrome is associated with liver failure, often due to the long-term complications of total parenteral nutrition (TPN). These individuals may be candidates for a small bowel/liver transplant, or a multivisceral transplant.

Note: Please see the following for additional information:

• TRANS.00008 Liver Transplantation

Medically Necessary:

A small bowel transplant using cadaveric intestine is considered medically necessary for adults and children with short bowel syndrome or irreversible intestinal failure who have failed total parenteral nutrition (TPN) and meet the general individual selection criteria listed below.

TPN failure is defined when any one of the following is met:

1. Impending or overt liver failure due to TPN induced liver injury. (Clinical indicators include: increased serum bilirubin or liver enzyme levels, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding, hepatic fibrosis, or cirrhosis); or
2. Thrombosis of two or more major central venous channels (subclavian, jugular, or femoral veins). Thrombosis of two or more of these vessels is considered a life-threatening complication and TPN failure; or
3. Frequent central line-related sepsis. Two or more episodes of line-induced systemic sepsis per year that require hospitalization are considered TPN failure. A single episode of line-related fungemia, septic shock, or acute respiratory distress syndrome is considered TPN failure; or
4. Frequent episodes of severe dehydration despite TPN and intravenous fluid supplement. Under certain medical conditions such as secretory diarrhea and non-constructable gastrointestinal tract, the loss of combined gastrointestinal and pancreatobiliary secretions exceed the maximum intravenous infusion rates that can be tolerated by the cardiopulmonary system.

A small bowel transplant using a living donor may be considered medically necessary only when a cadaveric intestine is not available for transplantation in an individual who meets the criteria noted above for a cadaveric intestinal transplant.

Combined small bowel/liver transplants from deceased donors are considered medically necessary for adults and children who meet criteria for intestinal transplant and have overt or imminent liver failure or anatomical abnormalities which preclude an isolated small bowel transplant.

Multivisceral transplants from deceased donors are considered medically necessary for adults and children who meet criteria for the combined small bowel/liver transplant and require one or more abdominal visceral organs to be transplanted due to concomitant organ failure or anatomical abnormalities which preclude a small bowel/liver transplant.

Retransplantation in individuals with graft failure of an initial small bowel, small bowel/liver, or multivisceral transplant, due to either technical reasons or hyperacute rejection is considered medically necessary.

Retransplantation in individuals with chronic rejection or recurrent disease is considered medically necessary when the individual meets general selection criteria as defined below.

Not Medically Necessary:

A small bowel transplant in adults or children is considered not medically necessary for those who can tolerate TPN.

A small bowel transplant using a living donor in adults or children is considered not medically necessary when a cadaveric intestine is available for transplantation.

Investigational and Not Medically Necessary:

All other indications for small bowel or multivisceral transplants in adults or children, including but not limited to treatment of pseudomyxoma  peritonei, are considered investigational and not medically necessary.

Living donor multivisceral transplants in adults or children are considered investigational and not medically necessary.

General Individual Selection Criteria

In addition to having one of the clinical indications above, the individual must not have a contraindication as defined by the American Society of Transplantation in Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation (2001) listed below.

Absolute Contraindications for Transplant Recipients include, but are not limited to, the following:

1. Metastatic cancer
2. Ongoing or recurring infections that are not effectively treated
3. Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery
4. Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured
5. Demonstrated patient nonadherence, which places the organ at risk by not adhering to medical recommendations
6. Potential complications from immunosuppressive medications are unacceptable to the patient
7. Acquired immune deficiency syndrome (AIDS) (diagnosis based on Centers for Disease Control and Prevention (CDC) definition of CD4 count, below 200cells/mm³) unless the following are noted:
   1. CD4 count greater than 200cells/mm³ for greater than 6 months
   2. HIV-1 RNA undetectable
   3. On stable anti-retroviral therapy greater than 3 months
   4. No other complications from AIDS (for example, opportunistic infection, including aspergillus, tuberculosis, coccidioide-mycosis, resistant fungal infections, Kaposi’s sarcoma or other neoplasm)
   5. Meeting all other criteria for small bowel or multivisceral transplantation

Steinman, Theodore, et al. Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation. Transplantation. Vol. 71, 1189-1204, No. 9, May 15, 2001.

Summary

Intestinal transplantation, combined liver-intestine transplantation, and multivisceral transplantation may be appropriate for selected high-risk individuals with life-threatening complications despite optimized intestinal rehabilitation. This includes both cases in which classic criteria based on total parenteral nutrition (TPN), the intravenous delivery of essential nutrients when the gastrointestinal tract, cannot be used, have not yet been met, and cases involving individuals with irreversible intestinal failure who cannot be sustained by TPN.

Evidence for the use of intestinal transplants comes primarily from clinical guidelines, multicenter registries, national datasets, and focused single-center series. Registries and national reports provide survival benchmarks and show improving outcomes at experienced centers. Adult cohorts quantify perioperative risks such as bleeding and thrombosis, while functional status data predict value for both listing and post-transplant survival. Pediatric longitudinal studies confirm gains in growth and nutrition, though some children remain dependent on tube feeding for longer periods. The first peer-reviewed pseudomyxoma peritonei cohort showed procedural feasibility and quality-of-life improvement but a very high recurrence rate, reinforcing its investigational status. Overall, evidence supports targeted intestinal transplantation when TPN failure criteria are met and justify restraint when data remain sparse or outcomes uncertain.

Discussion

Intestinal failure is a malabsorptive state in which the gastrointestinal tract cannot maintain nutrition, fluid, and electrolyte balance. The most common cause is extensive resection for short bowel syndrome, which itself can be due to volvulus, atresias, necrotizing enterocolitis, Crohn disease, gastroschisis, superior mesenteric artery thrombosis, desmoid tumors, or trauma. Motility disorders and malabsorptive or secretory disorders can also lead to intestinal failure. Individuals who cannot maintain their nutritional status orally or via enteral feeding may require TPN. Long-term TPN may fail or cause life-threatening complications that prompt consideration of intestinal transplantation (Bhamidimarri, 2014; Mangus, 2013).

Most intestinal transplants use deceased donors. Living donation is rare. Theoretical advantages include elective timing, improved matching, and shorter ischemia times, but early experience was limited to case reports and small series (Smith, 2016; Tzvetanov, 2010; Benedetti, 2006; Gangemi, 2009; Ji, 2009; Li, 2008). Contemporary registry analysis shows living-donor outcomes comparable to deceased-donor outcomes when matched. In a propensity-matched cohort from the International Intestinal Transplant Registry, 1-year survival was 74.3% for living donor transplants compared to 80.3% for cadaveric transplants. The 5-year survival was 49.8% compared to 48.1%; acute rejection rates were similar (Ceulemans, 2023).

Combined small bowel and liver transplantation is appropriate for individuals who meet criteria for intestinal transplantation and have irreversible liver disease. This pattern is more common in pediatrics (Middleton, 2005; Vianna, 2008). Multivisceral transplantation is reserved for concomitant organ failure or anatomy that precludes isolated grafts and remains complex, with improving but nontrivial mortality and late morbidity. Experience from single centers and national data support continued use in carefully selected cases (Mangus, 2013; Grant, 2005; Grant, 2015). National outcomes for primary intestinal transplantation in the United States from 2008-2015 show survival of 82.8% at 1 year, 68.9% at 3 years, and 59.1% at 5 years (OPTN, accessed 09/08/2023). Pediatric registry analyses show similar patterns, with chronic rejection the predominant cause of late graft loss. Inclusion of the liver is associated with lower chronic rejection in some series (Raghu, 2019; Hind, 2021).

Chronic intestinal pseudo-obstruction (CIPO) is defined by recurrent or continuous symptoms of intestinal obstruction (such as abdominal distention, pain, nausea, vomiting, and constipation) in the absence of a mechanical cause, due to impaired neuromuscular function of the gut wall. It can affect the small intestine, colon, or both, and may also involve other parts of the gastrointestinal tract. Single-center data suggest reasonable mid-term survival and graft outcomes after intestinal or multivisceral transplantation in selected adults with CIPO, with lower survival in children (Sogawa, 2021).

For neuroendocrine tumors extending beyond the liver, evidence remains limited to small retrospective series with heterogeneous populations and variable oncologic control, and transplantation is not established care (Duchateau, 2022).

Pseudomyxoma peritonei (PMP) is a rare condition characterized by the accumulation of mucinous (gel-like) material within the peritoneal cavity, usually resulting from a mucin-producing epithelial tumor. The label is imprecise because PMP can refer to both low-grade and high-grade disease. Standard therapy for PMP is cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Extensive small bowel serosal involvement is often an absolute contraindication to CRS and HIPEC. Guidelines do not address the use of transplantation for PMP, and there is no consensus therapy in that setting (Govaerts, 2020; National Comprehensive Cancer Network [NCCN] Colon Cancer V.4.2025). Reddy and colleagues reported outcomes for 15 consecutive individuals treated with intestinal or modified multivisceral transplantation for advanced, nonresectable PMP with nutritional failure when no conventional operative solution remained. Selection criteria for this single-center study required a high peritoneal cancer index with small bowel involvement, low-grade disease or slowly progressive high-grade disease, and TPN requirement or imminent TPN. Participants underwent tailored grafting, including isolated intestine or modified multivisceral grafts, with abdominal wall transplantation when needed. One-year and actuarial 5-year individuals survival were 79% and 55%. Death-censored graft survival was 77% and 56%, and 72% of evaluable survivors were free from home TPN at 1 year. Quality of life improved, with higher EQ-5D-5L index values and visual analog scores and reductions in pain and limitations in usual activities. Tumor progression or recurrence occurred in 91% of individuals with at least 6 months of follow-up. Operative intensity was high, with long procedures, substantial transfusion requirements, and prolonged hospitalizations, and early and late transplant complications occurred. This pioneering but preliminary case series showed that intestinal or multivisceral transplantation can extend survival and improve QOL in some individuals with terminal PMP not amenable to CRS/HIPEC. However, the study’s limited size, absence of controls, and very high recurrence rate mean the findings should be interpreted as hypothesis-generating rather than practice-changing. (Reddy, 2023).    

Possible types of transplants that include the small bowel are: isolated small bowel, combined small bowel/liver, and multivisceral transplant. The type of transplant is chosen on a case-by-case basis depending on anatomy and disease process (Kubal, 2015). The most common of these procedures is the isolated small bowel (intestinal) transplantation (Beyer-Berjot, 2012). An isolated small bowel transplant usually involves the removal of the small intestine from a deceased donor, removal of the recipient’s small intestine, and replacement with the donor’s intestine. If a living donor is used, a segment of the donor’s small intestine is transplanted. A small bowel transplant is intended to restore adequate nutrition in individuals with short bowel syndrome. This is a condition in which the absorbing surface of the small intestine is nonfunctional due to extensive disease or surgical removal of a large portion of the small intestine.

Evidence of intolerance or failure of TPN includes, but is not limited to, multiple and prolonged hospitalizations to treat TPN-related complications or the development of progressive but reversible liver failure. In the event of progressive liver failure, small bowel transplantation may be considered to avoid end stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant.

A small bowel/liver transplant involves the transplantation of a cadaveric small intestine and liver into a recipient. Small bowel/liver transplants are typically performed for individuals with short bowel syndrome and concurrent liver failure or anatomical abnormalities.

A multivisceral transplant typically includes the small bowel/liver, in combination with one or more other abdominal visceral organ such as the stomach, pancreas or colon which may be transplanted due to concomitant organ failure or anatomical abnormalities. The most common indications for multivisceral transplantation are total occlusion of the splanchnic circulation, extensive gastrointestinal polyposis, hollow visceral myopathy or neuropathy, and some abdominal malignancies.

Cadaver: The physical remains of a deceased person.

Short bowel syndrome: A malabsorption syndrome resulting from a significantly reduced small intestine.

Total parenteral nutrition (TPN): A method of supplying nourishment to children and adults who are unable to eat.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met for small bowel transplants; or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other indications including but not limited to the following diagnosis code; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Allan P, Reddy S, Moran B, et al. PTU-105 cytoreductive surgery and small bowel transplantation is a feasible option for patients with end-stage pseudomyxoma peritonei gut 2016; 65:A106-A107.
2. Benedetti E, Holterman M, Asolati M, et al. Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg. 2006; 244(5):694-699.
3. Beyer-Berjot L, Joly F, Dokmak S, et al. Intestinal transplantation: indications and prospects. J Visc Surg. 2012; 149(6):380-384.
4. Bhamidimarri KR, Beduschi T, Vianna R. Multivisceral transplantation: where do we stand? Clin Liver Dis. 2014; 18(3):661-674.
5. Boateng S, Ameyaw P, Gyabaah S, et al. Recipient functional status impacts on short and long-term intestinal transplant outcomes in United States adults. World J Transplant. 2024; 14(3):93561.
6. Ceulemans LJ, Dubois A, Clarysse M, et al. Outcome after intestinal transplantation from living versus deceased donors: A propensity-matched cohort analysis of the International Intestinal Transplant Registry. Ann Surg. 2023; 278(5):807-814..
7. Duchateau NM, Canovai E, Vianna RM, et al. Combined liver-intestinal and multivisceral transplantation for neuroendocrine tumors extending beyond the liver: a systematic literature review. Transplant Rev (Orlando). 2022; 36(1):100678.
8. Freeman RB Jr, Steffick DE, Guidinger MK, et al. Liver and intestine transplantation in the United States, 1997-2006. Am J Transplant. 2008; 8(4 Pt 2):958-976.
9. Gangemi A, Benedetti E. Living donor small bowel transplantation: literature review 2003-2006. Pediatr Transplant. 2006; 10(8):875-878.
10. Gangemi A, Tzvetanov IG, Beatty E, et al. Lessons learned in pediatric small bowel and liver transplantation from living-related donors. Transplantation 2009; 87(7):1027-1030.
11. Govaerts K, Lurvink RJ, De Hingh IHJT, et al. Appendiceal tumours and pseudomyxoma peritonei: literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment. Eur J Surg Oncol. 2021; 47(1):11-35.
12. Grant D, Abu-Elmagd K, Mazariegos G, et al.; Intestinal Transplant Association. Intestinal transplant registry report: global activity and trends. Am J Transplant. 2015; 15(1):210-219.
13. Grant D, Abu-Elmagd K, Reyes J, et al. Intestine Transplant Registry. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. 2005; 241(4):607-613.
14. Gupte GL, Beath SV, Protheroe S, et al. Improved outcome of referrals for intestinal transplantation in the UK. Arch Dis Child. 2007; 92(2):147-152.
15. Hind JM. Long-term outcomes of intestinal transplantation. Curr Opin Organ Transplant. 2021; 26(2):192-199.
16. Ji G, Chu D, Wang W, Dong G. The safety of donor in living donor small bowel transplantation-an analysis of four cases. Clin Transplant. 2009; 23(5):761-764.
17. Kato T, Selvaggi G, Gavnor J, et al. Expanded use of multivisceral transplantation for small children with concurrent liver and intestinal failure. Transplant Proc. 2006; 38(6):1705-1708.
18. Kato T, Tzakis AG, Selvaggi G, et al. Intestinal and multivisceral transplantation in children. Ann Surg. 2006; 243(6):756-766.
19. Kubal CA, Mangus RS, Tector AJ. Intestine and multivisceral transplantation: current status and future directions. Curr Gastroenterol Rep. 2015; 17(1):427.
20. Li M, Ji G, Feng F, et al. Living-related small bowel transplantation for three patients with short gut syndrome. Transplant Proc. 2008; 40(10):3629-3633.
21. Mangus RS, Tector AJ, Kubal CA, et al. Multivisceral transplantation: expanding indications and improving outcomes. J Gastrointest Surg. 2013; 17(1):179-186.
22. Middleton SJ, Jamieson NV. The current status of small bowel transplantation in the UK and internationally. Gut. 2005; 54(11):1650-1657.
23. Miri A, Iverson AK, Law N, et al. Long-term growth and nutrition outcomes in children following intestinal transplantation. J Pediatr Gastroenterol Nutr. 2025; 80(3):490-497.
24. Raghu VK, Beaumont JL, Everly MJ, et al. Pediatric intestinal transplantation: analysis of the intestinal transplant registry. Pediatr Transplant. 2019; 23(8):e13580.
25. Reddy S, Cecil T, Allan P, et al. Extending the indications of intestinal transplantation - modified multivisceral transplantation for end-stage pseudomyxoma peritoneii. Transplantation: 2017; 101(6S2):S89.
26. Reddy S, Punjala SR, Allan P, et al. First report with medium-term follow-up of intestinal transplantation for advanced and recurrent nonresectable pseudomyxoma peritonei. Ann Surg. 2023; 277(5):835-840.
27. Reeder F, Griffin J, Carter M, et al. Bleeding and thrombosis in intestinal transplantation; data from 145 consecutive adult transplants. Res Pract Thromb Haemost. 2025; 9(5):102990.
28. Smith JM, Skeans MA, Horslen SP, et al. Intestine. Am J Transplant. 2016; 16 Suppl 2:99-114.
29. Sogawa H, Costa G, Armanyous S, et al. Twenty years of gut transplantation for chronic intestinal pseudo-obstruction: technical innovation, long-term outcome, quality of life, and disease Recurrence. Ann Surg 2021; 273:325.
30. Sommariva A, Tonello M, Rigotto G, et al. Novel perspectives in pseudomyxoma peritonei treatment. Cancers (Basel). 2021; 13(23):5965.
31. Tzakis AG, Kato T, Nishida S, et al. The Miami experience with almost 100 multivisceral transplants. Transplant Proc. 2006; 38(6):1681-1682.
32. Tzvetanov IG, Oberholzer J, Benedetti E. Current status of living donor small bowel transplantation. Curr Opin Organ Transplant. 2010; 15(3):346-348.
33. Vianna RM, Mangus RS, Tector AJ. Current status of small bowel and multivisceral transplantation. Adv Surg. 2008; 42:129-150.
34. Vianna RM, Mangus RS. Present prospects and future perspectives of intestinal and multivisceral transplantation. Curr Opin Clin Nutr Metab Care. 2009; 12(3):281-286.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003; 124(4):1105-1110.
2. Centers for Medicare and Medicaid Services. National Coverage Determination: Intestinal and multivisceral transplantation. NCD# 260.5. Effective May 11, 2006. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=280&KeyWord=intestinal&KeyWordLookUp=Title&KeyWordSearchType=Exact&bc=CAAAAAAAAAAA Accessed on October 2, 2025.
3. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr Transplant. 2001; 5(2):80-87.
4. NCCN Clinical Practice Guidelines in Oncology^®. © 2025. National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on October 2, 2025.
   • Colon Cancer (V.4 2025). June 27, 2025.
5. Organ Procurement and Transplant Network (OPTN). Available at http://optn.transplant.hrsa.gov/.  Accessed on October 2, 2025.
6. Pironi L, Cuerda C, Jeppesen PB, et al. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr. 2023; 42(10):1940-2021.

1. Scientific Registry of Transplant Recipients. Available at: http://www.srtr.org. Accessed on October 2, 2025.
2. United Network for Organ Sharing (UNOS). Available at: http://www.unos.org. Accessed on October 2, 2025.

Intestinal Transplant
Small Bowel Transplant
Small Bowel/Liver Transplant
Multi-visceral Transplant
Total Parenteral Nutrition
TPN

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