Medical Policies - Surgery
Isolated Small Bowel Transplant
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A small bowel transplant using cadaveric intestine may be considered medically necessary in adult and pediatric patients with intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance), who have established long-term dependency on total parenteral nutrition (TPN) and are developing or have developed severe complications due to TPN.
A small bowel transplant using a living donor may be considered medically necessary ONLY when a cadaveric intestine is not available for transplantation in a patient who meets the criteria noted above for a cadaveric intestinal transplant.
A small bowel retransplant may be considered medically necessary after a failed primary small bowel transplant.
A small bowel transplant using a living donor is considered not medically necessary when a cadaveric intestine is available for transplantation.
A small bowel transplant is considered experimental, investigational and/or unproven for adults and pediatric patients with intestinal failure who are able to tolerate TPN.
NOTE 1: A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral organs, including the liver, duodenum, jejunum, ileum, pancreas, or colon. When the small bowel and liver are transplanted in conjunction with other gastrointestinal organs, the procedure is referred to as a multivisceral transplant. Small bowel/liver transplants and multivisceral transplants are considered in a separate policy (Refer to SUR703.009).
A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral organs, including the liver, duodenum, jejunum, ileum, pancreas, or colon. Isolated small bowel transplant is commonly performed in patients with short bowel syndrome (SBS). Small bowel/liver transplants and multivisceral transplants are considered in a separate policy (Refer to SUR703.009 for small bowel/liver transplants and multivisceral transplants).
A small bowel transplant is typically performed in patients with SBS. This is a condition in which the absorbing surface of the small intestine is inadequate due to extensive disease or surgical removal of a large portion of small intestine. In adults, etiologies of SBS include ischemia, trauma, volvulus, and tumors. In children, gastroschisis, volvulus, necrotizing enterocolitis, and congenital atresias are predominant causes.
The small intestine, particularly the ileum, does have the capacity to adapt to some functions of the diseased or removed portion over a period of 1 to 2 years. Prognosis for recovery depends on the degree and location of small intestine damage. Therapy is focused on achieving adequate macro- and micro-nutrient uptake in the remaining small bowel. Pharmacologic agents have been studied to increase villous proliferation and slow transit times, and surgical techniques have been advocated to optimize remaining small bowel. However, some patients with SBS are unable to obtain adequate nutrition from enteral feeding and become chronically dependent on total parenteral nutrition (TPN). Patients with complications from TPN may be considered candidates for small bowel transplant. Complications include catheter-related mechanical problems, infections, hepatobiliary disease, and metabolic bone disease. While cadaveric intestinal transplant is the most commonly performed transplant, there has been recent interest in using living donors.
Intestinal transplants (including multivisceral and bowel/liver) represent a small minority of all solid organ transplants. In 2011, 129 intestinal transplants were performed in the United States, of which all but 1 was from deceased donors. (1) In 2012, 106 intestinal transplants were performed in the U.S.; all were from deceased donors.
General Considerations for Small Bowel Transplantation
Potential Contraindications Subject to the Judgment of the Transplant Center:
1. Known current malignancy, including metastatic cancer;
2. Recent malignancy with high risk of recurrence;
3. Untreated systemic infection making immunosuppression unsafe, including chronic infection;
4. Other irreversible end-stage disease not attributed to intestinal failure;
5. History of cancer with a moderate risk of recurrence;
6. Systemic disease that could be exacerbated by immunosuppression;
7. Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.
Small Bowel-Specific Concerns
Intestinal failure results from surgical resection, congenital defect, or disease-associated loss of absorption, and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance. SBS is 1 case of intestinal failure.
Patients who are developing or have developed severe complications due to TPN include, but are not limited to, the following:
• Multiple and prolonged hospitalizations to treat TPN-related complications (especially repeated episodes of catheter-related sepsis); or
• Development of progressive liver failure.
In the setting of progressive liver failure, small bowel transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant. In those receiving TPN, liver disease with jaundice (total bilirubin >3 mg/dL) is often associated with development of irreversible progressive liver disease. The inability to maintain venous access is another reason to consider small bowel transplant in those who are dependent on TPN.
Small bowel transplantation is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
This policy was created in 1992, based upon MedLine database literature searches of scientific evidence. Since then, the policy has been updated and based on 1995 and 1999 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessments. The most recent literature search was performed through March 2017.
Small Bowel Transplantation
A 1995 BCBSA TEC Assessment concluded that, in children, small bowel transplant was associated with improved survival rates compared with total parenteral nutrition (TPN) because the associated adverse outcomes for small bowel transplant were offset by severe TPN-related complications. (2) This Assessment also concluded that, in adults, the outcomes for small bowel transplant were worse than that associated with TPN. A 1999 TEC Assessment reevaluated the data on adults and concluded that, because it is not possible to predict which patients would survive longer on TPN versus small bowel transplant, transplantation may be considered a reasonable option in selected adults. (3)
Much of the published literature consists of relatively small case series. For example, in 2014, Ueno et al. in Japan reported on 21 intestinal transplant patients; all but 1 received an isolated small bowel transplant for intestinal failure. (4) Overall 1- and 5- year survival rates were 86% and 68%, respectively. In the 15 patients who underwent transplantation after 2006, 1-year survival was 92% and 5-year survival was 83%.
These reports, as well as reviews of observational data, have noted that while outcomes continue to improve, obstacles remain to long-term survival. Recurrent and chronic rejections and complications of immunosuppression are significant issues in bowel transplantation.
One obstacle is timely referral for intestinal transplantation to avoid combined liver and intestine transplantation. (5) It has been suggested that improvements in survival may justify removing the restriction of intestinal transplantation to patients who have severe complications of TPN. However, Vianna et al. (2008) have reported on the status of intestinal transplantation, no randomized trials were identified that have compared intestinal transplantation with long-term TPN, and optimal timing for earlier transplantation has not been established. (6)
Another obstacle is the rate of various complications after small bowel transplant. Florescu et al. published several retrospective reviews of complications in a cohort of 98 pediatric patients. Twenty-one (21.4%) of these children had an isolated small bowel transplant; the remainder had combined transplants. Their 2012 study reported that 68 (69%) of the 98 patients developed at least 1 episode of bloodstream infection. (7) Among patients with an isolated small bowel transplant, the median time to infection for those who developed one was 4.5 months (95% confidence interval [CI], 2.4 to 6.7 months). Also in 2012, these researchers reported that 7 (7%) of 98 patients developed cytomegalovirus (CMV) disease; only 1 had an isolated small bowel transplant. (8) In 2010, Florescu et al. reported that 25 (25.5%) of 98 cases reviewed who developed at least 1 episode of fungal infection; Candida infection was most common. (9) Mortality rates did not differ significantly between patients who did (32.3%) and did not develop a fungal infection (29.8%; p=0.46).
Several other series have reported on renal failure after intestinal transplantation. In 2013, a research group in France reported that 7 of 12 children who had an isolated small bowel transplant had renal function complications at some point after surgery. (10) Before treatment, all patients had normal renal functioning. In 2014, Calvo Pulido et al. in Spain reported on 21 adults who underwent intestinal transplantation; 17 were isolated small bowel transplants. (11) Thirteen (62%) patients experienced renal failure; the etiology included high ileostomy output, immunosuppression, and medical treatment.
Living Donor Transplants
Cadaveric intestines have been most commonly used, but recently there has been interest in using a portion of intestine harvested from a living, related donor. Potential advantages of a living donor include the ability to plan the transplantation electively and better antigen matching, leading to improved management of rejection. Small case reports from the 1990s have reported on 1 or 2 patients with different lengths of the ileum or jejunum. (12-15) While there appear to be minimal complications to the donors, of the 6 cases reported, 5 recipients remain on TPN for at least part of their nutrition. One patient was weaned off TPN.
Benedetti et al. (2006) reported outcomes from 4 children and 7 adults who underwent 12 living small bowel transplantations between 1998 and 2004. (16) All related donors were reported to have had uneventful recovery following removal of up to 40% of the small intestine. The 3-year transplant patient survival was 82%, with graft survival of 75%. Longer follow-up from the earlier cases was not reported. Gangemi and Benedetti (2006) published a literature review of living donor small bowel transplantation reports from 2003 to 2006; all reports listed Benedetti as coauthor. (17) Reviewers commented that, “Due to the excellent result in modern series of deceased donor bowel transplantation, widespread use of the procedure [living donor] should not be recommended, in consideration of the potential risks to donor. Furthermore, few centers have acquired the necessary experience with the procedure.”
In 2010, Sudan published a review of current literature on long-term outcomes after intestinal transplantation. (18) Sudan noted that intestinal transplantation had become standard therapy for patients with life-threatening complications from parenteral nutrition therapy. Data from current single-center series indicated a 1-year patient survival rate of 78% to 85% and a 5-year or more survival rate of 56% to 61%. With respect to pediatric intestinal transplant patients, most achieve normal growth velocity at 2 years post-transplant. However, oral aversion is common; tube feedings are necessary in 45% of children. Sudan also reported on parental surveys of quality of life for pediatric transplant patients in which intestinal transplant patients appear to have modestly improved quality of life compared with patients remaining on TPN and slightly worse than matched school-age controls without intestinal disease.
HIV Positive Transplant Recipients
Transplants for recipients with HIV infection has long been controversial, due to the long-term prognosis for HIV positivity and the impact of immunosuppression on HIV disease. Although HIV-positive (+) transplant recipients may be a research interest of some transplant centers, the minimal data on long-term outcome in these patients primarily consist of case reports and abstract presentations of liver and kidney recipients. Nevertheless, some transplant surgeons have argued that HIV positivity is no longer an absolute contraindication to transplant due to the advent of highly active antiretroviral therapy (HAART), which has markedly changed the natural history of the disease.
As of 2013, the United Network for Organ Sharing (UNOS) policy on HIV+ transplant candidates stated: “A potential candidate for organ transplantation whose test for HIV is positive should not be excluded from candidacy for organ transplantation unless there is a documented contraindication to transplantation based on local policy” (Policy 4, Identification of Transmissible Diseases in Organ Recipients). (19)
In 2006, the British HIV Association and the British Transplantation Society published joint guidelines for kidney transplantation in patients with HIV disease. (20) These criteria may be extrapolated to other organs.
The guidelines, which are similar to the UNOS guidelines, recommend that any patient with end-stage organ disease with a life expectancy of at least 5 years is considered appropriate for transplantation under the following conditions:
• CD4 200 cells/microliter for at least 6 months;
• Undetectable HIV viremia (<50 HIV-1 RNA copies/mL) for at least 6 months;
• Demonstrable adherence and a stable HAART regimen for at least 6 months;
• Absence of AIDS-defining illness following successful immune reconstitution after HAART.
Section Summary: Small Bowel Transplantation
Small bowel transplant is infrequently performed, and only relatively small case series, generally single-center, are available. Risks after small bowel transplant are high, particularly related to infection, but may be balanced against the need to avoid the long term complications of TPN dependence. In addition, early small bowel transplant may obviate the need for a later combined liver/small bowel transplant. Guidelines and U.S. federal policy no longer view HIV infection as an absolute contraindication for solid organ transplantation.
Small Bowel Retransplantation
Desai et al. (2012) published the most comprehensive reporting of outcomes after repeat small bowel transplant in the U.S. They evaluated data in the UNOS database on patients who underwent small bowel transplants in the U.S. between October 1987 and August 2009. (21) Investigators identified 41 repeat isolated small bowel transplants in adults and 28 in children. Thirty-nine (95%) of the adults and 27 (96%) of the children had a previous isolated small bowel transplant; the remaining patients had an initial combined small bowel and liver transplant.
Among adults, survival rates after retransplant were 80% after 1 year, 47% after 3 years, and 29% after 5 years. Comparable survival rates for primary isolated small bowel transplant were 84% after 1 year, 67% after 3 years, and 54% after 5 years. Survival was significantly lower after repeat isolated small bowel transplant compared with primary isolated small bowel transplant (p=0.005).
Among children, patient survival was 81% after 1 year, 74% after 3 years, and 58% after 5 years. These rates did not differ significantly from rates after primary isolated small bowel transplant (85% after 1 year, 71% after 3 years, 64% after 5 years, respectively).
Section Summary: Small Bowel Retransplantation
Data from only a small number of patients undergoing retransplantation are available. Although limited in quantity, the available data after retransplantation suggested reasonably high survival rates after small bowel in patients who continue to meet criteria for transplantation.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in March 2017 did not identify any ongoing or unpublished trials that would likely influence this review.
Practice Guidelines and Position Statements
American Gastroenterological Association (AGA)
In 2003, the AGA produced a medical position statement on SBS and intestinal transplantation. (22) It recommended dietary, medical, and surgical solutions. Indications for intestinal transplantation mirror those of the Centers for Medicare and Medicaid Services (CMS). The guidelines acknowledged the limitations of transplant for these patients. The statement recommended the following Medicare-approved indications, pending availability of additional data:
1. “Impending or overt liver failure.…
2. Thrombosis of major central venous channels….
3. Frequent central line-related sepsis….
4. Frequent severe dehydration.”
Medicare National Coverage
“Effective for services performed on or after April 1, 2001, this procedure [intestinal and multivisceral transplantation] is covered only when performed for patients who have failed total parenteral nutrition (TPN) and only when performed in centers that meet approval criteria.
1. Failed TPN – The TPN delivers nutrients intravenously, avoiding the need for absorption through the small bowel. TPN failure includes the following:
• Impending or overt liver failure due to TPN induced liver injury. The clinical manifestations include elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding or hepatic fibrosis/cirrhosis.
• Thrombosis of the major central venous channels; jugular, subclavian, and femoral veins. Thrombosis of two or more of these vessels is considered a life-threatening complication and failure of TPN therapy. The sequelae of central venous thrombosis are lack of access for TPN infusion, fatal sepsis due to infected thrombi, pulmonary embolism, Superior Vena Cava syndrome, or chronic venous insufficiency.
• Frequent line infection and sepsis. The development of two or more episodes of systemic sepsis secondary to line infection per year that requires hospitalization indicates failure of TPN therapy. A single episode of line-related fungemia, septic shock and/or acute respiratory distress syndrome are considered indicators of TPN failure.
• Frequent episodes of severe dehydration despite intravenous fluid supplement in addition to TPN. Under certain medical conditions such as secretory diarrhea and non-constructible gastrointestinal tract, the loss of the gastrointestinal and pancreatobiliary secretions exceeds the maximum intravenous infusion rates that can be tolerated by the cardiopulmonary system.
• Frequent episodes of dehydration are deleterious to all body organs particularly kidneys and the central nervous system with the development of multiple kidney stones, renal failure, and permanent brain damage.
2. Approved Transplant Facilities – Intestinal transplantation is covered by Medicare if performed in an approved facility. The criteria for approval of centers will be based on a volume of 10 intestinal transplants per year with a 1-year actuarial survival of 65 percent using the Kaplan-Meier technique.” (23)
Summary of Evidence
For individuals who have intestinal failure who receive a small bowel transplant, the evidence includes case series. Relevant outcomes are overall survival, morbid events, and treatment-related mortality and morbidity. Small bowel transplant is infrequently performed, and only relatively small case series, generally single-center, are available. Risks after small bowel transplant are high, particularly related to infection, but may be balanced against the need to avoid the long-term complications of total parenteral nutrition dependence. In addition, early small bowel transplant may obviate the need for a later combined liver/small bowel transplant. Transplantation is contraindicated in patients in whom the procedure is expected to be futile due to comorbid disease or in whom post-transplantation care is expected to significantly worsen comorbid conditions. Guidelines and U.S. federal policy no longer view HIV infection as an absolute contraindication for solid organ transplantation. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
For individuals who have failed small bowel transplant without contraindication(s) for retransplant who receive a small bowel retransplant, the evidence includes case series. Relevant outcomes are overall survival, morbid events, and treatment-related mortality and morbidity. Data from only a small number of patients undergoing retransplantation are available. Although limited in quantity, the available data after retransplantation have suggested a reasonably high survival rate after small bowel in patients who continue to meet criteria for transplantation. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
44132, 44133, 44135, 44136, 44137, 44715, 44720, 44721
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM manual
ICD-9 Procedure Codes
Refer to the ICD-9-CM manual
ICD-10 Diagnosis Codes
Refer to the ICD-10-CM manual
ICD-10 Procedure Codes
Refer to the ICD-10-CM manual
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.
A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. OPTN – Allocation of Intestines (March 1, 2017). Organ Procurement and Transplantation Network. Available at: <http://optn.transplant.hrsa.gov> (accessed March 22, 2017).
2. Small Bowel Transplant. Chicago, Illinois: Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). TEC Assessments (1995) Volume 10, Tab 27.
3. Small Bowel Transplants in Adults and Multivisceral Transplants. Chicago, Illinois: Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). TEC Assessments (1999) Volume 14, Tab 9.
4. Ueno T, Wada M, Hoshino K, et al. Impact of intestinal transplantation for intestinal failure in Japan. Transplant Proc. Jul-Aug 2014; 46(6):2122-4. PMID 25131121
5. Matarese LE, Costa G, Bond G, et al. Therapeutic efficacy of intestinal and multivisceral transplantation: survival and nutrition outcome. Nutr Clin Pract. Oct 2007; 22(5):474-81. PMID 17906271
6. Vianna RM, Mangus RS, Tector AJ. Current status of small bowel and multivisceral transplantation. Adv Surg. 2008; 42:129-50. PMID 18953814
7. Florescu DF, Qiu F, Langnas AN, et al. Bloodstream infections during the first year after pediatric small bowel transplantation. Pediatr Infect Dis J. Jul 2012; 31(7):700-4. PMID 22466325
8. Florescu DF, Langnas AN, Grant W, et al. Incidence, risk factors, and outcomes associated with cytomegalovirus disease in small bowel transplant recipients. Pediatr Transplant. May 2012; 16(3):294-301. PMID 22212495
9. Florescu DF, Islam KM, Grant W, et al. Incidence and outcome of fungal infections in pediatric small bowel transplant recipients. Transpl Infect Dis. Dec 2010; 12(6):497-504. PMID 20626710
10. Boyer O, Noto C, De Serre NP, et al. Renal function and histology in children after small bowel transplantation. Pediatr Transplant. Feb 2013; 17(1):65-72. PMID 22882667
11. Calvo Pulido J, Jimenez Romero C, Morales Ruiz E, et al. Renal failure associated with intestinal transplantation: our experience in Spain. Transplant Proc. Jul-Aug 2014; 46(6):2140-2. PMID 25131125
12. Fujimoto Y, Uemoto S, Inomata Y, et al. Living-related small bowel transplant: management of rejection and infection. Transplant Proc. Feb 1998; 30(1):149. PMID 9474986
13. Gruessner RW, Sharp HL. Living-related intestinal transplantation: first report of a standardized surgical technique. Transplantation. Dec 14 1997; 64(11):1605-7. PMID 9415566
14. Jaffe BM, Beck R, Flint L, et al. Living-related small bowel transplantation in adults: a report of two patients. Transplant Proc. May 1997; 29(3):1851-2. PMID 9142299
15. Tesi R, Beck R, Lambiase L, et al. Living-related small-bowel transplantation: donor evaluation and outcome. Transplant Proc. Feb-Mar 1997; 29(2-Jan):686-7. PMID 9123480
16. Benedetti E, Holterman M, Asolati M, et al. Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg. Nov 2006; 244(5):694-9. PMID 17060761
17. Gangemi A, Benedetti E. Living donor small bowel transplantation: Literature review 2003-2006. Pediatr Transplant. 2006; 10(8):875-8.
18. Sudan D. Long-term outcomes and quality of life after intestine transplantation. Curr Opin Organ Transplant. Jun 2010; 15(3):357-60. PMID 20445450
19. OPTN – Policies Management (March 1, 2017). Organ Procurement and Transplantation Network. Available at: <http://optn.transplant.hrsa.gov> (accessed March 22, 2017).
20. Bhagani S, Sweny P, Brook G. Guidelines for kidney transplantation in patients with HIV disease. HIV Med. Apr 2006; 7(3):133-9. PMID 16494629
21. Desai CS, Khan KM, Gruessner AC, et al. Intestinal retransplantation: analysis of Organ Procurement and Transplantation Network database. Transplantation. Jan 15 2012; 93(1):120-5. PMID 22113492
22. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. Apr 2003; 124(4):1105-10. PMID 12671903
23. CMS – National Coverage Determination for Intestinal and Multi-Visceral Transplantation (260.5) (2006). National Centers for Medicare and Medicaid Services. Available at: <http://www.cms.gov> (accessed March 22, 2017).
24. Isolated Small Bowel Transplant. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (December 2016) Surgery 7.03.04.
|10/15/2018||Reviewed. No changes.|
|6/1/2017||Document updated with literature review. Coverage unchanged.|
|11/1/2016||Reviewed. No changes.|
|8/1/2015||Document updated with literature review. The following was added to the coverage section: 1) A small bowel retransplant may be considered medically necessary after a failed primary small bowel transplant; and, 2) A small bowel transplant is considered experimental, investigational and/or unproven for pediatric patients with intestinal failure who are able to tolerate total parenteral nutrition.|
|10/1/2013||Document updated with literature review. The following changes were made to coverage: 1) “short bowel syndrome” changed to “intestinal failure”. 2) Intestinal failure defined. 3) A small bowel transplant using a living donor may be considered medically necessary only when a cadaveric intestine is not available for transplantation in a patient who meets the criteria noted above for a cadaveric intestinal transplant. 4) A small bowel transplant using a living donor is considered not medically necessary when a cadaveric intestine is available for transplantation. 5) Note added referencing policy on small bowel/liver transplants and multivisceral transplants. Title changed from: Small Bowel Transplant. CPT/HCPCS codes updated.|
|2/1/2002||CPT/HCPCS codes updated|
|6/1/2001||CPT/HCPCS codes updated|
|Title:||Effective Date:||End Date:|
|Isolated Small Bowel Transplant||06-01-2017||10-14-2018|
|Isolated Small Bowel Transplant||11-01-2016||05-31-2017|
|Isolated Small Bowel Transplant||08-01-2015||10-31-2016|
|Isolated Small Bowel Transplant||10-01-2013||07-31-2015|
|Small Bowel Transplant||07-01-2004||09-30-2013|
|Small Bowel Transplant||03-01-2000||06-30-2004|