Duke University master surgeon Debra Sudan (right) performs a surgery with colleagues // Credit: Shawn Rocco
 

Nine-year-old Hwee Suan could only swallow small sips of soup or little bites of dumpling at a time, and often the food would come right back up. The rest of the nutrition a growing child needs came to her through a feeding tube.

Tiny Hwee Suan suffered all of this because her small intestine had been faulty at birth.

While tube feeding—total parenteral nutrition—had kept her well enough to attend school, Hwee Suan still had to wear a colostomy bag and be ready to vomit the contents of her mostly empty stomach several times a day. 

 
Not only was this uncomfortable, it was an unsustainable path. Total parenteral nutrition puts a lot of wear and tear on the liver and Hwee Suan’s was already showing signs of scarring. She was also running low on veins that could accept the needle for the procedure. 

Although intestinal transplants are quite rare, this little girl was going to need one to make it much further in life. 

Fortunately, a team of Singapore physicians had begun to develop a programme in this rare and difficult surgery years before she needed it and had reached out to a Duke University master surgeon to help. 
Years of training, video conferences and rehearsals later, Hwee Suan and another nine-year-old girl have undergone successful transplantations performed by the multidisciplinary team and both girls are doing well.

“They spent a lot of time ironing out exactly what their protocol was going to be and what they were going to do when.”

Prof Debra Sudan

The story begins in 2015, when gastroenterologist Dr Chiou Fang Kuan at KK Women’s and Children’s Hospital and Clinical Associate Professor Jeyaraj Prema Raj with the SingHealth Duke-NUS Surgery Academic Clinical Programme (ACP), recognised a need to develop an intestinal transplant scheme.

The Singapore doctors also connected with Duke University master surgeon and transplant specialist Dr Debra Sudan, while she was presenting cases at a conference in Hong Kong. Being ‘in the neighborhood,’ she swung by the SingHealth Duke-NUS Academic Medical Centre to meet the team and talk about bowel transplants. Sudan, a professor of surgery and paediatrics and Chief of the Division of Abdominal Transplant Surgery at Duke, had trained at the University of Nebraska and performed about 300 bowel transplants before coming to Duke, where she has done about 50 more transplants.

Raj’s teammate and colleague from the SingHealth Duke-NUS Surgery ACP, Clinical Associate Professor Koh Ye Xin, also went to Britain for a year to work at Cambridge University Hospital, the world’s leader in bowel transplants.

“They spent a lot of time ironing out exactly what their protocol was going to be and what they were going to do when,” said Sudan. “They were very organised and very meticulous about following their protocol. They identified a dietitian and a pathologist, and members of the team had really prepared in advance. The radiologist was ready to evaluate the bowel with ultrasound and things like that.”

“We discussed doing a bowel transplant in January of 2020, but sadly, that child died of sepsis before the date of her transplant,” she added.

Finally, in March of 2022—after more than ten rehearsal surgeries and approvals from the Singapore Ministry of Health—the team felt ready to attempt transplants. Unlike the British cases, where donor organs come from cadavers, both of these cases used a length of gut from the girls’ fathers.

The transplanted tissue is more than just a length of gut, and includes several other kinds of tissue, including the supportive blood vessels and a section of the superior mesenteric artery. 

Sudan sketches on a drawing of the digestive tract: a triangular piece of the small bowel and the arteries were harvested after the team carefully measured the entire length of his gut to determine how much could be spare for Hwee Suan. 

“We measure 20 centimetres to leave the distal ileum in the father, and then we measure the entire length,” said Sudan. “We don’t want to take more than a third.” In this case, the transplanted tissue was about 150 centimetres of gut with its attached blood vessels in a web-like sheet.

Koh removed the donor section of intestine from Hwee Suan’s father, while Sudan was the lead surgeon for the transplant into Hwee Suan at KKH. Sudan stayed in Singapore for a week after Hwee Suan’s surgery in early April of this year to monitor recovery, manage complications and teach the team what to watch for in the perioperative period.  

“Although it was a large commitment of time, I was happy to perform the implants for both of the bowels,” Sudan said. “After these two successful transplants, we have talked about my returning perhaps one or two more times to assist Dr. Koh, who will do the next one,” said Sudan. 

Rejection rates for transplanted intestines are much higher than for liver or other organs, and there is no reliable lab test to measure for rejection as there is for kidney or liver, explained Sudan. A weekly biopsy through an ostomy is the only way to watch for trouble. But they are watching their patients carefully.

“The Singapore team has a good foundation,” Sudan said. “They were really well prepared. I think that's why they were so successful because, you know, just having me come over for a couple of weeks and help with the surgery doesn't make it a success.”

For now, Hwee Suan’s small bowel still ends in a colostomy bag outside her abdomen, but if she can go about a year without any signs of organ rejection, the surgeons will do another procedure to connect it to her large intestine and she can be just like any ten-year-old.