Emerging concepts in anesthetic management for intestinal transplantation: a 2020-2025 narrative review

Intestinal transplantation remains the definitive treatment for irreversible intestinal failure, yet its perioperative anesthetic management presents substantial challenges. Recent innovations in organ preservation, monitoring, and enhanced recovery concepts have driven progress. However, a dedicated synthesis focused on anesthetic management is lacking, and the available evidence is largely observational and derived from small cohorts.

A structured literature search was conducted in PubMed, Web of Science, CNKI, and Wanfang databases for articles published between January 2020 and December 2025. Studies addressing perioperative anesthetic management in intestinal transplantation were included. The search was structured and transparent but not exhaustive to the standard of a registered systematic review; a narrative synthesis was employed to integrate the heterogeneous literature. A PRISMA flow diagram (Fig. 1), study characteristics table (Table 1), and quality assessments (using AMSTAR-2 and ROBINS-I) are provided.

Twenty-six studies met inclusion criteria. Because the included studies are predominantly small, single-center, and observational, all findings should be regarded as hypothesis-generating. Preoperative evaluation suggests that intestinal failure-associated liver disease and a history of thrombosis influence anesthetic planning. Intraoperative hemodynamic management may benefit from stage-specific approaches with dynamic parameters guiding fluid therapy. Regional anesthesia, particularly transversus abdominis plane block, has been associated in preliminary single-center reports with opioid reductions of 30-50% and has facilitated early extubation. Viscoelastic coagulation testing has been linked, mainly in liver transplantation and general surgery cohorts, to targeted blood component therapy with estimated reductions in unnecessary exposure of 20-30%. Normothermic machine perfusion represents a promising technology that, based on indirect evidence from liver transplantation, may reduce post-reperfusion syndrome and improve graft outcomes. Multimodal analgesia integrated with enhanced recovery principles has been associated with improved postoperative recovery.

Several developments hold promise in intestinal transplantation anesthesia, although high-quality evidence remains scarce. Regional anesthesia is increasingly incorporated into enhanced recovery protocols, normothermic machine perfusion has the potential to reshape perioperative strategies, and multimodal monitoring could contribute to optimizing patient outcomes. However, the findings remain exploratory, and there is an urgent need for multicenter collaborative research.