Introduction:  Patients with bowel perforation are largely excluded from organ donation due to potential risk of infection for recipients and related poor outcomes. Current Organ Procurement Transplant Network (OPTN) policy does not include donors with perforated bowel as expected donors in performance metrics. Transplant recipient outcomes from donors with a bowel perforation are not well described in the literature.

Method:  From 9/2020- 5/2023, New England Donor Services (NEDS) received 96 referrals of patients with reported bowel perforation. We describe the case of a 34-year-old donor with small bowel injury and stool spillage in the peritoneum following multiple gunshot wounds to the abdomen and present the outcomes of the transplant recipients.

Results:  Admission imaging noted small bowel injury with free spillage of stool into the peritoneum in the anterior pelvis, associated active arterial phase bleeding, moderate hemoperitoneum and free peritoneal air. Exploratory laparotomy revealed penetrating injuries to the small bowel and sigmoid colon. Two enterotomies were performed with stool spillage into the abdomen and 10cm of small bowel was resected. Abdomen remained opened with a wound vac in place. Subsequently, the patient was declared dead by neurologic criteria. Broad spectrum antibiotics were initiated. Blood cultures were negative and peritoneal fluid culture grew Enterococcus faecium and Candida albicans. The OPO infectious diseases medical director evaluated the case and donor allocation proceeded on hospital day 5. Surgical recovery of heart, liver and kidneys proceeded on hospital day 6 via standard protocol. The heart and left kidney were transplanted to a 54-year-old male and the liver and right kidney were transplanted to a 52-year-old female. Final donor blood cultures were negative and there were no reports of recipient positive blood cultures in the first week post-transplant. No 30-day complications were reported for either recipient. 

Conclusion:  Transplantation of organs from donors with a perforated bowel is a complex and challenging situation. A recent history of intestinal perforation with stool spillage may not render all patients medically unsuitable for donation. The outcomes for recipients who receive transplanted organs from such donors can vary depending on several factors, including the extent of bowel perforation, the time elapsed before organ procurement, the type of organ being transplanted, and the management of the donor and recipient. OPOs should closely evaluate these potential donors in collaboration with an infectious disease specialist and the donor hospital surgical and intensive care teams in order to maximize opportunities for donation and transplantation while minimizing donor-derived transmissions of infections and poor recipient outcomes.