**7. Postoperative considerations**

Patients are monitored in intensive therapy unit (ITU) post-operatively. It is common practice to administer broad-spectrum intravenous antibiotics and antifungals for 5–7 days post transplantation. Blood tests are sent daily and as well as arterial/venous blood gases to check bleeding and homeostasis.

Stoma output is monitored daily and will indicate the appropriate timing to resume enteral feeding via nasogastric tube or jejunostomy/gastrostomy. Some centers start elemental enteral feeding very early and gradually increase volumes depending on nasogastric tube aspirates. TPN is maintained for at least 2 weeks and can be discontinued once enteral nutrition is sufficient. Chyle leak can often be seen post-operatively due to the severed intestinal graft lymphatics. A no-fat or low-fat diet (<10 g/day) can be initiated as a first measure. Absorption of long-chain triglycerides, depends on lymphatic drainage, whereas medium-chain triglycerides are directly absorbed into the portal circulation.

Antiviral prophylaxis with intravenous ganciclovir (5 mg/kg OD) is common practice and regular CMV polymerase chain reaction (PCR) DNA tests are sent for monitoring. Oral valganciclovir is usually prescribed for 1-year post transplantation (900 mg OD). Epstein-Barr virus (EBV) is also monitored regularly by PCR. Trimethoprim-sulfamethoxazole is commonly used to prevent pneumocystis pneumonia for 1-year post operatively. Routine cultures are sent from all lines and most centers perform regular intestinal transplant endoscopies and biopsies via the stoma.

Oral medication is generally avoided in the early phase due to the unpredictable absorption and thus, bioavailability. Tacrolimus can be given sublingually and regular trough levels are sent for confirmation.

Plasma citrulline levels have emerged as a measure for overall for intestinal health as it is an indicator of enterocyte mass. However, compromised renal function is an important factor when considering plasma citrulline levels as a marker of intestinal failure as this potentially can increase circulating citrulline values [31]. Reduced citrulline levels can indicate the need for urgent investigations and also, commencement of TPN.
