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Five Hundred Intestinal and Multivisceral Transplantations at a Single Center: Major Advances With New Challenges

Abu-Elmagd, Kareem M. MD, PhD, FACS*; Costa, Guilherme MD*; Bond, Geoffrey J. MD*; Soltys, Kyle MD*; Sindhi, Rakesh MD*; Wu, Tong MD*; Koritsky, Darlene A. RN*; Schuster, Bonita RN*; Martin, Lillian ART*; Cruz, Ruy J. MD*; Murase, Noriko MD*; Zeevi, Adriana MD*; Irish, William PhD†; Ayyash, Maher O. MD*; Matarese, Laura PhD*; Humar, Abhinav MD*; Mazariegos, George MD*

doi: 10.1097/SLA.0b013e3181b67725
Original Articles

Objective: To assess the evolution of visceral transplantation in the milieu of surgical technical modifications, new immunosuppressive protocols, and other management strategies.

Summary Background Data: With the clinical feasibility of intestinal and multivisceral transplantation in 1990, multifaceted innovative tactics were required to improve outcome and increase procedural practicality.

Methods: Divided into 3 eras, 453 patients received 500 visceral transplants. The primary used immunosuppression was tacrolimus-steroid-only during Era I (5/90–5/94), adjunct induction with multiple drug therapy during Era II (1/95–6/01), and recipient pretreatment with tacrolimus monotherapy during Era III (7/01–11/08). During Era II/III, donor bone marrow was given (n = 79), intestine was ex vivo irradiated (n = 44), and Epstein-Barr-Virus (EBV)/cytomegalovirus (CMV) loads were monitored.

Results: Actuarial patient survival was 85% at 1-year, 61% at 5-years, 42% at 10-years, and 35% at 15-years with respective graft survival of 80%, 50%, 33%, and 29%. With a 10% retransplantation rate, second/third graft survival was 69% at 1-year and 47% at 5-years. The best outcome was with intestine-liver allografts. Era III rabbit antithymocyte globulin or alemtuzumab pretreatment-based strategy was associated with significant (P < 0.0001) improvement in outcome with 1- and 5-year patient survival of 92% and 70%.

Conclusion: Survival has greatly improved over time as management strategies evolved. The current results clearly justify elevating the procedure level to that of other abdominal organs with the privilege to permanently reside in a respected place in the surgical armamentarium. Meanwhile, innovative tactics are still required to conquer long-term hazards of chronic rejection of liver-free allografts and infection of multivisceral recipients.

Five hundred visceral allografts were transplanted in 453 patients. Survival outcome has significantly improved over time with the introduction of innovative management strategies including novel immunosuppressive modalities. Meanwhile, new tactics are required to overcome the long-term hazards of chronic rejection of the liver-free allografts and infection of the multivisceral recipients.

From the *Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; and †CTI, Clinical Trials and Consulting Services, Cincinnati, OH.

Reprints: Kareem M. Abu-Elmagd, MD, PhD, FACS, University of Pittsburgh Medical Center, 3459 Fifth Ave, MUH 7 South, Pittsburgh, PA 15213. E-mail: abuelmagdkm@upmc.edu.

© 2009 Lippincott Williams & Wilkins, Inc.