With the increased practicality of multivisceral transplantation, different innovative techniques have been introduced to further improve survival and reduce morbidities. The recent article published by Matsumoto in the January 27, 2007 issue of Transplantation is a testimony of such attempts (1). However, the title of the report reflected the current confusion concerning nomenclature of the different types of intestinal and multivisceral transplantation. In addition, the authors claimed originality of a technique that has already been introduced and described (2). Nonetheless, the primary goal of this report is to assess validity of the original premise (2, 3).
The operation of multivisceral transplantation stemmed from the pioneer work of Thomas E. Starzl more than four decades ago (4, 5). Although the procedure was designed for immunologic premises with no apparent clinical application at that time, it has been the conceptual centerpiece of any intra-abdominal grafting that involves more than one organ en bloc including the intestine. Thirty years later, soon after the successful clinical introduction of intestinal transplantation, Dr. Starzl portrayed the many faces of multivisceral transplantation because of his intuition of future need for distinctive nomenclature (6). The main subtypes were described as full multivisceral, upper abdominal (cluster), hepatic-intestinal, and isolated intestinal transplantation. With the intestine being the central component of the multivisceral and hepatointestinal allograft, the “cluster” operation was referred to homografts that contained the upper abdominal organs with a very short segment of jejunum. On the other hand, inclusion of the stomach distinguished the multivisceral from the hepatic-intestinal graft. Subsequently, most publications adopted the nomenclature for the descriptive classification of the given allografts (7, 8), with some modifications based upon exclusion or inclusion of other abdominal visceral and renal organs (3). Overall, the nomenclature is based upon the type and number of the allografted rather than the explanted organs. On the contrary, the Georgetown University group has recently considered preservation of the native spleen, pancreas, and duodenum as a modification of the multivisceral transplant procedure (1).
The technique of preserving the pancreaticoduodenal complex and/or splenic system among multivisceral recipients was first presented at the 121st Annual Meeting of the American Surgical Association and published in the Annals of Surgery in September 2001 (2). The main objective was to reduce risk of infection, particularly posttransplant lymphoproliferative disorder (PTLD) (9). Other potential advantages included preservation of the portosplenic circulation during implantation of a modified (without a liver) multivisceral graft, elimination of need for biliary reconstruction, and augmentation of the islet cell mass by retaining the native pancreas. The technique was initiated in July of 1999 and applied to a total of 16 multivisceral (14 modified, 2 full) adult recipients. The transplant indications were pseudo-obstruction (n=12), Crohn’s disease (n=2), Gardner’s syndrome (n=1), and vascular thrombosis (n=1). The technique was not warranted in patients with portomesenteric or splanchnic arterial thrombosis, duodenopancreatic malignancy, and prior splenectomy. The outcome analysis showed 1 and 3 year patient survival of 94% and 82% with a graft survival of 94% and 76%; respectively. Compared with a total of 11 contemporaneous modified multivisceral recipients who underwent spleno-panceaticoduodenectomy, there is a propensity for better graft survival (P=0.6) among the 14 modified multivisceral study patients (Figure 1) with no single example of PTLD, life-threatening infection, posttransplant diabetes, or graft versus host disease. With spleno-pancreaticoduodenectomy, infection was the leading cause of death, and two patients developed PTLD, which was fatal in one. In addition, another two recipients developed graft versus host disease. Accordingly, preservation of the native spleno-pancreaticoduodenal complex is a valuable option for the appropriate multivisceral recipients.
Kareem M. Abu-Elmagd
Intestinal Rehabilitation and Transplantation Center
Thomas E. Starzl Transplantation Institute
University of Pittsburgh Medical Center
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