title: Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges.
abstract: OBJECTIVE
  To assess the evolution of visceral transplantation in the milieu of surgical technical modifications, new immunosuppressive protocols, and other management strategies.
  
  
  BACKGROUND
  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%.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. abuelmagdkm@upmc.edu
authors.forename: Kareem M
authors.initials: KM
authors.lastname: Abu-Elmagd
authors.forename: Guilherme
authors.initials: G
authors.lastname: Costa
authors.forename: Geoffrey J
authors.initials: GJ
authors.lastname: Bond
authors.forename: Kyle
authors.initials: K
authors.lastname: Soltys
authors.forename: Rakesh
authors.initials: R
authors.lastname: Sindhi
authors.forename: Tong
authors.initials: T
authors.lastname: Wu
authors.forename: Darlene A
authors.initials: DA
authors.lastname: Koritsky
authors.forename: Bonita
authors.initials: B
authors.lastname: Schuster
authors.forename: Lillian
authors.initials: L
authors.lastname: Martin
authors.forename: Ruy J
authors.initials: RJ
authors.lastname: Cruz
authors.forename: Noriko
authors.initials: N
authors.lastname: Murase
authors.forename: Adriana
authors.initials: A
authors.lastname: Zeevi
authors.forename: William
authors.initials: W
authors.lastname: Irish
authors.forename: Maher O
authors.initials: MO
authors.lastname: Ayyash
authors.forename: Laura
authors.initials: L
authors.lastname: Matarese
authors.forename: Abhinav
authors.initials: A
authors.lastname: Humar
authors.forename: George
authors.initials: G
authors.lastname: Mazariegos
mesh_terms: D000293:Adolescent; D000328:Adult; D016026:Bone Marrow Transplantation; D002648:Child; D002675:Child, Preschool; D003586:Cytomegalovirus Infections / Q000453:epidemiology; D020031:Epstein-Barr Virus Infections / Q000453:epidemiology; D005260:Female; D006085:Graft Survival; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007223:Infant; D007422:Intestines / Q000637:transplantation*; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D016016:Proportional Hazards Models; D012086:Reoperation / Q000706:statistics & numerical data; D015996:Survival Rate; D019172:Transplantation Conditioning / Q000379:methods; D014781:Viscera / Q000637:transplantation*
chemical_list: D007166:Immunosuppressive Agents