Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges.
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.
Abu-Elmagd
Kareem M
KM
Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. abuelmagdkm@upmc.edu
Costa
Guilherme
G
Bond
Geoffrey J
GJ
Soltys
Kyle
K
Sindhi
Rakesh
R
Wu
Tong
T
Koritsky
Darlene A
DA
Schuster
Bonita
B
Martin
Lillian
L
Cruz
Ruy J
RJ
Murase
Noriko
N
Zeevi
Adriana
A
Irish
William
W
Ayyash
Maher O
MO
Matarese
Laura
L
Humar
Abhinav
A
Mazariegos
George
G
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*
D007166:Immunosuppressive Agents