Multivisceral Transplantation with Preservation of Native Liver, Pancreaticoduodenal Complex and Spleen. Indications and Long-Term Outcome
Ruy Cruz*, Guilherme Costa, Geoffrey Bond, Kyle Soltys, William C. Stein, Guosheng Wu, Dolly Martin, Rakesh Sindhi, George V. Mazariegos, Kareem M. Abu-Elmagd
Univ of Pittsburgh, Pittsburgh, PA
Due to scarcity of cadaveric liver donors, modification of the originally described multivisceral transplant (MVTx) operation was introduced at our Institution nearly 20 years ago. Native liver was preserved and donor stomach, duodenum, pancreas and intestine were transplanted en bloc with less extensive exenteration of the recipient left upper abdominal organs. This is the first report to outline proper indications, different recipient technical modifications, and long-term outcome. Methods: Out of a total of 279 adult visceral transplants, 29 (10%) patients received modified MVTx grafts between May 1990 and November 2009. Of the 29 modified MVTx recipients, 18 were female and 11 were male with a median age 36.3 years (range:19-58). Maintenance immunosuppression was with tacrolimus and induction was with Zenapax (14%), Thymoglobulin (24%) and Campath (62%). Results: Extensive pseudo-obstruction syndrome was the main indication for the procedure with a prevalence of 55%. The second most common indication was Gardner’s Syndrome and/or extensive desmoid tumors (28%). In the remaining recipients (17%), prior gastrectomy and/or duodenopancreatectomy were concomitant with the development of short bowel syndrome due to Crohn’s disease (n=3) and vascular thrombosis (n=2). Preservation of native pancreaticoduodenal complex and spleen was performed in most of the pseudo-obstruction patients. Native duodenopancreatectomy with preservation of the splenic vascular system was technically feasible in 5 patients with exentensive pathology of the native duodenum and pancreas. With a mean follow-up of 46.1±34 months, 22 (76%) recipients are currently alive with fully functioning grafts. The retransplantation rate was 21% and causes of graft loss were chronic rejection (n=4), acute rejection (n=1) and vascular thrombosis (n=1). The Kaplan-Meier Patient survival rate was 92% at 1 year and 68% at 5-years with graft survival of 89% and 45%, respectively. Compared to historical controls, incidence of rejection was similar to the intestine-only allografts. Preservation of native spleen reduced risk of PTLD with slight increase in risk of graft versus host disease. Conclusion: In the absence of significant liver damage and portomesenteric venous thrombosis, a modified MVTx is a valid therapeutic option for patients with diffuse gastrointestinal disorders such as pseudo-obstruction, Gardner’s Syndrome and other complex abdominal pathology. Preservation of the native duodenopancreatic complex and/or spleen is of added therapeutic benefits and should be performed when technically feasible.
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