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Background: Patients with diffuse porto-mesenteric thrombosis (PMT) are often not candidates for shunt surgery and are candidates for multi-visceral transplantation (MVT), despite normal liver and intestinal function. While results of intestinal and multi-visceral transplantation steadily improve, with 5-year survival following MVT of the order of 50%, waiting-list mortality upwards of 25% and need for immunosuppression, alternatives to MVT need to be considered when possible.Aim: To describe initial experience with a conservative, step-wise surgical approach in patients with diffuse PMT referred for MVT.Methods: Retrospective review of patients with diffuse PMT referred to a single surgeon, for consideration of MVT. PMT was defined as confluent thrombosis of portal, splenic, superior and inferior mesenteric veins. Surgical options graded along a risk-continuum are traditional shunts followed progressively by ‘make-shift’ shunts, ablative procedures (the complete, single-stage ‘modified’ Sugiura procedure), isolated liver transplant followed lastly by MVT.Results: There were 6 patients referred for MVT with diffuse PMT and life-threatening gastric and/or esophageal variceal bleeding, as the proximate indication for transplant. Three of the 6 had normal liver function and 5 of the 6 had normal intestinal function. Following evaluation for MVT, the 3 patients with normal liver function underwent single stage modified Sugiura Procedures (esophago-gastric devascularization with splenectomy and esophageal transaction). One patient underwent a meso-atrial shunt using a PTFE graft with inflow from a mesenteric collateral vein. One patient with hepatitis C, who had had had an aborted isolated liver transplant prior to referral for MVT, was successfully transplanted with an isolated liver graft after retrieving an MV graft, when trial dissection identified a large venous collateral deemed satisfactory for portal venous inflow to a transplanted liver. Only one of the 6 patients with sclerosing cholangitis and refractory tpn-dependence underwent uneventful MVT.All patients are alive with normal liver and intestine function, including the 2 transplant patients (1 isolated liver, 1 MVT), with minimum follow-up of 19 months. The patient with the meso-atrial shunt required angioplasty of the shunt inflow for a single re-bleed and has done well on continued follow-up.Conclusions: A multi-disciplinary approach allows some patients with complicated diffuse porto-mesenteric venous venous thrombosis to avoid or at least delay MVT. Our approach is not new, but simply uses MVT as an absolute last resort. We believe our initial results, with a surgical philosophy of “aggressive conservatism”, even in widespread porto-mesenteric thrombosis, appear to show promise. MVT remains an option if the other strategies fail.