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      Multivisceral and Small Bowel Transplantation at Shiraz Organ Transplant Center

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          Abstract

          Background: Multivisceral transplantations were initially done in animal models to understand the immunological effects. Later on, in human beings, it has been considered a salvage procedure for unresectable complex abdominal malignancies. With advancement in surgical techniques, availability of better immunosuppressive drugs, and development of better post-operative management protocols, outcomes have been improved after these complex surgical procedures.

          Objective: To analyze and report results of multivisceral, modified multivisceral, and small bowel transplantations done at Shiraz Organ Transplant Center, Shiraz, southern Iran.

          Methods: Medical records of all patients who underwent multivisceral, modified multivisceral, and small bowel transplants were retrospectively analyzed.

          Results: There were 18 patients. The most common indications for the procedure in our series were unresectable carcinoma of pancreas followed by short bowel syndrome. 10 patients were alive after a median follow-up of 8.7 (range: 3–32) months. The remaining 8 patients died post-operatively, mostly from septicemia.

          Conclusion: Multivisceral and small bowel transplantations are promising treatments for complex abdominal pathologies.

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          Most cited references25

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          Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges.

          Guilherme Costa Fausto, K A Elmagd, Noriko Murase … (2009)
          To assess the evolution of visceral transplantation in the milieu of surgical technical modifications, new immunosuppressive protocols, and other management strategies. With the clinical feasibility of intestinal and multivisceral transplantation in 1990, multifaceted innovative tactics were required to improve outcome and increase procedural practicality. 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. 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%. 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.
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            Orthotopic liver or multivisceral transplantation as treatment of metastatic neuroendocrine tumors.

            Michael Olausson, Styrbjörn Friman, Gustaf Herlenius … (2007)
            Liver transplantation can be a therapeutic option for individual patients with neuroendocrine tumors metastatic only to the liver. In this consecutive series of 15 patients (5 multivisceral and 10 orthotopic liver transplantations) with well-differentiated carcinoids, or endocrine pancreatic tumors, we allowed higher proliferation rate (Ki67 <10%), large tumor burden, and higher age than previous studies. Liver transplantation offered good relief of symptoms, long disease-free intervals, and potential cure in individual patients. The survival of grafts and patients compared well with transplantation for benign disease. The overall 5-year survival was 90%. The recurrence-free survival of both multivisceral and liver transplantation related to the time after transplantation (about 20% at 5 years) despite inclusion of patients with higher risk. In conclusion, the critical prognosticators for long-term outcome still remain to be defined. The experience with multivisceral transplantation for patients with endocrine tumors of the pancreatic head is still limited. (c) 2007 AASLD.
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              100 multivisceral transplants at a single center.

              J. Gaynor, Andreas G. Tzakis, Ernesto Pretto … (2005)
              The objective of this study was to summarize the evolution of multivisceral transplantation over a decade of experience and evaluate its current status. Multivisceral transplantation can be valuable for the treatment of patients with massive abdominal catastrophes. Its major limitations have been technical and rejection of the intestinal graft. This study consisted of an outcome analysis of 98 consecutive patients who received multivisceral transplantation at our institution. This represents the largest single center experience to date. The most common diseases in our population before transplant were intestinal gastroschisis and intestinal dysmotility syndromes in children, and mesenteric thrombosis and trauma in adults. Kaplan Meier estimated patient and graft survivals for all cases were 65% and 63% at 1 year, 49% and 47% at 3 years, and 49% and 47% at 5 years. Factors that adversely influenced patient survival included transplant before 1998 (P = 0.01), being hospitalized at the time of transplant (P = 0.05), and being a child who received Campath-1H induction (P = 0.03). Among 37 patients who had none of these 3 factors (15 adults and 22 children), estimated 1- and 3-year survivals were 89% and 71%, respectively. Patients transplanted since 2001 had significantly less moderate and severe rejections (31.6% vs 67.6%, P = 0.0005) with almost half of these patients never developing rejection. Multivisceral transplantation is now an effective treatment of patients with complex abdominal pathology. The incidences of serious acute rejection and patient survival have improved in the most recent experience. Our results show that the multivisceral graft seems to facilitate engraftment of transplanted organs and raises the possibility that there is a degree of immunologic protection afforded by this procedure.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Organ Transplant Med
                Journal ID (iso-abbrev): Int J Organ Transplant Med
                Journal ID (publisher-id): Ijotm
                Title: International Journal of Organ Transplantation Medicine
                Publisher: Avicenna Organ Transplantation Institute (Shiraz, Iran )
                ISSN (Print): 2008-6482
                ISSN (Electronic): 2008-6490
                Publication date (Print): 2014
                Publication date (Electronic): 1 May 2012
                Volume: 5
                Issue: 2
                Pages: 59-65
                Affiliations
                [1 ] Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,
                [2 ] Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
                Author notes
                [* ]Correspondence: Mohsen Aliakbarian, MD, Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Nemazee Hospital, Zand Blvd, Shiraz, Iran, Tel: +98-711-647-4308, Fax: +98-711-647-4307, E-mail: aliakbarianm@mums.ac.ir
                Article
                Publisher ID: ijotm-5-059
                PMC ID: 4089340
                SO-VID: 7041c14a-5ca5-49c4-9be4-69aeb5abd6a0
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, ( http://creativecommons.org/licenses/by/3.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Subject: Original Article

                Keywords: multivisceral,modified multivisceral,small bowel,transplantation,animal model,abdominal malignancies
                Data availability:
                Keywords: multivisceral, modified multivisceral, small bowel, transplantation, animal model, abdominal malignancies

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