OBJECTIVE(S):To assess evolution of intestinal/multivisceral transplantation and therapeutic efficacy of newly developed immunosuppressive and management strategies.
METHODS:Over nearly two decades, divided into three eras, 453 patients received 500 visceral transplants; 215 intestine alone, 151 liver-intestine, and 134 multivisceral. Each era was defined by the utilized immunosuppressive protocol with tacrolimus-steroids only in era I(n=114), adjunct induction multi-drug therapy in era II(n=87), and recipient pretreatment with Thymoglobulin/Campath and tacrolimus monotherapy with spaced dosage in era III(n=252). During eras II/III, adjunct donor bone marrow was given in 79(22%), the intestine was irradiated(7.5Gy) in 44(12%), and Epstein-Barr-viral load was monitored.
RESULTS:Actuarial survival for total population was 85% at 1-year, 62% at 5-years, 42% at 10-years, and 35% at 15-years with graft survival of 80%, 50%, 32%, and 29%. With 10% retransplantation rate, second/third graft survival was 75% at 1-year and 57% at 5 and 10-years. There was no significant difference in survival outcome according to age, bone marrow infusion, and allograft irradiation. The liver-contained allografts had best long-term survival and lowest risk(p=0.0001) of graft loss from rejection. Both patient and graft survival has significantly(p=0.000) improved during era III with 1 and 5-year patient survival of 92% and 71%; respectively. Despite pre-transplant lymphoid-depletion, era III was associated with significant reduction in morbidity(p=0.0001) and mortality(p=0.001) of post-transplant lymphoproliferative disorders.
CONCLUSIONS:The reported herein achieved survival outcomes with minimization of immunosuppression justifies lifting the level of intestinal/multivisceral transplantation to that of other abdominal organs with the potential to permanently reside in a respected place in the surgical armamentarium.