New trends in multivisceral transplantation

PURPOSE OF REVIEW: Intestinal transplantation has become the treatment of choice for irreversible intestinal failure. Within the field of intestinal transplantation, multivisceral transplants have also evolved to include indications other than intestinal failure complicated by parenteral nutrition-induced end-stage liver disease. RECENT FINDINGS: Over the last few years, multiple technical improvements have allowed the surgeon to perform multivisceral transplants in smaller and younger recipients. Gastro-gastric anastomosis, inclusion of the donor spleen and colon are some of the modifications that have been successfully applied to the technique of multivisceral transplants. Induction protocols include Campath 1-H or thymoglobulin and steroid-free maintenance immunosuppression with low-dose tacrolimus. Monitoring of the graft is conducted with repeated endoscopies, though new noninvasive markers of intestinal function, such as citrulline and calprotectin, are being evaluated. Infection and rejection are still the main causes of graft and patient mortality. Multivisceral transplants seem to have a protective effect from rejection compared with isolated intestine or combined liver-intestine transplants. SUMMARY: As more centers worldwide develop intestinal transplant programs, multivisceral transplants should be considered an integral part of their surgical armamentarium.