Approximately 200 patients worldwide currently undergo intestinal and multivisceral transplantation each year, the majority of which take place in the United States.  NewYork-Presbyterian Hospital/Columbia University Medical Center is among the few U.S. transplantation centers with the expertise to offer this rare clinical service.

Intestinal grafts are classified as one of the following types:

• Isolated intestinal transplantation for patients with intestinal failure but who have a functioning liver;
• Combined liver and intestinal transplantation, for patients with liver and intestinal failure but normal stomach and pancreas; and
• Multivisceral transplantation including the stomach, liver, pancreas, and intestine.

Because allograft rejection remains a serious risk, intestinal transplantation has largely been reserved for life-threatening conditions associated with total parenteral nutrition and liver failure.  As advances in surgical technique, immunosuppressant drugs, and post-operative monitoring have significantly improved survival, earlier transplantation (before liver failure) has become a viable option.  Approximately 70%of multivisceral transplant recipients now survive at one year.

Physicians should refer patients with short bowel syndrome for evaluation at the Center for Liver Disease and Transplantation as early as possible, and before the development of liver failure due to total parenteral nutrition (TPN).

Indications for referral and evaluation

• Short bowel syndrome caused by mesenteric vascular thrombosis;
• Crohn’s disease;
• Trauma;
• Volvulus;
• Functional disorders such as chronic intestinal pseudoobstruction;
• Multiple or extensive desmoid tumors, including
• Gardener’s syndrome,

Innovations

Autotransplantation for Ex Vivo Tumor Resection

Columbia transplant surgeons at NewYork-Presbyterian have established a new method of performing ex vivo tumor resection for tumors involving the blood vessels that supply the major abdominal organs.  Because of their inaccessibility and their location in or near the major vessels, such tumors are considered inoperable by most centers.  The option of autotransplantation allows surgeons to remove the intestine, liver, or other abdominal organs as required in order to access the tumor resection.  After excising the tumor, they reconstruct the blood vessel and then reimplant the patient’s native organs.  Patients undergoing autotransplantation need no immunosuppressant medications following surgery, and outcomes have been excellent.

AbdominalWall Transplantation

Abdominal wall transplantation is the reconstruction and closure of the abdominal compartment, which may be necessary after extensive abdominal resections, repeated laparotomies, tumor resection, wound infections or enterocutaneous fistulae.  Abdominal wall transplantation may also be required to close the abdomen after small-bowel and multivisceral transplantation.  NewYork-Presbyterian is one of the few centers in the country with experience performing this novel technique.

Outcomes

Worldwide, the one-year survival rate for isolated intestinal transplantation is over 77%.  Increased survival rates are associated with surgeons’ experience in intestinal and multivisceral transplantation, patient volumes greater than 10 cases per year, and immunosuppression protocols that include induction therapy.*

*Source: 2003 Report of the International Intestine Transplant Registry