Chandrashekhar Kubal, Richard Mangus, Joseph Tector, Jonathan Fridell, Rodrigo Vianna

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States

Introduction: Complete thrombosis of the porto-mesenteric venous system can be present in association with liver cirrhosis. In the absence of a large tributary, liver only transplantation is not possible in these patients. Although alternative vascular reconstructions are able to restore blood flow to the donor portal vein, portal hypertension and its complications persist after transplantation. We describe the use of multivisceral transplantation (MVT) as a therapeutic option for patients with complete thrombosis of the porto-mesenteric system.

Methods: A database of intestinal transplant patients was maintained with prospective analysis of outcomes. A diagnosis of diffuse porto-mesenteric thrombosis was established with triple phase computed tomography.

Results: Between July 2004 and March 2011, 34 patients with Grade IV porto-mesenteric thrombosis received 34 composite multivisceral grafts including the stomach, pancreatico-duodenal complex, liver and small bowel with a median follow up of 32 months. Six patients had intestinal failure from short gut syndrome. Eleven patients underwent simultaneous cadaveric kidney transplantation. Induction immunosuppression (thymoglobulin and rituximab) was followed by tacrolimus and prednisone maintenance. One patient required re-transplantation. Biopsy proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 32 months, the graft survival is 79%, 64% & 64% at 1, 3 & 5 years respectively, whereas the patient survival is 82%, 71% & 71% at 1, 3 & 5 years respectively. Overall survival among patients not receiving a simultaneous kidney transplant is 87% (versus 36%). All recipients have good graft function. Residual/ recurrent features of portal hypertension (gastro-esophageal varices and ascites) were not observed in any of the patients.

Conclusions: MVT is capable of removing the entire disease process in patients with diffuse porto-mesenteric thrombosis and offers superior survival outcomes and better quality of life. Those requiring MVT with simultaneous kidney transplantation have worse outcomes.