INTESTINAL AND MULTIVISCERAL TRANSPLANTATION FOR PORTOMESENTERIC VENOUS THROMBOSIS: TECHNICAL CONSIDERATIONS AND THERAPEUTIC EFFICACY

Abstract

P607 Aims: Splanchnic arterial and venous thrombosis is second most common indication for visceral transplantation. The underlying etiology, disease gravity and extent of thrombosis should guide the decision-making process and influence post-transplant outcome. This study is the first to address the different causes of splanchnic thrombosis, indications for each type of the visceral allograft, and survival outcomes. Methods: Between May 1990 and March 2004, 135 consecutive adult patients received 148 intestinal allografts at the University of Pittsburgh. Of these, 48(36%) were transplanted due to splanchnic thrombosis that was limited to the portomesenteric venous system in 20. Diagnosis was with abdominal imaging studies including visceral angiography. Age ranged from 23 to 65 years with a median of 45. Twelve patients suffered from short gut syndrome prior to transplantation and the remaining 8 required full visceral replacement because of variceal bleeding and hepatic failure. Results: Visceral venous thrombosis was due to protein C, S and anti-thrombin III deficiency in 3, Factor V/II mutation in 2, antiphospholipid antibodies in 3, myeloproliferative disorder in 3 and unknown etiology in the remaining 9 patients. The required intestinal allograft was tailored to intestine alone in 6(30%), combined liver-intestine in 4(20%) and multivisceral in 10(50%) patients. The median operative time (hr) was 12 for intestinal 18 for liver-intestinal, and 15 for multivisceral transplantation with an average blood loss of 4, 14 and 23 units, respectively. The pre-transplant liver functions were preserved in all of isolated intestinal recipients and the allograft venous outflow was drained into the recipient vena cava. In two of these, a splenorenal shunt was performed one year prior to transplant for treatment of gastric varcies in presence of chronic anticoagulation therapy. In 3 out of the 4 combined liver-intestinal recipients, systemic venous drainage of the retained left upper abdominal organs was via non-conventional portosystemic shunts. All of multivisceral recipients had combined extensive portomesenteric and splenic venous thrombosis with diffuse minute collaterals combined with Budd-Chiari(3), diabetes(2), renal failure(2) and hepatocellular carcinoma(1). All recipients were anticoagulated despite hepatic replacement. With a mean follow-up of 23±27 months, 14 recipients were alive with a cumulative survival rate of 79% at 6 months and 67% at 5 years. Causes of patient death were graft failure(1), upper gastrointestinal hemorrhage(1), enteric leak(1) and opportunistic infections(3). All of 14 survivors were free of TPN enjoying unrestricted oral diet 6 months to 8 years after transplantation. Conclusions: Despite disease gravity, inherent technical complexity and associated morbidity, intestinal and multivisceral transplantation are effective therapeutic modalities for patients with symptomatic splanchnic venous thrombosis. Thorough pretransplant evaluation with proper tailoring of the required allograft is mandatory for successful outcomes.