Abstract

386 Between May 1990, and December 1998, a total of 118 patients received intestinal transplantation at our Center. Forty eight were adult patients and splanchnic vascular occlusion was the cause of intestinal failure in 16 (33%). Of these 16 recipients, 7 received isolated intestine, and 9 received composite grafts including the liver. Twelve were male and four were female with a mean age of 37 ± 13 years. The vascular occlusion was arterial in 11, portomesenteric in 4, and combined in the remaining case. Concomitant extensive preoperative central venous thrombosis was present in 7 (47%) patients. The causes of the vascular thrombosis were hypercoagulable state in 8 (50%), TTP in 1 (8.5%), myeloproliferative disorder in 1 (8.5%), and undetermined in 6 (33%) patients. Protein C, S, and anti-thrombin deficiencies (n=7), and factor V mutation (n=1) were the underlying metabolic errors of the hypercoagulable syndromes. The composite visceral grafts were given only to patients with combined liver and intestinal failure and total visceral vascular occlusion. Accordingly, four of the patients with the hypercoagulable state received isolated intestinal transplantation with postoperative chronic anti-coagulation therapy. All donors were cadaveric and the baseline immunosuppression was tacrolimus and steroids. Results: With a mean follow-up of 25 months (range:1-101), the overall patient and graft survival was 63% and 56%, respectively. All current survivors with graft in place (n=9) are completely off TPN with full nutritional autonomy. The causes of deaths were sepsis (n=5) and TPN induced liver failure after graft enterectomy (n=1). None of the grafts were lost due to vascular thrombosis. However, long-term anti-coagulation therapy was reinstituted 2-3 months after composite visceral transplantation in 2 of the hypercoagulable patients who continued to develop deep venous thrombosis despite normalization of the protein C, S, and anti-thrombin serum levels. Conclusions: 1) Visceral vascular occlusion is a common indication for intestinal transplantation among the adult population. 2) The diagnosis of a hypercoagulable state does not indicate replacement of the native liver but mandates lifelong anti-coagulation after isolated intestinal transplantation.

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