Surgical Challenges in the Long Term Follow-up after Intestinal and Multivisceral Transplantation

Abstract

Background: Intestinal and multivisceral transplant recipients have often undergone mulitple operations prior to and early after transplantation. In addition, they receive high amounts of immunosupression. Thus abdominal surgery at a later stage posttransplant is very challenging and may increase the morbidity and mortality of these fragile patients. Methods: We retrospectively studied 69 patients (27 female, 42 male, 37±9 years) with isolated intestinal (ITX, n=48), modified (mMVTX, n=7) or typical multivisceral transplantation (MVTX, n=15) in 2 large european transplant centres. 4 grafts included a kidney and 17 included the abdominal wall. Maintenance immunosuppression consisted of either Tacrolimus Monotherapy in 31 patients or a double combination of Tacrolimus/MMF, Tacrolimus/Sirolimus, Tacrolimus/Everolimus. We recorded all intraabdominal interventions, which were performed after the first year posttransplant, and subdivided them into 2 groups depending on whether or not they were related to the intestinal graft. Results: The median follow-up time posttransplant was 8 years [1;15]. 20 intraabdominal operations were reported in 15 patients after a median of 5 years [1;13] posttransplant. 81% were emergency operations: Graft-related surgery was required due to graft ischeamia (n=2), adhesive ileus (n=3) and encapsulating ileus (n=2). Surgery for these patients included partial graft resection (n=5), graft explantation (n=4) and intestinal retransplantation (n=1). Non graft-related operations did not affect the graft or graft function and were: native colon resection due to Volvulus (n=1), native nephrectomy due to outflow obstruction (n=1), kidney transplantation due to CNI-toxicity (n=1), cholecystectomy due to necrotic cholecystitis (n=1), caesarian (n=1), post-mortem kidney/liver donation (n=1). There were no deaths related to surgery. 19% was elective surgery: Incisional herniotomy at the previous stoma-site (n=3) and a bilateral inguinal herniotomy without incarceration(n=1). A conservative treatment was attempted in 4 patients with: rectovaginal fistula in a stapled rectum stump (n=1), neutropenic colitis (n=1) and upper GI-haemorrhage (n=2). The latter 2 patients died. The median hospital stay following surgery was 27 days [7;210]. Six patients had to undergo repeated surgery (median number of operations 3 [2;13]). Conclusion: Abdominal surgery in ITX and (m)MVTX-recipients is challenging but feasible. Especially graft-related surgery was accompanied with a high risk of graft-loss but not with mortality. Non graft-related surgery did not affect graft function or longterm survival.