Ex Vivo Surgery and Multivisceral Transplantation

Intestinal and Multivisceral Transplantation

By transplanting several organs at once, we can give patients with serious intestinal malformations or infections hope for a healthy future. The Intestinal Failure Program at Morgan Stanley Children's Hospital has managed nearly 100 patients with devastating intestinal problems in recent years. The team includes dedicated specialists in pediatric surgery and transplantation; pediatric gastrointestinal medicine and nutrition; advanced practice nursing; and child life and social support services. This range of services, essential to helping these children and their families cope with overwhelming health problems, is only available at a world's leading children's hospital.

Intestinal or 'short bowel' transplantation is now recognized as a viable option for irreversible intestinal failure or short bowel syndrome. Patients who develop intestinal failure can become candidates for intestinal transplantation if life threatening complications are present or if bowel rehabilitation is impossible due to the congenital nature of the intestinal disease.

Intestinal transplantation is frequently associated with liver transplantation. Certain diseases, such as biliary atresia, and the use of total parenteral nutrition (TPN) for conditions such as short bowel syndrome, can contribute to liver failure. If the child has both intestinal and liver failure, intestinal transplantation may be performed in conjunction with liver transplantation. If the patient does not have liver failure, isolated intestinal transplantation may be performed while leaving the liver in place. Multivisceral transplantation may be considered if the patient's condition involves failure of multiple abdominal organs, with or without transplanting the liver.

Our experience with small bowel transplant spans two decades, including surgery on a four-month old girl, who today, at 18, is the longest survivor of a small bowel transplant in the world.

Dr. Tomoaki Kato – What is intestinal and multivisceral transplantation?

Dr. Tomoaki Kato – What happens during an intestinal and multivisceral transplant operation?

Dr. Tomoaki Kato – Who requires an intestinal and multivisceral transplantation?

Dr. Tomoaki Kato – Who is a good candidate for intestinal and multivisceral transplantation?

Ex vivo Surgery

Ex vivo transplant surgery entails the removal and re-implantation of as many as six abdominal organs in order to excise tumors that have grown to involve the organs and or blood vessels. Tomoaki Kato, MD, is recognized for his outstanding achievements in advancing ex vivo abdominal surgery. In these complex operations, the surgical team removes affected internal organs and blood vessels, excises the tumor, and reimplants the organs. Some procedures require extensive surgical repair and grafting of blood vessels.

About the Procedures: Isolated Small Bowel or Multiorgan Transplantation

Intestinal transplant is a complex procedure that may entail an isolated intestinal transplant, multivisceral transplant, or a modified multivisceral transplant. Depending on the cause of your child's intestinal failure and overall medical condition, the transplant team will determine the type of surgery that best meets your child's medical needs.

Our pediatric transplant surgeons can perform small bowel transplantation for specific sections of the colon, such as the large bowel. We also can combine liver and small bowel transplantation, as well as liver, small bowel, and colon transplantation if necessary. For some patients, our surgeons rebuild the colon to avoid any permanent colostomy. They can also perform a multi-visceral transplantation-the transplantation of more than four organs: stomach, small bowel, pancreas, liver, and large bowel.

Types of Multivisceral Transplant Surgery

Multivisceral transplant surgical options include the following:

  • Isolated Intestinal Transplant: an isolated intestinal transplant involves removing the diseased portion of the small intestine and replacing it with a healthy small intestine from a donor. This type of transplant is considered for patients with complications caused by intestinal failure, but who do not have liver failure.
  • Multivisceral Transplant: a multivisceral transplant may be considered for patients who have multiple organ failure, including stomach, pancreas, liver, small intestine and/or kidney failure. This type of transplant involves removing the diseased organs and replacing them with healthy organs from a donor.
  • Modified Multivisceral: a modified multivisceral transplant may be considered for patients who do not have liver disease/failure, but have organ failure of the stomach, pancreas, small intestine and/or kidney(s. This type of transplant involves keeping your own liver, and removing the remaining diseased organs and replacing them with healthy organs from a donor. Life-threatening complications include: loss, or impending loss of vascular access for total parenteral nutrition (TPN); development of TPN-induced liver failure with cholestatic disease (jaundice) and portal hypertension (which can lead to gastro-intestinal bleeding episodes); episodes of frequent sepsis from central venous line catheters and/or intestinal translocation; and recurrent, severe episodes of dehydration.

Indications for Intestinal Transplantation

Intestinal transplantation may be indicated for patients with the following conditions:

  • Gastroschisis
  • Volvulus
  • Necrotizing Enterocolitis
  • Intestinal Atresia
  • Intestinal Pseudo-Obstruction
  • Megacystis Microcolon Intestinal Hypoperistalsis Syndrome
  • Microvillus Inclusion Disease
  • Hirschsprung's Disease
  • Gardner's Syndrome/Familial Adenomatous Polyposis
  • Mesenteric Venous Thrombosis or Arterial Thrombosis 
  • Crohn’s Disease
  • Desmoid Tumor with Intra-Abdominal Infiltration
  • Trauma:
  • Multiple resections and explorations
  • Vascular Abdominal Trauma such as Superior Mesenteric Artery (SMA) or Superior Mesenteric Vein (SMV) Injuries
  • Endocrine Tumors
  • Infiltrative Diseases leading to intestinal failure: Sarcoidosis/Amyloidosis
  • Short Bowel Syndrome

Most patients needing a combined liver-intestine or multivisceral transplantation have:

  • TPN Cholestasis that has progressed to irreversible liver injury (fibrosis/cirrhosis)
  • End-Stage Liver Disease

Complications of Intestinal and Multivisceral Transplantation

Intestinal, multivisceral, or modified multivisceral transplantation is a life-saving therapy. However, your physicians cannot predict exactly how your child's body will respond to this transplant. The operation is extremely complex and the risks are significant.

The most common complications include postoperative hemorrhage, vascular leaks or obstruction, and biliary leaks or obstruction. Other potential complications include:

  • bleeding
  • infection
  • bile leaks
  • vascular complications
  • intestinal leaks
  • rejection of the transplanted tissue
  • side-effects of immunosuppressant medications
  • depression, anxiety, and mood-related disorders
  • increased risk of skin and certain other cancers