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Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges.

Abstract：

OBJECTIVE:To assess the evolution of visceral transplantation in the milieu of surgical technical modifications, new immunosuppressive protocols, and other management strategies. SUMMARY BACKGROUND DATA:With the clinical feasibility of intestinal and multivisceral transplantation in 1990, multifaceted innovative tactics were required to improve outcome and increase procedural practicality. METHODS:Divided into 3 eras, 453 patients received 500 visceral transplants. The primary used immunosuppression was tacrolimus-steroid-only during Era I (5/90–5/94), adjunct induction with multiple drug therapy during Era II (1/95–6/01), and recipient pretreatment with tacrolimus monotherapy during Era III (7/01–11/08). During Era II/III, donor bone marrow was given (n = 79), intestine was ex vivo irradiated (n = 44), and Epstein-Barr-Virus (EBV)/cytomegalovirus (CMV) loads were monitored. RESULTS:Actuarial patient survival was 85% at 1-year, 61% at 5-years, 42% at 10-years, and 35% at 15-years with respective graft survival of 80%, 50%, 33%, and 29%. With a 10% retransplantation rate, second/third graft survival was 69% at 1-year and 47% at 5-years. The best outcome was with intestine-liver allografts. Era III rabbit antithymocyte globulin or alemtuzumab pretreatment-based strategy was associated with significant (P < 0.0001) improvement in outcome with 1- and 5-year patient survival of 92% and 70%. CONCLUSION:Survival has greatly improved over time as management strategies evolved. The current results clearly justify elevating the procedure level to that of other abdominal organs with the privilege to permanently reside in a respected place in the surgical armamentarium. Meanwhile, innovative tactics are still required to conquer long-term hazards of chronic rejection of liver-free allografts and infection of multivisceral recipients.

journal_name

Ann Surg

journal_title

Annals of surgery

authors

Abu-Elmagd KM,Costa G,Bond GJ,Soltys K,Sindhi R,Wu T,Koritsky DA,Schuster B,Martin L,Cruz RJ,Murase N,Zeevi A,Irish W,Ayyash MO,Matarese L,Humar A,Mazariegos G

doi

10.1097/SLA.0b013e3181b67725

subject

Has Abstract

pub_date

2009-10-01 00:00:00

pages

567-81

issue

eissn

0003-4932

issn

1528-1140

journal_volume

250

pub_type

杂志文章

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Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges.