PE-11: Pediatric Multivisceral Transplant for Portomesenteric Thrombosis and Hostile Abdomen

Abstract

Intro: Intestinal failure(IF) continues to be the most common indication for an intestinal transplant (Itx). Given complications of parenteral nutrition (PN) such as liver disease or of the underlying condition such as gastroparesis, en-bloc transplantation including liver/stomach were developed. With evolution of the surgical technique, immunosuppression, graft monitoring and patient management, outcomes of Multivisceral transplantation (MVT) have improved. This allows the possibility to expand indications to other etiologies other than IF. Methods: We reviewed all pediatric Itx performed in our institution from 2013-2020, our most recent era. We performed 51 pediatric Itx. Induction was ATG/Rituximab/+/-Vedolizumab. Maintenance immunosuppression was Tacrolimus/mTOR inhibitor. We identified 4 patients who underwent MVT for hostile abdomen with portal +/-mesenteric thrombosis. Results: 3 female. Age 2-9yo. Weight 8.3-23.4kg. 3 had primary diagnosis of biliary atresia. 2/3 had undergone 2 prior orthotopic liver transplants (OLTs) with graft lost to hepatic artery thrombosis. 1/3 had 1 prior OLT with progressive cholestasis. All 3 patients developed extensive portal +/-mesenteric thrombosis of latest graft progressing to end stage liver disease. Evaluation for retransplant found abdomen to be hostile. 4 th patient had sclerosing cholangitis and antithrombin III deficiency leading to portomesenteric thrombosis. Follow up 285-1643d. LOS 46-68d. 3 patients were done without ostomy and 1 with ostomy given size. All patients are on regular/enteral diet. No patients are on PN/IVF supplementation. 2 patients had rejection, 1 mild and 1 moderate. Both were treated successfully with steroids. 1 patient developed PTLD and treated with Rituximab/Cyclophosphamide/Prednisone now in remission for > 3yr. 1 patient developed GVHD of the skin/bone marrow successfully treated with Alemtuzumab. Graft and patient survival are both 100%. 3 of 4 patients are school aged and attending regular school with good quality of life. Conclusions: Despite the high risk of this population, MVT proved to be a successful option in a pediatric population with portomesenteric thrombosis and hostile abdomen. We believe we are entering a new era in MVT with improved patient survival and good quality of life. An expansion of indications for such a procedure may be feasible.