Intestinal and multivisceral transplantation: future perspectives

The field of intestinal transplantation has experienced a progressive increase in patient and graft survival over the last few years, leading to a parallel increase in the number of programs performing such type of surgical procedures. Indications for intestinal transplant include irreversible intestinal failure, compounded by potential life-threatening complications such as loss of intravenous access, liver failure or multiple episodes of infections. The type of graft that is required is highly individualized according to the patient's original diagnosis and status. Presence of short gut syndrome alone is indication for isolated intestinal transplant; liver failure mandates the use of a liver graft (liver-intestine or multivisceral transplant); intestinal dysmotility disorders with intact liver function require the use of a modified multivisceral graft. Most of the current immunosuppression protocols consist in induction immunosuppression and maintenance doses of tacrolimus. Rejection and infectious complications remain the most common causes of morbidity and mortality; it is therefore essential to closely monitor the intestinal graft to prevent such occurrences. Future developments include: the use of non-invasive markers of rejection; a refinement in surgical techniques; development of advanced immunosuppression protocols; expansion of living related transplant and multivisceral transplantation in selected patients.