What to Expect From a Stomach or Multivisceral Transplant
In general, stomach transplants are not performed alone. The stomach may be transplanted as part of a larger scale transplant of multiple organs within the abdominal digestive system (gastrointestinal tract). When this is done, the procedure is referred to as a multivisceral transplant.
Viscera are internal organs such as the lungs, heart, stomach, liver, or intestines. Some conditions that may lead to stomach or multivisceral transplant include short bowel syndrome (SBS), intestinal blockage, or motility disorders.
Complications from a multivisceral transplant can include nutrition problems (feeding tubes or alternative methods of receiving proper nutrition may be necessary), or the rejection of transplanted organs, which is prevented by taking anti-rejection medications for the remainder of your life. Side effects of these medications may also cause complications since they affect the function of your immune system.
Reasons for a Multivisceral Transplant
Before discussing causes of multivisceral transplant, it is important to understand the main reason for intestinal transplants (ITx). Intestinal transplant is more common than the more extensive multivisceral transplant. Typically intestinal transplants are performed on individuals that have short bowel syndrome caused by:
Congenital anomaly (rare): Genetic abnormality present at birth
Gastroschisis: Intestines are located outside of the body
Intestinal atresia: Blockage of the intestines
Mid-gut volvulus: Twisted intestines causing obstruction
Necrotizing enterocolitis: Mostly seen in premature infants; bacterial infection that destroys the walls of the intestines
Short bowel syndrome is the term used to represent dysfunctional intestines that are not capable of properly absorbing nutrients. Intestinal transplant is considered when SBS occurs along with other complications related to central lines such as sepsis, or inability to adequately maintain a central line from other complications such as clotting.
In general these criteria are evaluated to determine necessity of transplant:
Failure to deliver parental (IV) nutrition at home
Increase risk of mortality (death)
Less than 10 centimeters of small bowel in children or less than 20 centimeters of small bowel in adults
Increased frequency of hospitalization, dependent on narcotics, or pseudo-bowel obstruction (symptoms similar to an obstructed bowel without actually being obstructed)
Unwilling or unable to maintain long-term parental nutrition at home1
The main cause for a multivisceral transplant is short bowel syndrome accompanied by cholestatic liver disease that is caused by total parental nutrition (TPN), which is complete nutrition by IV. While TPN is life-saving, some of the components in TPN under long-term administration can lead to liver disease.
Besides SBS, there are several other conditions that may warrant multivisceral transplant including:
Diffuse (widespread) clots in the portomesenteric vein
Cancers contained within the abdominal cavity
Genetic motility disorders
Multivisceral transplants are advantageous over separate transplants of abdominal organ transplants, due to the decreased number of surgical reconnections (anastomosis). This is, in particular, true for infants.2
Who is Not a Good Candidate?
Anyone who has the following conditions should not be a candidate for multi-visceral or stomach transplant:
A current infection
Some types of cancer
Multi-system organ failure
Types of Multivisceral Transplants
Your stomach is considered a nonessential organ as there are options to remove parts of your stomach or completely remove the stomach to treat many underlying health problems.
Because there are options to provide treatment without a transplant, and the associated risks with transplant, stomach transplants are typically not performed by themselves. However, a stomach transplant can be performed in series along with the transplantation of other organs.
A multivisceral transplant (MVTx) is the transplantation of several abdominal organs. Typically this type of transplant includes the following:
If the liver is not diseased, the liver may be excluded from the multivisceral transplant, which is commonly referred to as a modified multivisceral transplant (MMVTx). While the kidney is not typically performed in this type of transplant, if you are in end-stage kidney failure, kidney transplant may be performed at the same time.
Donor Recipient Selection Process
Several members of a professional team participate in the recipient selection process. Team members may include several doctors who specialize in areas related to your condition as well as psychologists and social workers.
Your overall health will be thoroughly evaluated and this may include an evaluation of your liver function such as a liver biopsy as well as medical imaging tests (ultrasound, MRI, etc.) and blood work to detect infections such as cytomegalovirus or HIV.
After this extensive medical evaluation if it is determined that you are a good candidate for transplant surgery you will be given an allocation score determined by certain factors including how soon you need the transplant, and placed on a waiting list.
The time between being placed on the waiting list and surgery varies, but the average wait is approximately one year. However, there is no way to know for sure an individual may spend on the transplant waiting list as many different factors play a role including your individual score and how soon a proper donor organ becomes available.1
The organization that oversees the waiting list and the distribution of donated organs in the United States is called the United Network for Organ Sharing (UNOS). Donor organs come from individuals who have passed away, often due to accidental death or another cause that does not cause damage to the donor organs.3
Donor candidates need to have the necessary organs in good condition. In addition to your allocation score, things that must be considered before transplanted organs are available to you include matching the blood type of the donor and recipient as well as the size of the organs (adult or child for example).3
If certain infections are present in a donor such as cytomegalovirus (CMV), their organs are only given to recipients who also have CMV. Living donors are seldom used currently but may be an option for some liver and intestinal transplantations.1
Waiting for your surgery can be mentally and emotionally challenging in addition to coping with a chronic and serious illness. Please talk to your healthcare team about support groups and resources that can assist you during this time of uncertainty.
Prior to your surgery you will need to work closely with your healthcare team to maintain your health. Active infections may affect your ability to receive transplantation so preventative measures may be necessary.
Once a donor organ(s) becomes available you will need to go to surgery right away. While you are on the waiting list is a good time to formulate a plan for your recovery including any help from loved ones that will be necessary during the recovery period.
Questions to ask your doctor may include:
How long do you expect me to remain hospitalized barring unforeseen complications?
What types of limitations on my activity can I expect after my surgery?
Approximately how long do you think it will be before I can return to work or school?
Tell me about the medications I will need to be taking after surgery.
How will I receive nutrition after surgery?
How will my post-surgery pain be managed?
Depending on whether or not you are only having an intestinal transplant, or also having your stomach, liver, and pancreas transplanted, your surgery can take anywhere from eight hours up to 18 hours. During surgery, your surgeon may have several different approaches based upon your individual situation.
If you do not have a functional colon, you will have an ileostomy placed to evacuate stool from your bowels. However if possible, your surgeon will connect your colon to the transplanted small intestines. In certain cases, you may start with an ileostomy and have a later reconnective surgery.
Several different types of feeding tubes may be placed. You may have a feeding tube placed through your nose into the stomach, or you may have tube placed into your stomach through your abdomen. Depending on where the tube enters your stomach or small intestine, this tube will be called a gastrostomy tube, jejunostomy tube, or a gastrojejunostomy tube.
Potential complications that may occur during the surgery include excessive bleeding, negative reactions to general anesthesia (respiratory problems, malignant hyperthermia), or infection of the surgical site. Your surgeon should discuss with you in detail these risks and any others just prior to the procedure.
Organ rejection is something that can occur anytime you receive an organ transplant from a donor. It is the process of a healthy immune system recognizing the donor organs as foreign and trying to attack them.
To prevent this process you will need to take anti-rejection medications, such as cyclosporine or tacrolimus (TAC), for the remainder of your life. Side effects of anti-rejection medications include a suppressed immune response, which may make you susceptible to infections.
While everyone’s individual experience will look different, this section is designed to give you a general idea of what to expect during the hospital following your multiviceral or stomach transplant.
Post-operative management following stomach transplant and other gastrointestinal transplants requires management of many different aspects of care. In particular close attention to rejection of the donor organs is important for successful transplant.
Because of the extensive nature of this operation where multiple organs are removed and donor organs transplanted, you will likely spend several days in the intensive care unit.
In general, you may be on a ventilator for 48 hours or more. Fluid shifting, where fluid normally in your blood vessels is moved into other tissue in your body, influences how long you are on a ventilator. This is normal. Your medical team may place you on diuretics, such as Lasix (furosemide), to help remove excess fluid and help you to wean off the ventilator faster.
In order to maintain appropriate nutrition, you may receive all nutrition via IV (parental) immediately after surgery. As your medical team can determine the acceptance of the donor organs, liquid feeding through a tube into your stomach or small intestines will be initiated and increased as tolerated. As you are able to receive more nutrients through your feeding tube, the parental nutrition will be tapered down.
Renal (kidney) function will also be closely monitored following surgery. Due to the severity of illness, issues of dehydration, and possible episodes of sepsis related to underlying causes requiring the transplant, renal function is often impaired.
Because it is necessary to ensure proper fluid management during surgery, decreased kidney function may cause fluids to shift into tissue causing swelling to occur. This will be monitored closely with blood analysis and measurement of urine volumes.
While it is understandable that you will be concerned with this, understand that this is fairly normal soon after surgery until your body begins to accept the transplant and stabilize.
Infections will be a continual risk following transplant related to the medications that you will be started on to reduce your risk of rejecting the donor organs. It will be important for you to follow your doctor’s instructions in relation to your medication regimen.
You may also be started on antiviral or antifungal medications to reduce your risk for acquiring opportunistic infections, which are infections that you would not typically acquire except for being on medications that reduce your immune response.
Studies suggest that most individuals (80%) undergoing multivisceral transplants rate their quality of life similarly to those who have not undergone transplant surgery. 1
It is estimated that 75% to 90% of transplants can recover to the point of removing parental nutrition.4
Following surgery and initial recovery patients are encouraged to return to school or work and participate in any hobbies or activities they did before the surgery as they are able.
Some precautions may be necessary since anti-rejection medication can make you more susceptible to illness. For example you will need to avoid people who are sick, frequently wash your hands, and practice good hygiene.3
Because of the rare nature of transplants involving the stomach, pancreas, small intestines, and livers simultaneously, long-term outcomes are not well understood.4
For those undergoing intestinal transplantation survival rates have improved but long term outcomes are still low according to recent research. These rates will likely continue to improve as new developments are made in improving anti-rejection medications. Your likelihood of survival is also strongly linked to the condition of your health prior to your transplant.1
Support and Coping
Coping with any longterm health problems can be difficult. It can be extremely helpful to talk to others who are experiencing similar issues. Online support groups are often found easily through social media, including Facebook.
Additionally, we recommend that you consult your healthcare team about in-person support groups in your area, the possibility of professional counseling, and any medication, such as antidepressants, that may be needed to aid your emotional well being.