40: Abdominal Organ Transplantation

Abdominal Organ Transplantation

Parissa Tabrizian1, Kiumars Ranjbar Tabar2, Ron Shapiro1, Kishore R. Iyer1, and Sander Florman1

1 Icahn School of Medicine at Mount Sinai, New York, NY, USA

2 Allegheny Health Network, Pittsburgh, PA, USA

Liver transplantation


  • Orthotopic liver transplantation (OLT) is the treatment of choice for selected patients with end‐stage liver disease and acute liver failure.
  • The first human OLT was performed by Dr. Thomas Starzl in 1963.
  • With the development of surgical techniques and the introduction of newer and more effective immunosuppressive medications, survival has now reached 70–80% at 5 years.
  • Organ allocation has also evolved over time, with the current system based upon the model for end‐stage liver disease (MELD) score (see Chapter 39), prioritizing patients based upon the severity of their disease and likelihood of death without transplantation.
  • Non‐cholestatic cirrhosis is the most common diagnosis of patients on the waiting list for liver transplantation.

Indications and contraindications

With improvement in medical and surgical techniques, conditions prohibiting transplantation have decreased over time, and most contraindications have become relative rather than absolute.


Indication Cause of condition
Acute liver failure Toxins and drugs

Acute viral hepatitis

Wilson’s disease, autoimmune hepatitis, Budd–Chiari syndrome

Chronic decompensated liver failure:
Non‐cholestatic diseases Hepatitis B/C

Alcoholic liver disease

Non‐alcoholic steatohepatitis

Budd–Chiari syndrome

Autoimmune hepatitis

Polycystic liver disease
 Cholestatic diseases Primary biliary cirrhosis (PBC)

Primary sclerosing cholangitis (PSC)

Secondary biliary cirrhosis

Biliary atresia

Alagille syndrome

Metabolic conditions causing systemic disease Primary oxaluria

Familial amyloidosis

Alpha‐1 antitrypsin deficiency

Wilson’s disease


Urea cycle enzyme deficiencies

Glycogen storage disease
Malignant disease Hepatocellular carcinoma



Neuroendocrine carcinoma

Epithelioid hemangioendothelioma


Relative contraindications
Age >70 years Assessment of overall health and performance status
Severe malnutrition or morbid obesity Associated with poor outcome, technical challenges
Other organ failure Consideration for multiorgan transplantation
Complex previous upper abdominal surgery Not technically feasible
Poor functional status Associated with poor outcome
Poor medical compliance Unlikely to comply with immunosuppression
Absolute contraindications
Severe cardiopulmonary disease Heart/lung disease that would prevent a successful operation
Irreversible cerebral injury Elevated intracranial pressure unresponsive to treatment
Sepsis/active infection Severe uncontrolled systemic infection
HIV/AIDS Untreated AIDS, unresponsive to treatment
Extrahepatic malignancy Disease‐free period of <2 years depending on the type of malignancy
Vascular Anatomic variations, extensive portal and mesenteric vein thrombosis leading to technical difficulties
Active chronic alcohol and drug usage Required abstinence for a minimum of 6 months
Psychosocial issues Severe disorder, lack of social support


Whole liver recipient procedure

  • Step 1: total hepatectomy via bilateral subcostal incisions with or without midline extension to the xiphoid process.
  • Step 2: assessing the need for veno‐venous bypass. This involves the extracorporeal circulation of blood from the venous system below the caval clamps (inferior mesenteric and femoral veins) and return to the central veins (axillary or internal jugular veins). This procedure is, however, associated with major complications (up to 30%) including lymphocele, hematomas, coagulopathies, plexus injury, and fatal pulmonary emboli. Relative indications of the use of veno‐venous bypass are pulmonary hypertension, poor left ventricular function, fulminant hepatic failure, renal failure, severe portal hypertension, and massive bleeding during the hepatectomy.
  • Step 3: implantation and caval techniques:

    • Standard technique with caval replacement (Figure 40.1): requiring anastomosis of supra‐ and infrahepatic cava.
    • Piggyback technique (Figure 40.2): this technique avoids caval cross clamping and preserves the retrohepatic native IVC. It helps maintain IVC flow during the anhepatic phase, therefore preserving venous return to the heart and minimizing effects related to full clamping. Potential additional advantages that have been described with this technique are reduction of renal dysfunction, reduced warm ischemia time, and less bleeding.

  • Step 4: portal reconstruction: end–end anastomosis or graft to native superior mesenteric vein (retrogastric/retrocolic).
  • Step 5: arterial reconstruction: end–end anastomosis or arterial graft to native aorta (retrogastric/retrocolic).
  • Step 6: biliary reconstruction: duct‐to‐duct with/without T‐tube or Roux‐en‐Y hepaticojejunostomy.

Special considerations and technique

  • Pre‐existing portal vein thrombosis: partial vein thrombectomy or donor iliac vein grafts from the superior mesenteric vein (tunneled retrogastric/retrocolic).
  • Hepatic artery dissection or inadequate flow: donor interposition graft to native aorta (retrogastric/retrocolic).
  • Pre‐existing transjugular intrahepatic portosystemic shunt (TIPS): incision of the pericardium and intrapericardial control of the suprahepatic cava may be necessary to remove TIPS that extends into the heart.

Partial liver recipient procedure

  • This includes reduced size, split, and living donor liver transplantation.
  • The piggyback technique is mandatory.
  • The actual splitting can be performed ex vivo or in situ in a manner analogous to living donor liver transplantation, at the discretion of the surgeon performing the procedure.


  • Tacrolimus (FK506), a calcineurin inhibitor (CNI) is used as the first line drug in OLT.
  • Corticosteroids have been the mainstay for induction of immunosuppression.
  • Antimetabolites such as mycophenolate mofetil (MMF) are used in combination with steroids and CNIs to reduce CNI‐related renal insufficiency and to prevent rejection.


Early complications Hemorrhage

Primary non‐function

Early graft dysfunction

Acute cellular rejection

Hepatic artery or portal or hepatic vein thrombosis

Biliary stricture or leak

Infections (bacterial, viral, fungal)
Late complications Recurrence of disease (HCV, HBV, NASH, autoimmune disease)

Chronic rejection

Biliary strictures

Metabolic syndrome (hypertension, dyslipidemia, diabetes, coronary disease)

Malignancies (skin, post‐transplant lymphoproliferative disorder)

Immunosuppressive side effects


  • Two, 5, and 10 year survival in patients undergoing transplantation is 94%, 79%, and 60%, respectively.
  • Graft survival at 2, 5, and 10 years is 87%, 75%, and 59%, respectively.
  • Recurrence of disease is an important determinant of survival as some conditions do not recur after transplant, while others may recur.

Kidney transplantation


  • The first successful kidney transplant was with a living donor between identical twin brothers in 1954.
  • With the development of 6‐mercaptopurine, followed by azathioprine in the early 1960s, and implementing the use corticosteroids, the medical community has witnessed great advances in patient and graft survival rates in kidney transplantation.
  • As knowledge of the immune system evolved, the first polyclonal antilymphocyte globulin was used in 1967, ciclosporine was introduced in 1980s, followed by the introduction of MMF and tacrolimus in 1990s in kidney transplantation.
  • Kidney transplantation, depending on the source of the donor organ, is classified as deceased donor/cadaveric or living donor transplantation.
  • Living donors are genetically related (living related) or non‐related (living unrelated), depending on whether a biologic relationship exists between the donor and recipient.
  • Currently, there are over 120 000 people waiting for a life‐saving organ transplant in the USA, among whom about 100 000 are on the kidney transplant waiting list.

Indications and contraindications

  • Kidney transplantation is definitive treatment for eligible patients with end‐stage renal disease (ESRD) (creatinine clearance <20 mL/min) regardless of the primary cause.

Indications Contraindications
Chronic glomerulonephritis Chronic illness with life expectancy of less than 1 year
Systemic arterial hypertension AIDS untreated or unresponsive to treatment
Fabry’s disease Sepsis
Hyperoxaluria Advanced cardiovascular disease
Diabetes mellitus Poor respiratory status
Unknown renal insufficiency Cancer (active/unresolved)
Obstructive and toxic uropathy Psychosocial
Alport’s syndrome
Polycystic kidney disease
Nephrotic syndrome
Chronic obstructive pyelonephritis
Lupus nephritis
Focal segmental glomerulosclerosis


  • Regardless of the donor type, the kidney transplant operation is the same.
  • The standard kidney transplant procedure with heterotopic pelvic approach has been widely accepted for its multiple advantages and is considered the standard (Table 40.1).

Table 40.1 Liver transplant procedure.

Procedure Important points
Approach Extraperitoneal approach of the iliac fossa

Contralateral or ipsilateral fossa

Lymphostasis to avoid lymphocele

Total mobilization of the external iliac vein

Minimal dissection of the iliac artery

Vascular anastomosis Generally external iliac vessels

Internal iliac should not be used except in specific situations

Ureteral anastomosis Extravesicular implantation at the anterolateral surface of the bladder is the method of choice

Double J stenting prevents major urinary complications

Utero‐ureteral anastomosis is an alternative to a very short or poorly vascularized transplant ureter

Kidneys from donor <15 kg En bloc transplantation including aorta and IVC

The ureters are implanted either separately or after partial anastomosis using an extravesical technique

Special considerations If the iliac arteries do not allow clamping, endarterectomy or vascular prosthesis should be considered

If the iliac vein/vena cava is thrombosed, the native renal vein or SMV can be used


Early complications Late complications
Acute rejection/acute renal failure Ureteral stenosis
Infection Reflux and acute pyelonephritis
Hemorrhage Kidney stones
Incisional hernia Renal artery stenosis
Urinary fistula AVF and pseudoaneurysms
Arterial thrombosis Lymphocele
Venous thrombosis Chronic allograft dysfunction
Delayed graft function Recurrent disease



  • Immunosuppressive drugs are started in the operative room with thymoglobulin (2 mg/kg) and methylprednisolone (500 mg) to suppress the immune system from rejecting the donor kidney.
  • Thymoglobulin (2 mg/kg) is given on postop day 1 and 2 to complete a total dose of 6 mg/kg. Steroids are tapered and withdrawn after 3 days. In high risk patients the steroid is tapered and maintained for at least 1 year. Note that a number of transplant programs utilize non‐depleting antibody induction in the form of basiliximab 20 mg IV intraoperatively and on postop day 4.
  • Tacrolimus and MMF are started on postop day 1.

Graft survival

  • One year survival (living donor): 99%.
  • Three year survival (living donor): 91%.
  • One year survival (deceased donor): 88%.
  • Three year survival (deceased donor): 77%.

Pancreas transplantation


  • Since the first pancreas transplant performed in 1967, there have been over 1200 pancreas transplants performed annually in the USA.
  • In most cases, pancreas transplantation is performed in the setting of type 1 diabetes and ESRD.
  • The three main types of pancreas transplantation are:

    • Simultaneous pancreas–kidney (SPK) transplantation (Figure 40.3), where the pancreas and kidney are transplanted from the same deceased donor. Performed in two‐thirds of cases.
    • Pancreas after kidney (PAK) transplantation, where the deceased donor pancreas transplant is performed after a living or deceased donor kidney transplant.
    • Pancreas transplant alone (PTA) (type 1 diabetic patient with adequate renal function).
    • Significant improvements in surgical techniques, organ preservation, and anti‐rejection protocols have made pancreas transplantation an effective therapy for some diabetic patients, and serves to enhance their quality of life and long‐term survival.

Indications and contraindications

  • In the majority of, cases, pancreas transplantation is performed in individuals with type 1 diabetes with ESRD and associated complications, such as uremia, retinopathy, progressive neuropathy, and hypoglycemic unawareness.
  • Living donor pancreas transplantation represents only 0.5% of pancreas transplants performed. Long‐term benefits to the recipient must be balanced against both short and long term risks to donors/recipients before this procedure can be advocated.

Acceptance criteria for pancreas transplantation at Mount Sinai Medical Center

  • Patient on insulin with C peptide value ≤2 ng/mL.
  • Patient on insulin with a C peptide ≥2 ng/mL and a BMI less than or equal to the Organ Procurement Transplantation Network (OPTN) maximum allowable BMI (currently 28).
  • Insulin requirement 0.5 U/kg/day if on dialysis and 0.7 U/kg/day if not on dialysis.
  • Pancreas transplant alone indicated for documented frequent and life‐threatening hypoglycemic unawareness and preserved renal function (Cr clearance >70).


  • Absolute contraindications to pancreatic transplant include untreated infection at the time of transplant, chronic illness with life expectancy of less than 1 year, and active substance abuse.
  • Relative contraindications are those which require careful evaluation and possible therapy prior to transplant. These include cirrhosis of the liver (clinical or pathologic diagnosis) and HIV infection (unless the individual is on appropriate medications, has an undetectable viral load, does not have AIDS‐related complications, and has a CD4 >200).
  • Other contraindications include advanced COPD, severe coronary artery disease, severe congestive heart failure with ejection fraction <20%, and active or recent malignancy (other than superficial skin cancers).
  • The candidacy and waiting time for clearance will be discussed on a case‐by‐case basis for the following conditions: proven habitual medical non‐compliance, uncontrolled psychiatric condition, active systemic lupus requiring more than 10 mg/day prednisone, lack of cognitive capacity to make informed decisions, understand procedure, and sign the consent, obesity (where the benefits of transplantation do not outweigh the risks of the procedure), severe peripheral vascular disease, and severe cerebrovascular disease.

Guidelines for acceptance of deceased donor pancreas at Mount Sinai Medical Center

  • Donor age <50 years.
  • Donor BMI <30.
  • There should be no history of active alcohol abuse.
  • Total cold ischemia time should be less than 24 hours.
  • Preservation of intact pancreato‐duodenal arterial arcade, splenic artery, and superior mesenteric artery.

Pancreas donor grading system

  • Usable: absence of edema, nodularity, and fatty infiltrate.
  • Usable in most cases: mild disease, fat infiltrate <20%, mild nodularity but soft, mild edema.
  • Not usable: any of the following factors – fat infiltrate >20%, firm, significant nodularity, significant edema.


Categories of pancreas transplant (Table 40.2)

Techniques of exocrine and venous drainage (Tables 40.3 and 40.4)


  • Pancreas transplant (SPK/PTA) immunosuppression starts with induction protocol of methylprednisolone (10 mg/kg) and thymoglobulin (2 mg/kg; total dose 6 mg/kg) intra‐operatively. Methylprednisolone will be switched to prednisone postoperatively and tapered for at least a year in the majority of cases.
  • Intravenous immunoglobulin (IVIg) is indicated for patients with either positive CDC or positive T‐cell/B‐cell flow cytometry cross match as well as patients with donor‐specific anti‐HLA antibodies. IVIg is given at 1000 mg/kg starting 2 hours before transplantation, 500 mg/kg on postop day 1, and 500 mg/kg on postop day 2.
  • The most common regimen used for maintenance immunosuppression includes tacrolimus and MMF as triple therapy in conjunction with prednisone. Steroids may be discontinued after a year in selected patients with a low risk of rejection and stable graft function.

Table 40.2 Advantages and disadvantages of the different types of pancreas transplant.

Category Advantage Disadvantage
Simultaneous kidney‐pancreas transplant (SPK) Rejection can be monitored by transplant kidney function
Immunosuppresion already needed for kidney transplant
Better quality of life
Longer waiting list than pancreas transplant with living donor kidney transplant
Increased risk of surgery than kidney transplant alone
Pancreas transplant alone (PTA) Better quality of life Rejection should be monitored
Life‐long immunosuppression
Risk of peri‐operative morbidity
Pancreas after kidney transplant (PAK) Better quality of life
Immunosuppression already started for previous kidney transplant
Rejection should be monitored
Risk of peri‐operative morbidity
Simultaneous deceased donor pancreas and living donor kidney Shorter waiting time
Immunosuppression already needed for kidney transplant
Rejection should be monitored
Increased risk of surgery than kidney transplant alone
Islet cell transplant No need for surgery Lower success rate (insulin independence)
Multiple injections may be needed

Table 40.3 Exocrine drainage.

Type of duct management Advantage Disadvantage
Bladder drainage Urinary amylase can be used to monitor for rejection
Easier access to pancreas graft for biopsy
Urinary complications (UTI, urethritis, cystitis, hematuria, prostatitis)
Metabolic acidosis, dehydration, and electrolyte imbalance
Enteric drainage (ED) No urinary complications
More physiologic
Loss of urinary amylase to monitor rejection
Need percutaneous, laparoscopic, or open biopsy to exclude rejection
Leak has higher morbidity
ED with Roux‐en‐Y venting jejunostomy Endoscopic surveillance and biopsy for pancreas rejection
No urinary complication
Extra‐abdominal ostomy
Leak has higher morbidity
ED with gastro‐jejunostomy Endoscopic surveilance and biopsy for pancreas rejection
No urinary complications
Leak has higher morbidity
ED with duodeno‐duodenostomy Endoscopic surveillance and biopsy for pancreas rejection
No urinary complications
Leak has higher morbidity

Table 40.4 Venous drainage.

Type of venous drainage Technique Advantage Disadvantage
Systemic drainage Graft portal vein anastomosed to the recipient inferior vena cava or external iliac vein Easier technique
Lower rate of graft thrombosis due to high flow systemic system
Not physiologic
Long‐term dyslipidemia
Portal drainage Graft portal vein anastomosed to the recipient superior mesenteric vein Physiologic More difficult technique
Higher rate of graft thrombosis due to low flow portal system


Early complications Late complications
Thrombosis Urinary tract infections/hematuria
Hemorrhage Sterile cystitis, urethritis, balanitis
Reperfusion pancreatitis Metabolic acidosis
Peripancreatic abscess Reflux pancreatitis
GI bleeding or hematuria Arterial stenosis (Y graft or native iliac)
Leak (bladder or bowel) Rejection related

Complication of biopsy

Arterial fistulae


Procedure 1 year survival 5 year survival
SPK 86% 74%
PAK 79% 62%
PTA 74% 51%

Small bowel and multivisceral transplantation


  • The first case of human bowel transplantation was reported in 1967. The first multivisceral transplantation performed in the USA was in 1987.
  • Small bowel transplantation (SBT) is one of the most technically challenging procedures and the least commonly performed solid organ transplantation procedure worldwide.
  • SBT can be done as an isolated procedure (47%), combined small bowel/liver (27%), or small bowel/liver combined with other organs, including stomach, pancreas, or kidney (multivisceral transplantation).
  • Current survival rates of intestinal transplantation have improved significantly and are similar to other organ transplants.

Indications in adults

  • Intestinal transplant (Figure 40.4) is a therapeutic option for patients with intestinal failure, defined as the inability to maintain sufficient electrolyte nutrient and fluid balance for >1 month without TPN.
  • Indications for transplantation include intestinal failure and one of the life‐threatening complications of parenteral nutrition. These include loss of venous access (thrombosis of two or more central venous access sites), recurrent life‐threatening catheter‐associated bloodstream infections, frequent episodes of severe dehydration despite TPN and IV fluid supplementation, and the development of intestinal failure‐associated liver disease.

Techniques (Table 40.5)

Table 40.5 Intestinal transplant procedures.

Isolated intestinal graft Liver and intestine Multivisceral
Indication Intestinal failure
Catheter‐related infections
Poor venous access
Moderate hepatic dysfunction
Severe fluid and electrolyte imbalance that cannot be managed with TPN
Intestinal failure
Irreversible hepatic failure or coagulopathy
Following extensive surgical resection of abdominal organs for aggressive tumor or severe abdominal trauma
Venous outflow Portal vein (into IVC or portal vein) Suprahepatic IVC (hepatic piggyback anastomosis) Suprahepatic IVC (hepatic piggyback anastomosis)
Arterial inflow Superior mesenteric artery Celiac and superior mesenteric artery Celiac and superior mesentenric artery
Biliary reconstruction No need Roux‐en‐Y hepatico‐jejunostomy (no need if graft includes pancreas) No need (Roux‐en‐Y if graft does not include liver)
Proximal GI tract Jejuno‐jenunostomy Jejuno‐jenunostomy Esophago‐ or gastro‐gastrostomy
Distal GI tract Ileocolostomy with various type of stoma (loop, Mikulicz, Bishop–Koop) Ileocolostomy with various type of stoma (loop, Mikulicz, Bishop–Koop) Ileocolostomy with various type of stoma (loop, Mikulicz, Bishop–Koop)


  • SBT induction immunosuppression starts in the operating room with high dose methylprednisolone (20 mg/kg), and prednisone will be continued at least for a year in a tapering fashion.
  • Thymoglobulin (2 mg/kg) is also infused as an induction agent in the operating room and will be repeated for two more doses to achieve a total amount of 6 mg/kg.
  • Maintenance immunosuppression begins on postop day 1, with tacrolimus for life.


  • Early complications of SBT are mostly surgical. Anastomosis leak with intra‐abdominal infection, graft vessel thrombosis, and bleeding are not uncommon and necessitate surgical exploration.
  • Intermediate to late complications include rejection, bacterial and viral infection (EBV, CMV, adenovirus), GVHD, and post‐transplant lymphoproliferative disorder.
  • Rejection is the most common cause of graft loss and requires immediate biopsy when suspicion arises and treatment.
  • Post‐transplant lymphoproliferative disorder can manifest between 2 weeks and 6 months after transplantation. Depending on the clinical status, treatment can range from reducing/discontinuing immunosuppression to chemoradiotherapy.


  • One year survival after isolated intestinal transplantation is 79%.

Reading list

  1. Fishbein TM. Intestinal transplantation. N Engl J Med 2009; 361:998–1008.
  2. Kidney Disease: Improving Global Outcomes (KIDGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant Recipients. Am J Transplant 2009; 9:S131–55.
  3. Martin P, et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology 2014; 59:1144.
  4. Robertson RP, et al. Pancreas and islet transplantation in diabetes mellitus. Diabetes Care 2006; 29:935.


Schematic illustration of standard liver transplantation technique with caval replacement.

Figure 40.1 Standard liver transplantation technique with caval replacement.

Schematic illustration of piggyback technique in liver transplantation.

Figure 40.2 Piggyback technique in liver transplantation.

Schematic illustration of simultaneous pancreas–kidney transplantation.

Figure 40.3 Simultaneous pancreas–kidney transplantation.

Schematic illustration of intestinal transplant.

Figure 40.4 Intestinal transplant.

Nov 20, 2022 | Posted by in ANESTHESIA | Comments Off on 40: Abdominal Organ Transplantation
Premium Wordpress Themes by UFO Themes