Visceral transplantation is indicated for the patients with (1) irreversible and permanent intestinal failure, and (2) presence or onset of life-threatening complications from TPN.

The onset of liver disease or central venous catheter-related complications such as recurrent or potentially fatal sepsis/fungemia and loss of venous access sites are life-threatening complications from TPN, as well as Medicare-approved criteria for visceral transplantation. Preemptive visceral transplantation (before the patient develops TPN-related complications) is still a controversial issue, as it has not been approved by Medicare or most insurance carriers [1, 2]. In addition to the indications above, patients with liver cirrhosis and mesoportal thrombosis (Group 3) are indicated for liver/intestine or full multivisceral transplantation.

Contraindications to visceral transplantation are similar to those for transplantation of other solid organs due to malignancy, severe systemic disease, etc. They may be even more absolute because of the considerable morbidity and mortality following this procedure. Thus, patients with multiple severe congenital anomalies, recent extra-abdominal malignancy, or severe neurologic disability are not appropriate candidates for transplantation. Recent line infections could be a frequent dilemma for visceral transplant patients. However, the patient can undergo transplantation if a line infection is treated at least for a few days, and the patient is not bacteremic at the time of the procedure. Multisystem autoimmune diseases such as scleroderma and severe immune deficiencies are also relative contraindications to visceral transplantation [1–3].

Patients frequently suffer subclinical cerebrovascular events, especially in the setting of hypotension, due to sepsis and ischemic bowel or systemic atherosclerosis. Therefore, our program performs a routine head computerized tomography (CT) scan at the time of outpatient evaluation. Anti-epilepsy drugs need to be checked prior to transplantation since many of them interact with tacrolimus (Prograf). Pretransplant consultation with the neurology service and switching anti-seizure medication to levetiracetam (Keppra) should be considered.

Many Group 1 and 2 patients have received numerous surgeries. Some of them undergo 20–30 surgeries prior to coming to a transplant center. Many may have depression and anxiety disorders. Evaluation of patients by a designated psychiatrist who is familiar with intestinal failure and transplantation is essential. It is also not uncommon that patients use narcotics regularly for chronic abdominal pain and have high narcotic tolerance, factors which are extremely challenging in the perioperative setting. Preoperative evaluation by a chronic pain specialist to reduce narcotic use using alternative techniques is important. We prefer transdermal pain management while patients are on the waiting list. This facilitates establishment of a perioperative game plan.