'Domino' Liver Transplantation Combined With Multivisceral Transplantation Andreas G. Tzakis, MD; Jose R. Nery, MD; Jeffrey B. Raskin, MD; Deborah Weppler, MSN; M. Farrukh Khan, MD; Georgios P. Fragulidis, MD; Phillip Ruiz, MD, PhD; K. Rajender Reddy, MD Transplantation of the liver contemporaneously with another organ from the same do- nor is thought to confer an immunologic advantage.1,2 The latter is particularly desir- able in intestinal transplantation because of the propensity of the intestinal graft to early and late rejections and because in some cases it may facilitate the operation. In clinical practice, shortage of liver grafts constrains liver transplantation to cases in which there is coexisting end stage liver disease. We describe a technique in which the liver is included in a multivisceral graft and the resected liver is used for another needy pa- tient. To our knowledge, this is the first such report. PATIENTS Recipient of the Multivisceral Graft (RMVG) A 17-year-old white girl with neurogenic intestinal pseudo-obstruction was re- ferred to us for total abdominal gut trans- plantation. The disease had been diag- nosed at 12 years of age and included all intra-abdominal hollow organs. The pa- tient was unable to be fed enterally and was dependent on total parenteral nutrition for survival. Symptoms included vomiting, bloating, and persistent severe abdomi¬ nal pain. Attempted treatments consist¬ ing of gastric and small-bowel decompres¬ sion and narcotic epidural and celiac blockade were unsuccessful. Liver func¬ tion was normal. She was placed on the transplant list for abdominal multivis¬ ceral transplantation, excluding the liver. A search began for a cytomegalovirus- negative donor of the same blood type (type B) and of similar size (64 kg). Recipient of the Liver Graft A 46-year-old white woman of the same blood type (type B) and of similar size (70 kg) was hospitalized in liver failure await¬ ing liver retransplantation. The patient's relevant history started with a gun shot wound to the liver. Initial surgery was a hepatorrhaphy and duodenorrhaphy. Two years later she developed biliary stric¬ tures requiring choledochoduodenos- tomy. Her course was complicated by the development of arterioportal fistula and he- mobilia. Attempts at control with mul¬ tiple arterial embolizations, surgical ex¬ plorations, and hepatic resections failed and she subsequently developed portal vein thrombosis. The patient underwent liver transplantation that was technically difficult and required resection of the first part of the duodenum and Billroth opera¬ tion II. After initial recovery, the patient returned to the hospital 10 months later with liver graft failure (owing to hepatic artery thrombosis), jaundice, encepha¬ lopathy (ammonia 55), and coagulopa- thy (prothrombin time, 32.2; partial thromboplastin time, 48). An urgent search for a donor started. The Donor A 10-year-old, weighing 18 kg, cytomega- lovirus seronegative, of the same blood type (type B) as both recipients, and a vic¬ tim of anoxia from hanging (no signifi¬ cant medical or surgical history), was of- From the Department of Surgery, Division of Transplantation, and the Department of Medicine, Division of Gastroenterology (Drs Tzakis, Nery, and Raskin), the Department of Pathology, Division of Immunopathology (Ms Weppler and Drs Khan, Fragulidis, and Ruiz), and the Department of Medicine, Division of Hepatology (Dr Reddy), University of Miami, Miami, Fla. Downloaded From: http://archsurg.jamanetwork.com/ by a University of Iowa User on 06/18/2015