The Miami Experience With Almost 100 Multivisceral Transplants A.G. Tzakis, T. Kato, S. Nishida, D.M. Levi, W. DeFaria, G. Selvaggi, D. Weppler, J. Moon, J.R. Madariaga, A.I. David, J.J. Gaynor, J. Thompson, E. Hernandez, S. Tuteja, P. Tryphonopoulos, and P. Ruiz ABSTRACT We report our experience with 98 patients who received primary multivisceral transplan- tations. Three eras can be distinguished based on the evolution of technique, immuno- suppression, and monitoring: August 1994 to December 1997 (first era); January 1998 to December 2000 (second era); and January 2001 to present (third era). Sixteen patients were transplanted during the first era, 18 during the second era, and 64 during the third era. Fifty-three patients are alive with a median follow-up of 37.5 months (range: 1 to 116 months). The leading cause of mortality was infection (n = 17), followed by rejection (n = 6). Seven patients required retransplantation and five of them subsequently died. The estimated 3-year survival was 25%  11% for era 1; 44%  12% for era 2; and 58%  7% for era 3. Additionally, 45.3% (29/64) of patients in the third era never developed rejection versus 23.5% (8/34) of patients in the first two eras combined. The percentage of patients who developed a moderate or severe rejection was significantly less in the third era compared with the first two eras combined, 31.6% (20/64) versus 67.6% (23/34). A comparison of the hazard rate of developing severe rejection showed a protective effect of the multivisceral graft (P = .0001). In conclusion, multivisceral transplantation is indicated for patients with short bowel syndrome and extended abdominal catastrophies. Evolution in surgical techniques, immunosuppression, and monitoring have improved patient survival, which is now similar to that of other complex solid organ transplants. M ultivisceral transplantation is the simultaneous trans- plantation of the stomach, pancreaticoduodenal complex, and intestine with (MVTx) or without (modified multivisceral, MMVTx) the liver. METHODS Herein we have presented all patients who received primary MVTxs in our program. Three eras were distinguished based on the evolution of technique, immunosuppression, and monitoring: August 1994 to December 1997 (first era); January 1998 to Decem- ber 2000 (second era); and January 2001 to present (third era). Maintenance immunosuppression was based on tacrolimus (Pro- graf, Fujisawa Pharmaceuticals, Deerfield, IL, USA). In the first era we aimed at 12-hour trough tacrolimus levels of 15 to 20 ng/mL. When daclizumab (Zenapax, Roche Pharmaceuticals, Nutley, NJ, USA) was used for induction, 1 the target levels were decreased to 10 to 15 ng/mL (second and third eras), and when alemtuzumab (Campath-1H [C1H], Berlex Laboratories, Montville, NJ, USA) was used, 2 they were further decreased to 5 to 10 ng/mL (third era). Steroids (methylprednisolone; Solumedrol, Pharmacia and Upjohn Co, Kalamazoo, MI, USA), were used in all cases except with C1H induction. In the second and third eras, we performed frequent protocol endoscopies and introduced the routine use of the magnify- ing endoscope for all but the smallest recipients (2 years of age). 3 RESULTS One hundred patients received a primary multivisceral transplant (MTX) between December 1994 and April 2005. From the Departments of Surgery (A.G.T., T.K., S.N., D.M.L., W.D., G.S., D.W., J.M., J.R.M., A.I.D., J.J.G., S.T., P.T.), Pediat- rics (J.T.), Medicine (E.H.), and Pathology (P.R.), University of Miami Miller School of Medicine, Miami, Florida, USA. This study was partially supported by NIH grant 1 R03 DK061445-01 A2 and was also presented before the American Surgical Association (Tzakis A, Kato T, Levi D, et al: One hundred cases of multivisceral transplantation. Annals of Surgery, in press) at the 125th Annual Meeting, Palm Beach, Fl, April 14 –16, 2005. Address reprint requests to Andreas G. Tzakis, MD, PhD, Department of Surgery, University of Miami Miller School of Medicine, Highland Professional Building, 1801 NW 9th Ave, Suite 511, Miami, FL 33136. E-mail: atzakis@med.miami.edu © 2006 by Elsevier Inc. All rights reserved. 0041-1345/06/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2006.05.015 Transplantation Proceedings, 38, 1681–1682 (2006) 1681