Transplant surgeons perform multivisceral transplant to treat children with two failing abdominal organs such as liver failure and intestine failure. The procedure is a simultaneous transplant of multiple organs, including the liver, small intestine, pancreas and, often, the stomach and part of the large intestine.
Multivisceral transplant is used to treat:
- Liver damage or liver injury from long-term parenteral nutrition (IV feeding), which is often used for patients with intestinal failure
- Severe abdominal injury from trauma
- Neuroendocrine tumors that start in the pancreas and intestine and spread to the liver (in some cases, a multivisceral transplant can cure the cancer)
Multivisceral transplant is a major operation and often a last resort for very sick children. Outcomes are positive and often better than intestine transplant. This is because all of the donated organs and blood supply come from the same donor, so the liver can protect the intestine from rejection.
A multivisceral transplant includes removing the damaged organs and replacing them with donor organs and their associated blood supply. The operation takes between eight to 12 hours to perform.
The specially trained transplant surgeons at IU Health Transplant at Riley Children’s Health carefully evaluate children to determine if a multivisceral transplant can improve their quality of life. Your child’s current health is a primary factor in the evaluation, which is similar to the process for intestine transplant and liver transplant.
Your child’s surgeon will order extensive medical testing such as:
- Medical history and physical exam. The surgeon will obtain a full medical history and perform a physical exam to learn everything about your child's overall health.
- Blood tests. The surgeon will conduct blood tests to assess liver function, rule out other causes of liver disease and find out if your child has a virus that may complicate a liver transplant. Some of the blood tests the surgeon may perform during a transplant evaluation include a chemistry panel, kidney function tests, a blood typing and antibody screen and tests to check for infectious diseases such as human immunodeficiency virus. Liver function tests that may be performed include:
- Albumin blood test. The amount of albumin protein in the blood tells how well the liver makes protein.
- Bilirubin panel. Elevated levels of bilirubin in the blood show the liver is not working well or bile flow from the liver is blocked.
- Coagulation tests. A coagulation test (blood-clotting study) measures the liver’s ability to make the proteins that help the blood clot. It can also indicate a vitamin K deficiency, which can be caused by liver disease.
- Liver enzyme test. Elevated levels of liver enzymes in the blood indicate injury to liver cells and can reflect problems with the bile ducts.
- Autoimmune liver disease blood tests. The surgeon may perform numerous blood tests to check for specific antibodies associated with a variety of autoimmune liver diseases.
- Metabolic liver disease blood tests. Various blood tests can measure the levels of proteins, fatty acids and minerals in the blood to check for specific metabolic malfunctions.
- Viral hepatitis blood tests. The surgeon may check for the presence of different viruses, antibodies and infections related to hepatitis A, hepatitis B and hepatitis C.
- Ultrasound. Your child's surgeon may order an abdominal ultrasound to evaluate the liver and connecting blood vessels.
- X-ray. The surgeon also may order an X-ray to evaluate the liver and connecting blood vessels and the intestines. The size and position of the lungs also will be noted to help ensure the donated liver is properly sized.
- Echocardiogram. An echocardiogram (a test that uses sound waves to produce images of the heart) may be performed to evaluate the heart’s function and strength prior to transplant surgery.
- Motility tests. These tests examine how well food moves through the gastrointestinal system.
- Imaging tests. Other imaging tests that may be performed include:
Your child’s surgeon will also have you meet with a transplant social worker to ensure a strong family support system is available to help you provide the care and assistance your child will need at home after the transplant.
If the medical evaluation shows a multivisceral transplant is the best treatment option, your child will be placed on the national transplant waiting list. There is only one list managed by the United Network for Organ Sharing.
Waiting for donated organs to become available can be stressful. To help during this waiting period, your family can use the time to learn as much as you can about the transplant procedure and the care your child will need when he or she returns home.
The transplant team at Riley at IU Health will work with you to get your family ready. The team includes pediatric specialists in transplant surgery, gastroenterology, hepatology, radiology, pathology, pharmacy, and social work. Your child's transplant team also will include a transplant nurse coordinator and a dietitian. You will meet regularly with the transplant nurse coordinator who will work with you to ensure the best care and recovery for your child before and after the transplant.
Your meetings with the transplant team will address any questions you may have such as:
- The medical regimen your child will need before and after surgery
- Your child’s surgery and recovery
- Your child's nutritional requirements before and after transplant
- Additional services such as financial assistance and home care
Donated organs work best when they are transplanted as soon as possible. You can expect the transplant team to notify you to come to the hospital right away once donated organs that are a match for your child become available.
What to Expect
What to Expect
You can expect the following prior to your child’s multivisceral transplant:
- Your child’s surgeon and transplant nurse coordinator will outline the required medical regimen of daily medicines, frequent lab tests and regular medical visits.
- It is important for you to be fully engaged in your child’s care. The transplant team will watch this closely as it shows how well you can care for your child after the multivisceral transplant.
- The surgeon will give you instructions on how to keep your child as healthy as possible prior to the transplant.
- You must optimize your child’s nutrition with guidance from his or her surgeon.
- Your child’s surgeon will provide instructions for physical fitness, including exercise and physical therapy as needed.
You can expect the following on the day of your child’s multivisceral transplant:
- You will need to follow the surgeon's instructions if your child is receiving gastrointestinal tube or parenteral (IV) feedings.
- When you arrive at the hospital, your child’s surgeon will explain the transplant procedure to you and answer any remaining questions.
- You will be asked to read and sign a consent form for your child’s surgery. Be sure to review this document carefully and ask any questions you may have about the form.
- Your child will change into a hospital gown in a private room.
- After your child has changed, the surgery team will prepare him or her for surgery. Procedural sedation may be used to help your child relax.
- Your child will have an IV line inserted into his or her arm or hand. Additional catheters may be placed in your child’s neck and wrist to monitor heart and blood pressure.
- Just before surgery, an anesthesiologist will administer surgical anesthesia. You may stay with your child until right before he or she is taken into the operating room.
- A tube will be inserted through the mouth and into your child’s lungs to help him or her breath with the help of a ventilator during surgery.
- A catheter will be inserted into the bladder to monitor urine output.
- The anesthesiologist will constantly monitor your child’s heart rate, blood pressure, breathing and blood oxygen level during the surgery.
- The surgical team will sanitize the incision site with an antiseptic solution.
- The surgeon will make an incision, and the damaged organs will be removed.
- Once the surgeon has placed the new organs into the abdomen, he or she will create new connections to blood vessels and bile ducts.
- Most transplanted livers immediately begin to maintain metabolism, create proteins and produce and drain bile. Other organs such as the intestines take longer to begin working.
- After all vascular and bile duct connections are made, the surgeon may insert tubes to drain fluid from the surgical site.
- The surgeon will close the incision and cover the wound with a sterile dressing.
You can expect the following immediately after surgery:
- After surgery, your child will be moved to a recovery room in the pediatric intensive care unit (PICU).
- A nurse will closely monitor your child’s vital signs.
- Pain medicine will be given to keep your child comfortable.
- Immunosuppressive (anti-rejection) medicines are given in large doses at the time of surgery to prevent rejection of the transplanted organs. These medicines include:
- Calcineurin inhibitors such as tacrolimus and cyclosporine which stop the action of the protein calcineurin which activates T-cells in the immune system
- Intravenous corticosteroids such as methylprednisolone which prevent inflammation and graft-versus-host disease
- IV antibodies to initially suppress the immune system (“induction”)
- Your child will likely remain on a ventilator for one to two days.
- He or she will stay in the PICU for a few days or longer depending on how sick he or she is after the transplant.
- The nurse will draw blood frequently to check liver function, and sometimes ultrasounds will be done to check the blood vessels.
- Your child's surgeon will take biopsies to check intestine function and look for signs of rejection.
- Your child will remain in the hospital for one month or longer.
- The transplant team will evaluate your child’s condition every day to make sure the new organs are functioning correctly. They will monitor your child for signs of complications such as transplant rejection, infection, bleeding, high or low blood pressure and problems with kidney function.
- Gradually, your child will be able to eat soft foods by mouth followed by a regular diet.
- The transition to a regular diet can take two to three weeks to complete.
- Your child will be encouraged to sit up and walk around his or her room as soon as he or she is able.
- A specially trained nurse may perform coughing and deep breathing exercises with your child to prevent fluid buildup in the lungs.
- Your child's care team will provide follow-up care instructions prior to discharge, including medicine instructions and proper exercise and nutrition routines. The team will also provide information on how to recognize the symptoms of transplant rejection. It is important that you follow these instructions and contact the surgeon if there are any signs of transplant rejection.
Below are some additional guidelines for when you return home:
- Your child will take anti-rejection and immunosuppressive medicines for life.
- The procedure does carry risks for graft-versus-host disease and lymphoma.
- Encourage your child to walk. The activity can help restore strength and maintain lung function.
- Eating a healthy diet will give your child needed calories for recovery and health.
- Frequent follow-up visits are required to monitor the function of the new organs and check for any complications.
- Over time, the frequency of follow-up visits will decrease.
Multivisceral transplant surgery is complex and recovery can have its ups and downs, but over time, your child will be able to return to school and regular activities.
The five-year survival rate for multivisceral transplant is 60 percent. At 10 years, the survival rate is 50 percent.
Key Points to Remember
Key Points to Remember
- Surgeons perform multivisceral transplant to treat children with two failing abdominal organs such as liver failure and intestine failure.
- A surgeon with IU Health Transplant at Riley Children’s Health will carefully evaluate your child to determine if a multivisceral transplant can improve his or her quality of life.
- Your child’s surgeon will also have you meet with a transplant social worker to ensure a strong family support system is available to help you provide the care and assistance your child will need at home after the transplant.
- Your child will remain in the hospital for a month or two after transplant surgery.
- Multivisceral transplant surgery is complex and recovery can have its ups and downs, but over time, your child will be able to return to school and regular activities.
In addition to our primary hospital location at the Academic Health Center in Indianapolis, IN, we have convenient locations to better serve our communities throughout the state.