Introduction: Despite improvement in short term outcomes, rejection remains a main cause of graft and patient loss in intestinal transplant. A temporary ostomy to assess the intestinal mucosa and easily perform a biopsy is still the standard of care. Decompression of the distal anastomosis may be another reason to create an ostomy. However, patients with an ostomy frequently present with dehydration and lower quality of life. In addition, given the mucosa is exposed to air, a change in the intestinal flora may occur, potentially triggering rejection.

Methods: We reviewed our experience with 15 patients undergoing a multivisceral transplant with primary anastomosis without an ostomy.

Results: Fifteen patients were transplanted without an ostomy. Nine patients were adults (60%). Average age for adults was 47 years (24.5-61.2) and for children 2.5 years (1.28-4.17). The mean follow-up was 232 days (24-473). A colonoscopy was performed within 90 days of transplant but never before day 14. The mean postoperative day for colonoscopy was 28 days (14-90). Three patients have not yet had a colonoscopy. One adult patient had mild rejection, recovering completely after steroid cycle. Another adult patient had a complicated postoperative course with multiple intra-abdominal infections as well as severe rejection succumbing on postoperative day 79. One pediatric patient developed severe rejection complicated by enteric strictures and is currently home on TPN. One adult patient suffered a colonic perforation during colonoscopy requiring surgical intervention; loop ileostomy was subsequently performed to protect the new anastomosis. One pediatric patient presented with primary EBV infection with complete resolution after treatment. No patients had CMV infection. Two adult patients had GVHD, of which one died. Overall survival for this series is 87% (13/15), with survival 78% for adults (7/9) and 100% for children (6/6). With exception of one pediatric patient, all the others (12/13) have complete enteral autonomy and do not require any additional IV fluids for hydration.

Conclusion: Our initial experience with multivisceral transplant without an ostomy has proven to be feasible and safe. Postoperative management seems to be easier with decreased frequency of dehydration, readmissions and infections in addition to higher patient satisfaction. Perforation of the colon is a potential complication of early colonoscopy.

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