Mass homotransplantation of abdominal organs was introduced by Dr Starzl in 1960 as a model for the study of the physiology of the denervated graft. It was the beginning of the “cluster” concept according to which the abdominal organs are like the clumps of a cluster. They can be used as composite or solitary grafts.

Clinical attempts started in the mid 80s, the first series of such Transplants was started in the early 90s. Now we are able to analyze their use and long term results.

Almost 20 years after after transplantation, more than 1/3 of the pediatric and about 25% of the adult patients are alive.

Short term survival improved overtime, all surviving patients are independent of intravenous treatments except patients who lost or are losing their grafts.

Their BMI on oral nutrition is normal or nearly normal.

Still, patients and grafts, alive and well at 5 years, have a high rate of attrition on further follow up.

In an elegant study Dr. Kareem AbuElmagd showed that there were 2 major risk factors: the absence of the liver from the graft, which was expected and then something we all suspected but were never able to prove: the lack of social support. Indeed the lack of social support had just as much an impact as the liver!

Long term survivors had lots of problems: hearing loss, developmental delay, depression, substance abuse, impaired cognitive functions.

Nevertheless, most patients completed education, 84% maintained marital status, 75% were appropriately employed.

Other Composite abdominal transplants have been byproducts of the clusters and have two main advantages:

A technical: there are only 2, large vascular anastomoses, the abdominal Aorta and Inferior Vena Cava and an immunologic: protective effect of the liver.

Disadvantage is that one has to consider the 3 dimentional fit of the composite grafts before implantation to avoid technical imperfections.

En block Liver Kidney transplants is such a variant, we had done 9 such transplants in Miami with my associate, Dr. Akin Tekin.

All patients were children, 8 of 9 suffered from congenital hepatic fibrosis and autosomal recessive polycystic kidney disease, one from hyperoxaluria.

All are alive with functioning grafts except one who died of rejection due to non compliance

A variant of this procedure is the combined Liver, pancreas and K Tx for Wolcott Rallison Syndrome. This is a rare genetic disorder caused by mutations in the gene which controls protein unfolding. It is the most common cause of neonatal diabetes. Death usually occurs in childhood from fulminant liver and kidney failure. We have performed one such successful case which, for the first time, resulted in control of the syndrome. The child is alive and has been well for almost 2 years following the transplant**

The composite abdominal wall transplants have been byproducts of the cluster transplants.

Initially presented in 2003, the blood supply was through the inferior epigastric arteries, anastomoses through the iliac vessels of the donor which were anastomosed onto the lower abdominal vessels of the recipient.
It is pretty adaptable and can cover practically any abdominal wall defect. The same, or a different, compatible donor can be used, at the same or subsequent surgical session.

In Miami we did a total of 10 such grafts.

Other programs have used a variant with microvascular anastomoses.

And then: the Intestinal/multivisceral autotransplants, designed to treat otherwise unresectable lesions of the route of the mesentery, as desmoid tumors and severe vascular malformations. Usually, the head of the pancreas is removed en block with the intestine, the pathology is resected in the bloodless field of the back table as well as any vascular reconstructions. Then the graft is reimplanted.

In our series of Ten patients, four children and six adults, who underwent these procedures since January 1999, * 7 patients are alive up to 13 years later, 6 with functioning autografts; one had to be rescued with an allotransplant.

UTx is a procedure devised for the treatment of uterine infertility which is a very common problem. It is due to to congenital absence, as in the Rokitansky syndrome, surgical resection or damage from abortions or infections.

At the moment, there are 2 options for these women: adoption and surrogacy. They are good for many. The reason uterine transplants are needed is because it is impossible for many others.

UTx just like face, extremity and other composite tissue transplants is not a vital transplant.

Unlike any other transplant performed till now, it is an ephemeral transplant: the first transplant not intended to last for the duration of the patient’s life but only till the delivery of one or more healthy offspring. After that time, the immunosuppression is stopped and the graft left to reject or removed.

Three lives are at risk: the mother, the donor and the offspring. One has to be sure that they are protected.

Ideally, the procedures involved are tested in animals with anatomy and physiology like the humans and only then applied clinically.

It’s for a fact that the anatomy and physiology of reproduction is species specific. The closest one can get are the non human primates.

Non human primates have anatomy and physiology that is closest to human, techniques used are directly applicable to humans. But there are problems with them:

The number of experiments that can be performed with primates is very limited. There are emotional difficulties due to their humanoid features and their use is very restricted. They are also very expensive.

Long term Immunosuppression is notoriously difficult in baboons, which are the most accessible non human primates. They are also subject to TB and Simian CMV.

Male baboons have frequently low sperm counts.

IVF is tenuous. So, one can only go so far with Baboons.

For these reasons data have accumulated by pasting together findings from different species.

*The group of the U Gothenburg, Sweden led by Dr. Mats Brannstrom, has the most extensive experience. They showed in small animals that transplantation of the vascularized uterus can be performed safely. The graft can tolerate cold ischemia, can become pregnant and deliver offspring not different than controls. They also showed that autotransplantation in baboons is safe, information which is directly transferable to a living donor situation.

We performed UTx on mini swine. We used a heterotopic location and exteriorized the graft.

This allowed us to perform numerous hysteroscopies and study rejection and its treatment.

We showed the safety of donor and recipient procedures and that longterm survival can be achieved in these animals.

We had the opportunity to collaborate with the Swedish group which has included Dr. Michael Olausson for the past several years. Together we performed U allografts in baboons in a procedure mimicking deceased donor UTx and showed its safety and longterm survival.

Other groups showed that healthy offspring can be delivered from allografts in sheep and autograft in baboon.

There have been 11 clinical cases:
First case in SA from a living donor 13 years ago, without any experimental preparation, the graft had to be explanted 3 months postoperatively.

Second case in 2011 in Antalya, Turkey, from a deceased donor, again without any experimental preparation. The graft is intact, without evidence of rejection. Attempted IVFs have not been successful as yet.

Then there has been a series of 9 Transplants from living donors at the U Gothenburg by a team led by Profs Brannstrom and Olausson which I was privileged to attend.

This is very exciting times because, at this moment the team is preparing the first patients for IVF, scheduled to start 1 year after the transplant.

A successful outcome will be hope to many women who’s desire to bear a child is unfulfilled due to Uterine Infertility.