🧬 Intestinal Transplantation for End-Stage Pseudomyxoma Peritonei: A Radical Frontier

Intestinal transplantation pseudomyxoma peritonei

Yesterday, I had the honor of serving as both moderator and speaker at the Pre-Congress Course of the Brazilian Congress of Surgical Oncology, held at the Windsor Barra Hotel in Rio de Janeiro.
During one of the discussions, a participant asked:

“Where do we stand today with multivisceral transplantation for pseudomyxoma peritonei (PMP)?”

This question brought to mind an extraordinary article mentioned by Dr. Raul Anselmi — the first clinical report of intestinal and multivisceral transplantation for advanced, recurrent, non-resectable PMP, published by Reddy et al. in Annals of Surgery (2022).
The study emerged from a unique collaboration between the Oxford Transplant Centre and the Peritoneal Malignancy Institute in Basingstoke, two of the UK’s leading reference centers in their respective fields.

🔬 Study Overview

Title: First report with medium-term follow-up of intestinal transplantation for advanced and recurrent non-resectable pseudomyxoma peritonei
Authors: Reddy S, Punjala SR, Allan P, Vaidya A, Mohamed F, Dayal S, Moran B, Friend PJ, Cecil T
Institutions: Oxford Transplant Centre & Peritoneal Malignancy Institute (Basingstoke, UK)
Journal: Annals of Surgery – 2022
DOI: 10.1097/SLA.0000000000005769

✳️ Background

For most patients with PMP, cytoreductive surgery (CRS) combined with HIPEC remains the gold standard. Yet a subset develops extensive small-bowel involvement that precludes safe resection — the “end-stage” form of the disease.

These patients typically face nutritional failure, fistulas, progressive abdominal-wall destruction, and dependence on parenteral nutrition (PN). Median survival in this setting is 6–12 months, and palliative options are limited.

The Oxford–Basingstoke group sought to push beyond these limits, combining radical exenteration of all involved viscera with intestinal or multivisceral transplantation, effectively replacing the diseased peritoneo-visceral block.

Intestinal transplantation pseudomyxoma peritonei

🩺 Study Design

Between 2013 and 2022, 15 patients with low-grade or slowly progressive PMP and PCI 30–39 underwent transplant-based exenteration.

Inclusion criteria

• No remaining option for cytoreductive surgery due to diffuse small-bowel involvement
• Absence of distant metastases (confirmed by CT staging)
• Nutritional failure or imminent PN dependence
• Psychological and physical fitness for transplantation (cardiopulmonary + psychiatric evaluation)
• ABO & HLA compatible, CMV-matched donors

⚙️ Surgical Technique

Intestinal transplantation pseudomyxoma peritonei

1️⃣ Explant Phase (Recipient)

Radical exenteration of all involved intra-abdominal organs was performed. Depending on tumor extent, resections included stomach, duodenum, pancreas, small bowel, and colon. In some cases, high-power diathermy liver capsulectomy was used to clear disease from the hepatic surface. Minimal residual disease was left only in critical areas (porta hepatis or diaphragm).

2️⃣ Donor Graft Preparation

• Isolated intestinal transplant (n = 8) – used when upper abdominal organs were spared.
• Modified multivisceral transplant (n = 7) – including stomach, pancreatic-duodenal complex, small bowel, and right colon.
• Vascularized abdominal-wall grafts (n = 7) harvested from the donor (based on inferior epigastric vessels) for extensive wall defects or loss of domain.

3️⃣ Transplant Phase

• Vascular reconstruction: For isolated intestinal grafts — anastomosis between donor and native superior mesenteric vessels. For multivisceral grafts — arterial inflow via a donor aortic segment to recipient infra-renal aorta; venous outflow to the portal vein.
• Abdominal wall closure: Primary closure in 8 patients; vascularized wall or donor fascia grafts in 7 cases to achieve tension-free coverage.

4️⃣ Immunosuppression

• Induction: Methylprednisolone 500 mg + Alemtuzumab 30 mg × 2 doses
• Maintenance: Tacrolimus (target 10–12 ng/mL for 6 months) ± Azathioprine or Mycophenolate + low-dose Prednisone

💥 Was HIPEC Performed?

No. None of the patients received HIPEC at the time of explantation. The authors cite two reasons:

1. Technical & safety concerns — after total visceral exenteration, the risk of anastomotic breakdown and infection was prohibitive.
2. Immunologic considerations — intra-operative chemotherapy could worsen toxicity and compromise graft healing under immunosuppression.

Nevertheless, the team explicitly suggests that future protocols may incorporate HIPEC at the explant stage to improve local disease control once procedural refinements allow.

📊 Key Results

Intestinal transplantation pseudomyxoma peritonei

Despite the high recurrence rate, only one death was directly attributed to tumor progression after 3.5 years — an extraordinary outcome in this context. Most recurrences were indolent, allowing sustained survival and acceptable quality of life.

🧩 Discussion

Intestinal transplantation pseudomyxoma peritonei

This pioneering experience demonstrates that intestinal or multivisceral transplantation can be feasible and worthwhile for a highly selected subset of PMP patients — those for whom no conventional CRS-HIPEC options remain.

The median 5-year survival of 55% far exceeds the historical 6–12-month expectancy for PMP with intestinal failure on PN, and even compares favorably to survival after major oncologic surgeries such as pancreatic cancer resections.

It also underscores that organ-allocation ethics differ: while liver grafts face donor scarcity, intestinal grafts are underused, enabling responsible expansion of indications to select oncologic conditions.

Next steps include early listing (before profound nutritional decline), integration of HIPEC at explant, evaluation in high-grade variants, and standardization of abdominal-wall reconstruction techniques.

🌍 Reflections from the Field

This paper represents more than a surgical innovation — it’s a window into how the Basingstoke team has chosen to face one of the most distressing scenarios in peritoneal oncology: patients with pseudomyxoma peritonei deemed unresectable.

Basingstoke is, today, the highest-volume center for CRS and HIPEC worldwide, performing over 350 procedures per year within the well-structured NHS referral system. Their accumulated experience gives them a unique authority to explore the limits of what’s surgically and ethically possible.

For those of us who work with these patients, we know the heartbreaking sense of helplessness when slow but relentless progression causes malnutrition, bowel failure, and loss of independence. Symptoms evolve gradually, often leading to inanition or lifelong PN dependence, with patients and families enduring prolonged suffering.

There are many ways to discuss dignity at the end of life — palliative care, nutritional support, compassionate presence — yet what stands out here is the transparency and honesty with which the authors describe their attempt to offer something more. They sought not merely to prolong life, but to restore autonomy and relieve the agony of decline.

That courage — to innovate, document, and share such complex experiences — deserves profound respect.

📚 Reference

Reddy S, Punjala SR, Allan P, et al. First report with medium-term follow-up of intestinal transplantation for advanced and recurrent non-resectable pseudomyxoma peritonei. Annals of Surgery. 2022. DOI: 10.1097/SLA.0000000000005769

💭 Closing Thought

“Even in end-stage PMP, there’s room for innovation — not resignation.
What Oxford and Basingstoke achieved challenges our definition of the possible.”
— Artur Reis, MD, ESPSO Certified European School of Peritoneal Surface Oncology

🔗 Explore More

• Access the full article in Annals of Surgery
• Join the P.life Papers newsletter
• Visit the P.life Hub to discuss this study with peers

Pseudomyxoma Peritonei, Intestinal Transplantation, Multivisceral Transplant, CRS and HIPEC, Peritoneal Surface Oncology, End-Stage PMP, Surgical Innovation, Peritoneo.life, Basingstoke, Oxford Transplant Centre, P.life Papers, Transplant Oncology