Sixty-eight percent of visceral transplant patients may have neurological complications such as headache, encephalopathy, seizures, neuromuscular disorders, opportunistic central nervous system infections, and ischemic strokes [1]. Tacrolimus (Prograf) especially can cause neurological toxicity such as tremor, headache, mental status change, seizure, and PRES (Posterior Reversible Encephalopathy Syndrome). Since many visceral transplant patients receive numerous kinds of medications, at least in the beginning, interaction between medication and their toxicities and metabolites can be frequent causes of neurological symptoms. Simplifying medications is advised if feasible.

Patients often have pretransplantation psychiatric conditions (depression and anxiety disorders) partly because they tend to have long-standing chronic illnesses with frequent hospital stays and surgeries. Chronic use of pain medications is one of the most difficult problems to deal with, presenting a big challenge after transplantation in terms of pain control. Therefore, it is important for a pain management team and psychiatrist to see a patient with these issues before transplantation. Tacrolimus and steroid use also can cause neurotoxicity, which can manifest as psychosis.

Group 2 and 3 patients are treated like liver transplant patients. The Swan-Ganz catheter is useful in the operating room and soon after transplantation for these groups.

In the operating room, fluid management and coagulation management are essential in these patients, especially those in Groups 2 and 3. Proper fluid resuscitation with 5 % albumin or blood products should be obtained before starting infusion of vasoactive medications. If a vasopressor is necessary in the operating room, starting with a small dose of norepinephrine of 0.05 mcg/kg/min and titrating to a minimum necessary dose is preferred.

In the postoperative period, we prefer to start a continuous infusion of Prostaglandin E1 (alprostadil, Prostin VR^® Pediatric, Pfizer) at small doses of 0.2 mcg/kg/h titrated to a maximum dose of 0.6 mcg/kg/h when hemodynamic stability is achieved. The dose is titrated up if the blood pressure tolerates it. The vasodilator and anti-platelet aggregation properties of alprostadil aim to protect the microvasculature of the recently reperfused intestine [2].

Hypertension is common after transplantation. Tacrolimus can cause renal vasoconstriction and corticosteroid administration may lead to fluid retention, both of which can cause high blood pressure. Calcium channel blockers decrease the arterial vasoconstriction caused by tacrolimus. Amlodipine has less of an effect on tacrolimus concentrations than on nondihydropyridine calcium channel blockers such as verapamil. Other medications such as beta-blockers, clonidine, and angiotensin-converting enzyme (ACE) inhibitors can be added if Amlodipine alone is not enough to control blood pressure. It is important to avoid hypotension due to excessive treatment, since transplanted intestine seems more sensitive to hypotension.

Group 1 (isolated intestine) recipients have better overall reserves and normally are able to be extubated on the same day of the transplant or on the first postoperative day. If the patient cannot be weaned from the ventilator soon after transplant, early tracheostomy should be considered. In the postoperative period, the importance of avoiding aspiration pneumonia should be emphasized, since it is very common in intestinal transplant patients.

Liver management in Group 2 and 3 patients is similar to that of post liver transplantation patients. Liver enzyme and lactate trends and patient mental status are good indicators with which to evaluate liver functions. In general, liver enzymes trend down after transplantation. Doppler ultrasound is necessary for any uncertainty of liver functions, but we do not use it routinely.

In Groups 2 and 3, 16 % of patients have pancreaticobiliary problems, which include ampullary stenosis, bile duct stones, bile duck leak, necrotizing pancreatitis, edematous pancreatitis, and pancreatic duct fistula [3]. Pancreatitis can be encountered due to ischemic perfusion injury and can be managed with a nonoperative approach (NPO and octreotide, etc.). However operative interventions are sometimes necessary if pancreatic fistula is suspected. When ischemic reperfusion injury such as swelling of pancreas or hemorrhage in the pancreatic parenchyma, is seen during the operation, an octreotide drip is used. Biliary complication may occur in patients receiving modified multivisceral grafts containing stomach, duodenum, pancreas, and small intestine due to lack of blood supply from gastroduodenal artery and duct to duct biliary anastomosis. Sphincter dysfunction can be treated by sphictorotomy [3].