Intestinal and Multivisceral Transplantation: Where We Stand Today.

Intestinal and multivisceral transplantation has evolved from an experimental to a life-saving procedure for children and adults with complications of gut failure (GF). Suboptimal long-term outcomes of transplant elicit recent advances in surgical and medical gut rehabilitation along with the introduction of glucagon-like peptide-2 (GLP-2) that has established a new paradigm achieving nutritional autonomy reserving transplantation for rescue. Notably, continued improvement of transplant has been observed over the last decade. The 2025 International Intestinal Transplant Registry (IITR) report demonstrates continued era-based improvement, with overall 5-year patient survival of 60% and graft survival of 51% for pediatric recipients, and 52% and 46%, respectively, for adult recipients. Over 90% of long-term transplant survivors achieve full nutritional autonomy. Contemporary cohorts show substantially better outcomes, reflecting advances in surgical technique and immunosuppression. Key developments include refined indications, sophisticated surgical techniques for complex anatomy, and updated immunosuppressive protocols. The integration of composite tissue transplantation, particularly abdominal wall allografts, vascularized and non-vascularized rectus sheath fascia has addressed closure challenges. Despite advances in transplantation, chronic rejection remains the primary barrier to long-term graft survival. Future directions include technological innovations in organ preservation, machine perfusion and organoid transplantation.