Recipient Procedure

Complete and detailed discussions of the operative procedures used in small bowel transplantation with the various modifications have been reported previously.[43,56,57,60,61] The duration of surgery varies depending upon the type of transplant, the number of previous surgeries, and the patient's medical status, but usually ranges from 8 to 24 hours. In isolated intestine transplantation (Figure 1),[53] the abdomen is exposed and the diseased intestine is removed from the ligament of Treitz to the ileocecal valve or the ileocolic anastomosis in patients with dysmotility or absorptive dysfunction. Otherwise, the residual small bowel is retained.

Isolated small intestine graft.[53]Source: Reyes J, Bueno J, Kocochis S, et al. Current status of intestinal transplantation in children. J Pediatric Surg. 1998;33:245.

Vascular anastomoses depend on recipient anatomy that can be distorted as a result of previous surgeries.[43] Most commonly, however, the superior mesenteric artery of the donor is anastomosed to the infrarenal aorta and the donor superior mesenteric vein to the recipient portal vein or inferior vena cava.[38] Following reperfusion, the intestine is reconstructed with the donor jejunum anastomosed to the recipient's residual duodenum or jejunum. Distally, the ileum is connected to the native colon in an end-to-side fashion. An ileostomy is created by exteriorizing the distal end of the graft by the "chimney" method with the recipient's ileum or colon anastomosed to the side of the graft below the stoma.[38] The ileostomy is usually temporary and provides access for frequent routine endoscopic evaluations during the first 3-6 months posttransplantation.

Combined Small Bowel-Liver Grafting

In the composite liver and small bowel graft, an enterectomy and hepatectomy is performed. Following removal of these organs, the suprahepatic vena cava of the donor is anastomosed to the recipient's vena cava (Figure 2).[53] The celiac and superior mesenteric arteries are anastomosed to the infrarenal aorta using a Carrel patch. Since the stem of the portal vein between the donor organs of a composite graft is intact, the portal flow is completed by attaching the portal vein of the remnant foregut of the recipient to the intact portal stem of the donor.[38] If there is a significant size discrepancy, a permanent portocaval shunt is performed. After reperfusion, the donor jejunum is anastomosed to the recipient's residual duodenum or jejunum. Distally the ileum is connected to the native colon in an end-to-side fashion and an ileostomy is created. Biliary reconstruction is completed with a Roux-en-Y choledochojejunostomy at the proximal end of the graft jejunum.

Multivisceral Grafting

Composite small intestine-liver graft.[53]Source: Reyes J, Bueno J, Kocochis S, et al. Current status of intestinal transplantation in children. J Pediatr Surg. 1998;33:246.

In multivisceral transplantation, the donor suprahepatic vena cava is attached to the recipient hepatic veins and the arterial conduit is attached to the recipient celiac or infrarenal aorta (Figure 3).[53] A portal vein anastomosis is not required since the recipient's portal vein, GI tract, pancreas, and liver are removed and replaced by a composite graft including the stomach, liver with the portal vein, pancreas, and intestine. The distal esophagus or remaining stomach is anastomosed to the anterior gastric wall of the donor organ. The distal portion of the intestine is anastomosed as in isolated intestine transplantation.[17]

Complete multivisceral graft.[53]Source: Reyes J, Bueno J, Kocochis S, et al. Current status of intestinal transplantation in children. J Pediatr Surg. 1998;33:246.

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