TECHNICAL ASPECTS OF INTESTINAL ... - Semantic Scholar

TECHNICAL ASPECTS OF INTESTINAL TRANSPLANTATION

Hiroyuki Furukawa, M.D. Kareem Abu-Elmagd, M.D. Jorge Reyes, M.D. 8akr >lour, t1. D . .:'. .J1dreas

~:aKis,

>1.8.

Satoru Todo, M.D. Thomas E Starzl, M.D,

Pittsburgh Transplantation Medical Center, Pittsburgh,

Ph.D.

=:1stitute, ?A 15213

iJnivers.:..:'/

.:upported in part by research grants from the Veterans :\dml:-:.:..stration and ProJect Grant No. DK-29961 from the Natlonal =nst.:..tutes of Health, Bethesda, MD _,ddrc:::s :'3.1:.

reprint requests to: Thomas E. Starzl, M.D., 3601 f'ifth .;venue, Pittsburgh, FA 15213

·~.:.:-.lC,

Ph.;).,

:::C

INTRODUCTION

Since ::!1e advent 506,

0

f :::he potent immunosuppress 1 ve agent

:ntestlnal transplantation has become a feasible therapeutic

cpt.:..on :or patients wi th irreverslble intestinal failure :n

=K

::his

chapter,

we

present

.:..ntestinal transplantation,

our

clinical

(1,2).

experience

with

focusing on the technical aspects of The logistics of the

both the donor and recipient operations.

operative procedure have been descrlbed previously (3).

Type of transplantation

?rom May 1990 to July 1993, tntestlnal

transplantation

at

d

total of 55 patlents recelved

our

center.

successfully completed In 53 patients. during

dissection of

bleeding,

complicated

.:pl~ncnnlc

~enous

:"?C~~:l~nts,

::at:...::nt

grafts.

~n

in

. ::~

~iver,

~n

vpr~r:wtn

and

Two adult patients died

organs

extenslve

and

by

vena

Multivisceral

~iver,

grafts

which the liver was omitted.

::0

due

to

uncontrollable

thrombosis

:nferior

lntestine

was

:.n

cava.

both ::he

Jf

and consisted

the 53

;raft,

r-ecelved af

the

pancreas, duodenum, and intestlne, except for one

~ntestlnal

: ~ ::.?:npt

system

combined

~Ul~':"~lsceral

.:tc~ach,

by

native

operation

patlents were glven an isolated lntestlnal

~8

• {~Cel'led

the

The

The colon was included

graft of the last :3 consecutlve recIplents :n

reduce

the

incIdence

of

jiarrhea

preservlng the :leocecal valve.

::ind ::;acterlal

Recl.pients

:he

reciplent

populatlon

consisted

of

24

adults

and

29

chlldren. The age of the adult group ranged from 19.1 to 58 years with a mean (±SD) of 33.7 ± 10.1 years.

The age of the pediatrlc

recipients ranged from 6 months to 15.5 years with a mean of

~

3.7

prlmary

years.

3.8

indication

Irreversible

for

intestinal

intestinal

failure

transplantation.

(±SD)

was

the

Causes

of

lntestlnal failure for the 53 recipients are surnmarl:ed 1n Table

=~;ClIJlned

for

'~

1ntest.:.ne and

patients

'...;ho

had

related cholestatic l.iver ~ul

ti visceral

transplantatlon ',.,:as iJer:ormed

~l'ler

total

failure

parenteral and/or

transplan ta tion was done

uncorrectable

disorder

of

the

r.utrlt.:.on

inborn

(TPN)

liver disease.

for pat len ts '...;ho had an

entire

gastrolntestlnal

tract,

mostl'! from extensive thrombosls of the major abdominal 'lessels. reclpients :~

r e c c era t 1 vel y .

:3 / [,:", '/ ::: =S tat 1 n ,

routine

received

gut

decon tannna t .:.on

The antimicroblal agents used were dmphoterlc.:.n aminoglycosides,

and

polymyxln

:ntravenous

lntlblotics were also used prophylactically for all patlents.

Donors ::lonors were cadaveric, ABO ldentlcal,

, d....

.-;ll~::'::':"'/ :0:-'., ::-:~

-.:maller,

::-,:mged

:r=~~~atcn

or

from

~arger

3 days

than the to

~r,:l1:'t

j'ears.

The

The 3.ae)f the ~

ymphocitotOX1C

was strongly posltive 1:1 four of the 53

...;ere -.:uccessfully transplanted. -::-:e

47

reciplent.

()f Sl:1nlar Sl:e,

pat:~nts

who

No attempts were made :0 alter

':"ymphoretlcular tissue with ant.:.lymphocyte pr·C'''.lrations

:Jr

8ther

Isolated

modali ties. ,o.Wl

:ytcmegalovirus

seronega ti ve

frcm CMY seronegative donors. the

reduce

intestinal

:ncidence

should

recipients onl y

This policy was

of

CMY

receive recent~y

in

enteritis

who

are

grafts adopted

t!1.::.s

unique

population. ~ut

The same

decontamination was attempted for all donors.

antlmicrobial agents used for recipients were given to t!1e donors :hrcugh a

nasogastrlc

::ube.

.=\t

the

same

tlme,

amplc.::.llin and

:etctaxlrne were glven intravenously every ci to 8 hours and at the --: :..:-::e .': ,:;rgan proc'.lremen:. :-!1e Universlty of ;'Jisconsin ~lC~

,(jW)

solution was usea for In-

perfusion and slmple cold storage of the entire graft.

total volume of the UW solution used for to Z liters 10nors.

for adul t

Initially, secame

:c __ ~

-

~as

imp:lccerlcin

s tandara procedure

B,

':::.:~

~actated

aminoglycosides,

later

I

for pediatrlc

~umen

',..;as omitted,

~speciall

'/ ',.;hen

the

:i.e

two

Ringer's and

solutlon

poly'IDyxin

'~o

~ontaining

·,..;ere

'lsed

for

cold ischemia time ranged from 2.8 to 11.: hours wlth a a::..._

'::"::-".~:::'

mIlkg

100

flushing of the intestinal

chilled

....

~he

to

perfusion was 1

procured as a part of the intestlnal ;raft.

, ..... --:..,..... r -.. ' ......,

--

a

donors and SO

~n-situ

The

~,ours

.

These relatively short

~olj

:..schemia

:',:;flect our adopted policy of utilizlng 10calionors,3.nd

::"::.}tlno the tlrnino :.Jr the donor and recipient .:;per3.tlons.

Surgical Techniques I

Isolated intestine

Al :onor Operation (Figure la,lbl :he

retrieval The

inc:.sion.

procedure starts

greater

omentum

wi th

a

cruciate

carefully

is

abdominal

dissected

and

After kocherizing the

separated from the transverse mesocolon.

duodenum, the cecum, ascending colon, mesenterium and descending Attention is then

.:olcn are mobiL.:ed from the retroperitoneum. to the ;:roxlmal =eJunum,

:ii:-~c:ed

~:.::ament

·.-.ihich :.s transected c2.ose to

:':-.e :!1.:.:-d ,1nd

of :':-elt:.

:ourt:-. ;:ortion

iuoaenum with the attached proximal jeJunal segment are mobili:ed

and

dissected

dividing

small

numerous

from

the

branches

:-oot

of

the

the :~rther

mesenterium by

that communicate between

the

superlor mesenter.:.c vessels, and the duodenum and the pancreas. :~

nonpancreatic donors,

~el~31re

::.J.r.c:-r:3.s •

exposed by t:-ansectIng the pylorus and the After exposing the anterlor surface

.;u~(~:-:.::: r mesenterlC veins, ii:::sec:ed ~anc:-e3.t:c

)f

'~e

the portal and superior mesenteric

:rom :!1e and

0f the

~ortal

and

the lateral and pos ter lor ·.... al.:.s are

pancreas

d~odenal

:!1e

\Jf

~eck

and duodenum by

tributaries.

interruptIng

the

Meanwhile, a short segment

splenic veln at the confluence is dissected and encircled

:.J:-

:''': ture cannul-a tlon.

,r.G

,,:-:poslng

::'.e~·':';:::'2r.:.-=

the

.:.liac

JHter dissecting the :.nfrarenal aorta arteries,

the

or 19 in

arter:: :.s carefully identlfied.

0

f

:he

:.nter ior

The slqmold cel-on

~s

':::o2!: . :-J.Dsected a:ter belng mobili:ed by dissecting the mesocolon

:.J'.-.ir, " ir.a

~::e

the rectoslgmold =unct ion.

The distal abdomlnal aorta

splenic vein are cannulated after systemlc heparlnl:atlon

of

:he

Yhe

donor.

,:l.amped,

supraceliac

and the graft

or

thoraclc

aorta

~~ver

~rom

cross-

is perfused via the abdomlnal aorta and To separate

portal -leln with an adjusted volume of UW solution. ~he

:s

the intestine,

the portal veln 1S transected above

the confluence ef the superior mesenteric and splenic veins. ':'lver ]raft

is

:!1en retrieved using standard

:or :!1e :ntestinal graft, arter'! and

the

l:1ferlOr :nesenterlC artery are

,}nd

;;ancreat:c

';eln

are

ioners,

intrapancreatic border or

Jnd

~:1

. .to. erlor

bot::

completely

colic vessels.

just

The

t!1e

~l.iac

and the

isolated

,1rtery

below

orlgln of

the

the

middle

the superior :nesenter 1C ';essels are

divided

and

the

lntestinal

artery and veln obtalned :Orcm t!1e

'.J.r::e

:cnor are

':el:,

: ':!1e graft on the back table.

;; \

:ashloned to

1ndividually

superler :nesenter:c

above

artery

cut

;!1e 1ntestine 1S removed and

dissected

.;fter perfuslon, mesenteric

(4,5).

the origlns of the superior mesenteric

'lS1;:0 -'::!1e Carrel patch teC!1nlque .

• :1

techniques

The

t!1e superlor :nesenter:c

::r:ery Clnc

.','c1p.:.ent Operation _:1

,} 11

, .• ~.,~l':;:,

pa t:ents,

the

abdomen

lS

opened

.1

:111d1 ine

',-nth a '.lnllateral or bllateral transverse extenslon All

adheslons

frem

multlple -:'he

·;'~.3::.~e _:1:~~:::1al

through

1ntest::1e disease.

are

resected

The

juodenum

1n lS

preVlOUS

remaln.:.ng

reclplents carerully

:Jissect:on

of

the

surqlcal

port:..:;ns wlth

_' ..

;;rl:nary

:dentlfied :naln

1:

stt.:mp

a.nd

either the superlor mesenteric vein, splenic vein, or the side of ~ortal

:he

:nfrarenal ~esenteric

vein :s performed :n all recipients. aorta

proximal

to

the

origin

Exposure of the of

the

inferior

artery is also performed before bringing the graft to

the operative field.

a) 'Iascular Anastomoses (Figure 2) :n

intestinal

isolated

::1esenteric artery of ~a~: ~sed

:~

:he rec:;lent

~he

graft

~~~rarenal

:..s anastomosed to lorta.

recipient

.superior

portal

~he

venous

intestinal graft is drained into

system by

~esenterlC

vein,

anastomosing

=:ltestinal Reconstruction (Figure

:r ':ransplantation.

!I:''}~::: -=~osed

3)

The proximal

to el ther the J ej unum,

..1c:·/e ileum,

:e~CC::-3ry

lS

::1ethod

enterostomy

of

''';1

th or wi thou t

enterostomy.

~acllitates

3t the

of the qraft

~ejunum

:3

1S

tomach) f the

anastomosed to

transverse -:olon, descending colon,

.:.:. .s~op-Koop :.. ':"eostomy, ~:.:rrent

~stablished

duodenum,Jr

The distal end of the graft

:'~:e

::-ecipient

7he reclpient inferior vena cava

=ontinuity of the alimentary canal is

·:--.l:

the

donor

be chosen for the route of graft venous outflow.

,::30

'":l::',c;

the

its confluence wi th the splenic vein,

:,r ':-:e side of t:-.e portal vein.

~:)

::he anterlor

:nterposltlon ]rafts are

superior mesenterlC veln to either the stump of

:3n

superior

the

when technically :ndicated. ihe venous outflow of

the

transplantation,

,;r

~lther

::-ect:.:m.

"chlmney" -:c los tomy, construction

clinlcal,

of

endoscoplC,

the and

-----------.-.~--- ..

histologlC

monitoring

of

the

Terminal

graft.

ileostomy

or

colostomy is performed for most patients who lost their native ~ectosigmoid

colon. to

~ecipients

Gastrostomy the

a.meliorate

is

added

symptoms

in

of

:nost

·:Jf

delayed

the

gastric

emptying. Exteriorization of both the proximal and distal ends of the 'jraft using

the

:irst

0

In the remalning recipients, the proximal enterostomy

pat:ents. :5

the chimney method was performed for

~ubst::uted

~y

insertion of a jejunostomy tube,

gut decompresslon and temporary enteral

,~ar~;

:ni::ally, anastomoses fashion.

performed

Recently,

~eedi~g.

of the proxlmal and distal gastrointestinal

~ost

were

:s used

~hich

in

an

end-to-side

or

side-to-side

the technique was modified to an end-to-end

anastomoS1S as often as possible, to improve graft motility based ~:pon

·:xperimental observations in dogs.

II

Intest~ne

,-.. )

~,~nor

w~th

liver

:peration (Figure -la,b,

~fter :~v

combined

S)

enter:ng the abdominal cavity,

:: vldi::g i ts

The gallbladder is inclsed ::oL.owing

~igaments.

of the cornmon bile duct,

':~.]:::::ect::n

the liver :s mobilized

and the biliary system is

The portal vein is exposed after jivlding the rlght r3S~~~~ ';':;~'~:::,:

~~d

gastroduodenal

7he

arteries.

~eft

Jastr:c

and

:rteries are then .:.dentified and Jivlded.

r :':'.obi 1 i zlng and Jissect:ng the :.n tes t lnal part ire ~:::~S::::3~

the

same

graft .:.n a

as

those

~sed

~onpancreatic

to

retrleve

donor.

:t

the

-.=

the

isolated

.:.s :..:nportan t

':0

emphasize proc~re

that the

the

pancreas

:iver

and

has

to

~ntestinal

be

sacrificed

grafts

en

::.n

order

bloc.

to

Complete

dissect:on and separation of the superior mesenteric vessels from ~he

juodenurn and pancreas

is carrIed out primarily on ::::e cack

table. ~fter

portal

cross-clamping,

~eIn

both

the

:nfrarenal

aorta

and

the

are indiVIdually perfused with the adjusted volume of A Carrel patch is fashioned containing the origIns

:f

the

:~ot:--.

~:--.e

:-J::-::.:1. ·,'elns.

cellac

aXIS

~nfrahepat~-=

c.nd superIor :-:',esenteric arter'/-Jn ':ena ,:3va

placed

~n

the

standard

~:-:e

::ransected above

-:'he .:.nferlor :-:-.esenteric artery

uSIng :he Carrel patch technIque. and

~s

~s

:::e

:::-enal

preserved and procured

The organs are removed en bloc

plastic

bag

containing

::::old

'JW

solution, and packed in an ice container for transport. ~he

-::n :3'';,) ;;h(~n

back

table,

the suprahepatIc and

Ire prepared in :he same 'way as .. :--.e

:r3::=,

pancreas ~oth

are

,:md

iuodenum

carefully

for :"iver transplantat:cn.

areJ. ttached

dissected

and

~he

'ci.rrel

~o

~he

separated

.;fter dissecting both the celiac axis ~esenter.:.c

infrahepatic 'Jena

~::;mbH:.ed

~he

from

and :he superlor

artery down :0 the orIgIn of the mIddle col::::: artery, patch

is

anastomosed to

an aortic

qraft

for

common

performed

WIth

.·asc.::-....:.:.ci.r ,::onduIt:E"igure 5).

:nost

pat:ents,

hepatectomy

:;res •.'r':,1tlcn of the retrohepatic cava.

::-:e

.::: e

~::

~his

~s

method can elimInate

a veno-venous bypass at the anhepa tic phase.

~1ost

-J!

the

parenteral

nutrltion

preserved

:or

:TPN) ,

postoperative

or

the

maJor

maintenance

:rom

vessels

maJor

thrombosed

:"ave

:-ecipients

~eed

vessels

of

.;;.fter

TPN.

total to

be

:'1ilar

iissectlon,

transient or permanent portocaval shunt is routinely

crea ted to

facili tate venous decompression and drainage of the

:-ec1pient's remaining upper abdominal organs (Figure la,/b left). :'he

:.den:1f:icatlon

1)

brought to

_5

segment

and

t:"e

with iistal

t~e

cperat1~e

the

~ield.

''-a.scular Anas tcmoses :"epatic venous :low is :-econstructed by the piggy back

~he

technique is

:'he cornmon arterial conduit of the entire graft

(7).

anastomosed

:,\ftc r

to

reper fus ion,

:on~pr:ca

the

~~[:

side of t:"e oraft portal

patients whose portal vein

~ortal ~~

infrarenal

aorta

to a portoporral shunt by reanastomosinq

:~ :r~:t

recipient

place

vein

1S

1S

~Jeln

:~8_e

::1:::::' ~

6).

rec1plent

t~e i';)

too short,

:r

~nen

the

too small, the reciplent portocaval shunt is

permanent~y.

:;--.testlnal and biliar'l reconstruction (Figure :':~e

(E'igure

the previous 1 y per formed portoca va 1 shunt:.. s

:'oc-::"-,- ':eln to ::::e

::)

duodenojeJunal

dissected

then

.;;.fter exposure of the infrarenal,iOrta,

:.f present.

:olc:-:, :r~:~

the

·of

is

intestine

native

:-emaining

8)

.8illar'l reconst:-uction of the new liver 15 perro:-::-,ed tv :oop choledochoJeJeunal anastomosis.

:.:-::estlnal tract

:"5

restorea

~n

J.

Slmilar :asnlcn ":::: ::;,at :'ube.; as t rc s temy

:'..loe

]eJunostcmy

are

routinely

performed

:or

t:"ese

III Intestine as part of a multivisceral graft Al

Jonor Operation (Figure 9) ~n

~hat

bloc retrieval of the multivisceral grafts

:nclude

the stomach, duodenum, pancreas, Intestine, and liver is a unique technical

the

requires

that

(3 )

procedure

following

::'.odifications. Devascularization ~reservation

of

of

~he

.:8';'enectomy

_3

the

individual ~vold

~~e

~~e

with

The short gastrIc

.:;n

:.::-:e

table.

:~ac~:

from

the

retroperl toneal

dissection of the splenic hilus and

of the splenic vessels ,)re mandatory to

inJury to the pancreas.

esophagogastrlc Junction 1S transected uSIng

·~·.?c:-::llque

1 •

cr

~n-situ

spleen and pancreas

~igation

curvature

performed after complete mobl:ization

1S

~eticulous

structures.

gastric

omentum are ligated and ,iivlded .

:one ':':It;-.er

:n-situ splenectomy both

greater

gastroepIploic arch.

t~e]Teater

".'essels in

of

the

:~e

stapler

.

:nul t i. vIsceral Jraft

1

~

s per fused

througn ::--.e .:i s tal

1bdominal aorta WIth one to two liters of UW solutIon. :~y loroplas t'l

or

~y loromyotomy

is

performed

'~I

ther

)n

the

::acJ.: table or after 1mplantation of the graft.

·'C:.81ent Operation ,Figure :::l) ::':enteratlon ~CC:~:0nts

'~xtr0mely

1S

a

)f

·"'hole

5urglcally

dbdomlnal

c~allenging

difficult :n patIents who have

::J.\·"~~xtensive

::hromboses

..)rgans

:710 S

proceaure.

audd-C~iarl

in the portal system,

the

t

:'h l

S

:. s

syndrome and

:-;epatlc 'leins,

and

·:ena

,::JCC':" '-.:s

:'0

cava.

lon

0

f

::~e

control

cel iac

:ntraoperati ve

and

superior

blood

':'oss,

Jlesen teric

balloon

arter les

'''''as

successfully attempted preoperatively in two such patients.

a)

~:ascular

Anastomoses

..;s with the combined

(liver-intestine)

:econstruction of the multivisceral graft 'JenoL:s :3V2 ::a,c:-:

and graft

~s

arterlal

anastomosed to

-,ethod.

:eCl~lent

_.• e

-h

:~e

graft,

includes both hepatic The

anastomoses.

the vascular

graft

suprahepatic

:eclplent hepatlc velns USlna a plggy

.'lrterla':'

=cnauit

:.s

:0

:he

:ract

1S

.:=mastomosea

Infrarenal aorta.

b) Gastrointestlnal Reconstruction ?roximal ~st~b':"lshed .:Jla':"~

:econstruction

the

of

alimentary

by anastomoslng the distal esophagus or the remalning

;:ortion of :ecip1ent stomach to the anterlor :raft.

:st:::..;~:.~::hed

Jlstal

contlnu1ty

of

the

'Jastrlc '''''all

intestlna~

:r3C:

LS

as w1th the other grafts.

: ) : :...:..:. 3ry Drainage ~~mporary ::1Ul::.·:~:::ceral

diversion of the bile flow 1S always added in all reclpients

to

mlnlmlze

:he

rlsk.)f

postoperative

:'his is achieved through cannulatIon :r::~::.:.;e:f

the :Qrnrnon ::lle duct ':1a the c:ystIciuct.

~na

~xternal

Var1ation of the surgical techniques

~~ansplantation

~ecessitated

,... ith

experlence

surglcal

cumulative

subsequent

:.:-:test:.nal

modificatlons

:.n

both

ionor and reciplent operations. ~ith

the possible need for additional organ replacement at

:ime ~et~:eval

transplantation,

and

iissection

of

multivisceral

has been recently adopted as our standard procurement The ]raft .:.s

: ec:,.:-:':' que .

then tallored on the back table jased

:::::e:-: ::'.eJrgans :-.eeded.

cre~er~at:.on

~;;ts

~~e·ntlre

dOlng colen

well down

with to

functional

the

~::,=~.:.::.:.na

=n _l':(Or

preser":ed and

the

:Ivpn :0 another reclplent. :.r::~

ts

was

marg lnal

80th

:3phl;,cters. requ.:.red

at

:::100d

.3upply

normal

:1ative

the Inferlor mesenterIC arcade.

ane of .::ur multivlsceral

',oJas

anorectal

rectosigmoid 1

disease.

recipients,

retrieved

the

liver '.oJas

Technlcally,

separated

and

the liver was separated

..-:e;rafts ::'1 dissectlng and transecting the.::ommon :--.epatic

:~:-