Chapter 20 - Intestinal and Multivisceral Transplantation

Abstract

All different types of visceral organ transplants containing small bowel can be categorized into three main prototypes: isolated intestinal, liver-intestinal, and multivisceral transplantations. The proper understanding of vascular anatomy is necessary to procure these different types of visceral allograft in donor surgery. Pancreas and intestinal allograft can be procured by dividing superior mesenteric artery distal to the origin of inferior pancreaticoduodenal artery to maintain sufficient arterial flow to the head of the pancreas. Recipient surgery is initiated with removal of diseased native organs followed by vascular reconstruction and implantation of new organs. Interposition arterial and venous grafts are commonly used for implantation of isolated intestinal allograft. With composite visceral graft (liver-intestine and multivisceral graft), both celiac and superior mesenteric arteries are retrieved and constructed on donor aortic conduit on the back table. Venous outflow is established with portal or systemic drainage for intestinal allograft and with hepatic venous reconstruction for composite visceral allografts. Foregut reconstruction is part of multivisceral transplantation. The residual native stomach or abdominal esophagus is anastomosed to the anterior wall of the allograft stomach with pyloroplasty as a drainage procedure. With liver-intestinal transplant, the very proximal allograft jejunum is anastomosed to the retained short segment of the native jejunum. Reconstruction of the hind gut is established in recipient residual colorectal segment with creation of chimney ileostomy or simple loop ileostomy.