Intestine Transplant

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Dr. Mukut Minz

  • MS - General Surgery, PGIMER, Chandigarh, MBBS - Sambalpur University, Odisha
  • 37 years experience

Dr. Vivek Vij

  • MBBS, MS, MRCS (Ed.), DNB
  • 17 years experience

Dr. Manav Wadhawan

  • DM (Gastroenterology), MD (Internal Medicine), MBBS
  • 10 years experience

Dr. Priyadarshi Ranjan

  • M.Ch Urology-2008
  • 0 years experience

Dr. Vivek Jawali

  • 0 years experience

Dr. Mohan Keshavamurthy

  • MS (General Surgery), MCh (Uro), FRCS (C), FASTS
  • 0 years experience

Dr. A.S Bawa

  • MS and MCh from PGIMER, Chandigarh
  • 22 years experience

Dr. Ramesh Mahajan

  • MS, Mch(Urology)
  • 20 years experience

Dr. Pankaj N Maheshwari

  • MS, Mch(Urology)
  • 18 years experience

Dr. Prithwiraj Ghoshal

  • M.Ch (Urology)-2004-2007. (PGIMER), MRCS (EDIN) Part II-Royal College of Surgeons of Edinburgh-2003., MRCS (EDIN) Part I-Royal College of Surgeons of Edinburgh-2002., 4. MS (General Surgery) CNMCH 2000-2003, House Surgeon (Department of Surgery) (NRSMCH) Apr 1999 to Aug 1999., Rotating Internship (NRSMCH) Oct 1997-Sep 1998., M.B.B.S (NRSMCH) 1992-1997.
  • 18 years experience

Dr. K. M. Nanjappa

  • M. S - LTMCMNAMS (Genito- Urinary surgery)
  • 17 years experience

Dr. Vikram Aurora

  • MBBS
  • 16 years experience

Dr. Dushyant Nadar

  • M.S General Surgery from M.L.B Medical College Jhansi, National boards in Urology
  • 14 years experience

Dr. Prem Kumar K

  • DNB
  • 14 years experience

Dr. Ayush Choudhary

  • MCh(Urology)
  • 14 years experience

Dr. M G Shekar

  • MS, MRCS, MCh (Uro), FMAS
  • 13 years experience

Dr. Shrinivas Narayan

  • MCh(Urology)
  • 13 years experience

Dr. Manish Ahuja

  • M.Ch. (Urology) from King George Medical university, Lucknow, M.S. ( Surgery) from Christian Medical College, MBBS from Govt. Medical College, Patiala
  • 10 years experience

Dr. Sandeep Gupta

  • DNB (Urology)
  • 10 years experience

Dr. Ashish Jindal

  • M.B.B.S FROM Govt Medical College, M.S (General Surgery) and DNB (Urology)
  • 8 years experience

Dr. M. R. Pari

  • MCh (Urology), MS
  • 8 years experience

Dr. Feroz Amir Zafar

  • Robotic Surgery Training and Certification, Intuitive Surgical, Atlanta, USA, Observership Training in Men’s Health, Cleveland Clinic, Florida, USA, Fellowship in Kidney Transplant, Medanta – The Medicity, Gurgaon, India, MRCS, Royal College of Surgeons, England, DNB Urology, Apollo Hospitals, Hyderabad, India, FMAS(Fellowship in Minimal Access Surgery), AMASI, India, M.S.(Gen. Surgery), RIMS, Ranchi, India, MBBS (Hons.), MGMMC, Jamshedpur, India
  • 7 years experience

Dr. Piyush Varshney

  • M.Ch. (UROLOGY), M.S. (GENERAL SURGERY), M.B.B.S.
  • 6 years experience

Dr. Aman Gupta

  • M.Ch (Urology) (2009), M.S. (Gen. Surgery) (2003), M.B.B.S. (2000)
  • 6 years experience

Dr. Pushkar Shyam Chowdhury

  • MCh. (Urology)- Bombay Hospital Institute of medical Sciences (MUMBAI) , MS- General Surgery – Ramakrishna Mission Seva Pratishthan , M.B.B.S.- Calcutta Medical College
  • 6 years experience

Dr. Sudarshan kanti Baishya

  • DNB UROLOGY superspeciality. , M.S. (Safdarjung hospital, new delhi) , M.B.B.S.( JIPMER)
  • 4 years experience

Dr. Rahul Gupta

  • M.B.B.S., M.S. General Surgery , M.Ch. Neurosurgery
  • 0 years experience

Dr. Priyadarshi Ranjan

  • M.Ch Urology-2008
  • 0 years experience

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About Intestine Transplant

Intestine Transplantation is also known as small bowel transplantation. This has emerged out as the final option for individuals suffering from intestinal failure and receives no positive response from other surgical and non-surgical procedures.

Intestinal transplants remain the most challenging and least frequently performed vascularized intraabdominal organ transplants. However, over the last one and a half decades, intestinal transplant outcome has significantly improved and the yearly number of transplants has steadily increased (1,2). This phenomenon can be attributed to a variety of factors that include:

  • The refinement of surgical techniques,
  • The introduction of more powerful immunosuppressive agents and optimization of perioperative immunosuppressive protocols,
  • Better donor and recipient selection,
  • Increasing sophistication inperioperative prophylaxis of, and monitoring for, posttransplant infections and lymphoproliferative diseases (PTLD),
  • Availability of more potent, yet less toxic antibacterial, antifungal, and antiviral agents,
  • Improvements in organ preservation, and
  • Advances in postoperative intensive care management of the high-risk intestinal transplant recipients

Intestinal transplants are most commonly performed in patients with intestinal failure who develop intractable total parenteral nutrition-related complications (2,3). The causes of intestinal failure can be subdivided into two groups:

  • Short bowel syndrome (frequently a postsurgical condition) and, resulting in a similar clinical presentation,
  • Functional disorders (e.g. impaired motility or absorptive capacity in the presence of sufficient intestinal length and surface area).

As the main intestinal disease process moves further, considerable overlap between these two categories may develop (e.g., worsened malabsorption by bacterial small intestinal overgrowth in patients with short bowel syndrome who lost their ileocecal valve)(10).

The distribution of the primary diseases leading to intestinal failure is age-dependent. In children, these include congenital malformations (e.g., small bowel atresia, gastroschisis, aganglionosis), infections of the gastrointestinal tract (e.g., necrotizing enterocolitis), extensive bowel resections due to mesenteric ischemia (e.g., midgut volvulus), and absorptive impairment (e.g., intestinal pseudo-obstruction, microvillus inclusion disease). In adults, intestinal failure is most frequently due to short bowel syndrome after extensive resections secondary to mesenteric ischemia (e.g., following thrombosis, embolism, volvulus, trauma), inflammatory bowel disease (e.g., Crohn's disease), small bowel tumors (e.g., Gardner's syndrome), and tumors of the mesenteric root and retroperitoneum (e.g., desmoid tumor).

The severity of the short bowel syndrome in these patients depends on a multitude of factors, including length and type (jejunum or ileum) of the remaining bowel, preservation of the ileocecal valve, individual variability of intestinal adaptation, as well as the presence of an intact anatomy, physiology, and function of the stomach (pylorus), pancreas, and the hepatobiliary system.

Contraindications to intestinal transplantation are similar to the guidelines established for other solid organ grafts and include:

  • Systemic and untreated local infections (bacterial, fungal, viral).
  • Malignancies (other than the previously mentioned indicationsformultivisceral transplants), and
  • Severe cardiac and/or pulmonary disease.

The Procedure

Cadaveric transplantation

Donor operation

  • The intestine is generally obtained fromamulti organ donor
     
  • Dissection ofthesupraceliac and infrarenal aorta and identification of the aortic take-off of the celiac axis and superior mesenteric artery; dissection of the superior mesenteric vein, splenic vein, and portal vein
     
  • .Afteraorticcross clamping, an aortic flush with University of Wisconsin (UW) solution is performed
     
  •  Intestinal procurement without simultaneous pancreas procurement: the superior mesenteric artery is included with the bowel graft on an aortic Carrel-patch, the splenic vein is ligated near its junction with the portal vein, the superior mesenteric vein is dissected free (similar to the Whipple procedure), the portal vein is divided halfway between the superior border of the pancreas and the liver)
     
  •  Intestinal procurement with simultaneous pancreas procurement: dissection of the proximal superior mesenteric artery and identification of the take-off of the inferior pancreaticoduodenal artery (which remains with the pancreas graft), division of the superior mesenteric artery distal to this take-off; division of the superior mesenteric vein proximal to its junction with the portal vein
     
  •  The intestinal graft type determines the level of visceral transsection and the anatomy of its vascular supply: for small bowel alone-grafts, the intestine is transected just proximal to the ileocecal valve; for small bowel-colon grafts a short segment of ascending and proximal transverse colon (with the right and middle colic artery) is procured (the inclusion of the ileocecal valve with the graft may increase the decreased transit time frequently observed in small bowel grafts); and for stomach-bowel grafts the left gastric artery on an aortic Carrel-patch must also be procured
     
  • Donor pretreatment with mono- or polyclonalantilymphocyte antibodies, graft irradiation (directed against the abundant mesenteric lymphatic tissue), selective bowel decontamination, and preoperative bowel irrigation all have no significant impact on transplant outcome (3,5).
     
  • Recipient operation
     
  • Intraoperative flexibility is paramount; the individual operative technique (e.g., venous drainage technique) depends on the intraabdominal vascular anatomy of the recipients who frequently have had multiple previous laparotomies
     
  • The graft can be drained systemically (e.g., into the infrarenal vena cava)orportally (e.g., into the superior mesenteric vein)
     
  • Arterial revascularization is typically achieved by creating an arterial anastomosis to the infrarenal abdominal aorta
     
  • After proximal anastomosis between the graft and the recipient's gastrointestinal tract, the distal graft ileum is exteriorized and intestinal continuity is restored by creating a Bishop-Koop ileostomy (thus allowing for easy endoscopic access to the intestinal graft for monitoring and obtaining biopsies).

Living donor transplantation

Donor operation

  • taking into account the preoperative angiography results, an ileal segment of approximately 150 to 200 cm length is isolated on a vascular pedicle consisting of the ileocolic artery and vein. The ileocecal valve and the distal 20 to 25 cm of the ileum (for vitamin B12 absorption) remain with the donor, supplied by the right colic artery(14)
  • the ileocolic artery and vein are dissected at their respective take-offs (which represents the level of vascular transsection) from the superior mesenteric artery and vein
  • the graft is flushed ex situ with UW-solution
  • intestinal continuity in the donor is restored by creating an idea-ileal anastomosis.

Recipient operation

  • the graft is revascularized by creating end-to-side anastomoses between the ileocolic artery and the recipient's infrarenal aorta as well as the ileocolic vein and the inferior vena cava(14)
  • Intestinal continuity in the recipient is restored as previously described.

Combined bowel-liver transplantation

Donor operation

  • Dissection of the aortic origin of the celiac axis and superior mesenteric artery, the suprarenal inferior vena cava, and the superior mesenteric vein (after the division of the overlying pancreatic parenchyma)
     
  • Division of the common bile duct (unless - as done in pediatric recipients - the head of the pancreas and duodenum are included with the graft)
     
  • After an in situ flushes (with UW-solution) and suprarenal and supradiaphragmatic transsection of the inferior vena cava as well as proximal and distal small bowel transsection, the bowel-liver graft is procured en bloc, including a 10cmsupraceliac aortic segment in continuity with an aortic Carrel-patch bearing the celiac axis and superior mesenteric artery. Combined bowel-liver procurement precludes the simultaneous procurement of a whole pancreas graft. However, procurement of the distal pancreas (body and tail, supplied by the splenic artery and vein) for a segmental pancreatic transplant remains possible the distal end of the aortic segment is oversewn.

Recipient operation

  • Hepatectomy as for liver transplantation
  • End-to-side anastomosis between donor and recipient aorta, the creation ofthecavo-caval anastomosis (orthotopic if the recipient cava was resected, piggy-back if the recipient cava was preserved)
  • End-to-side anastomosis between the portal vein of recipient and donor
  • Arterial flush of the bowel-liver graft prior to removal of thecaval vascular clamps
  • Intestinal reconstruction as described above (including the creation of a Bishop-Koop ileostomy)
  • Biliary drainage is achieved via a Roux-Y-choledocho-(bowel graft) enterostomy, unless the graft comprises the duodenum and head of the pancreas.

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