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Multivisceral and isolated intestinal procurement techniques
SPECIAL ARTICLE
Multivisceral and Isolated Intestinal Procurement Techniques Hasan Yersiz, John F. Renz, Garrett M. Hisatake, Sherylin Gordon, Bob H. Saggi, Nicholas J. Feduska Jr, Ronald W. Busuttil, and Douglas G. Farmer Improved outcomes in multivisceral and isolated intestinal transplantation have generated increased demand for these procedures. Enhanced recognition of potential multivisceral/intestinal donors and widespread application of advanced organ procurement techniques is necessary in the current climate of organ scarcity. This manuscript details the multivisceral and isolated intestinal procurement techniques currently performed at the University of California Los Angeles. (Liver Transpl 2003;9:881-886.)
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mproved outcomes after multivisceral and isolated intestinal transplantation1-6 have renewed interest in these techniques as evidenced by United Network for Organ Sharing (UNOS) data showing annual increases in isolated intestinal and multivisceral transplantation since 1998.7 In an era of limited cadaver-donor supply, enhanced recognition of potential multivisceral/intestinal cadaver-donors is necessary. This article details the techniques applied by our donor recovery team in performing multivisceral and isolated intestinal procurements. The procurement techniques herein are a modification of the original descriptions of Starzl et al,8-10 Bueno et al,11 and Abu-Elmagd et al12 of the University of Pittsburgh. Our technique has been routinely used at donor medical facilities without specialized equipment and has not precluded additional abdominal and thoracic organ retrieval. Multivisceral organ procurement requires tailoring the donor procedure for the individual needs of a recipient. Donor selection is restricted to optimal candidates according to widely recognized criteria6,13 including ABO compatibility, appropriate size-match, minimal vasopressor requirements, absent/scant arrest period, serum sodium ⬍ 160 mEq/dL. Preparation of the donor before procurement includes selective intestinal decontamination using neomycin, erythromycin, and amphotericin B, in addition to intravenous antibiotic prophylaxis with a third-generation cephalosporin at the time of surgery.12
Procurement of Multivisceral and Liver/Intestine Allografts All procedures begin with the standard techniques of abdominal organ procurement.14 A thorough celiot-
omy is performed with particular attention to evidence of traumatic injury, the presence of mesenteric or retroperitoneal hematoma, and assessment of organ perfusion. The round ligament is divided, and the falciform is dissected to the hepatic vein/inferior vena cava confluence. Medially, the left coronary and triangular ligaments are released and the gastrohepatic ligament is assessed for aberrant hepatic arterial anatomy. The supraceliac dissection proceeds with division of the gastrohepatic ligament as well as the right diaphragmatic crus to expose the supraceliac aorta.14 Infrarenal aortic dissection is initiated with medial rotation of the colon and duodenum en bloc as described by Cattel-Braash et al.15 The inferior mesenteric vein is isolated and cannulated to begin a pre-cool perfusion with isotonic (donor serum sodium ⬍ 150 mEq/dL) or hypotonic (donor serum sodium ⱖ 150 mEq/dL) saline solution. The abdominal aorta, below the take-off of the inferior mesenteric artery, is exposed and prepared for cannulation. The gallbladder is evacuated, and the biliary system is flushed with normal saline. The above steps ensure that unanticipated donor instability can default to rapid heparin administration, aortic cannulation, cross-clamp, and organ cold perfusion. The essential element of multivisceral and liver/intestine allograft procurement is maintenance of the superior mesenteric artery–portal vein axis. In cases in which the liver is a component of a multivisceral allograft, our preference is to preserve the integrity of the biliary system through inclusion of donor duodenum and pancreas (head) as described by Bueno et al11 and Sudan et al.16 The gastrocolic ligament is divided from the pylorus From the Dumont-UCLA Transplant Center, Department of Surgery, University of California at Los Angeles, Los Angeles, CA. Address reprint requests to Hasan Yersiz, MD, Dumont-UCLA Transplant Center, Room 77-120 CHS 10833 Le Conte Ave, Los Angeles, CA 90095-7054. Telephone: 310-267-0391; FAX: 310-267-0392; E-mail: [email protected] Copyright © 2003 by the American Association for the Study of Liver Diseases 1527-6465/03/0908-0018$30.00/0 doi:10.1053/jlts.2003.50155
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Figure 2. Multivisceral allograft with inclusion of the pancreas. Inclusion of the pancreas is dependent on the individual needs of the recipient. En bloc inclusion of the pancreas with multivisceral allografts must include the spleen to preserve the tail of the pancreas as depicted. The spleen will be carefully separated from the pancreas during ex vivo graft preparation. Note the cannula in the inferior mesenteric vein for pre-cool perfusion and portal vein cold perfusion.
Figure 1. Combined liver/intestine allograft before aortic cross-clamp. (A) Anterior view. The round ligament has been ligated, the falciform ligament has been divided, and the liver has been completely mobilized. The colon has been liberated to the splenic flexure and retracted out of the surgical field. The stapled terminal ileum is apparent in the lower left corner, and the aortic cannula has been positioned. (B) Superolateral view. The supraceliac dissection is complete, and the stomach is retracted out of the surgical field (lower right). The colon has been mobilized to the splenic flexure and also has been removed from the surgical field (lower left). The stapled terminal ileum is apparent (middle left), and the gallbladder had been evacuated. The aortic cannula is in position, and the supraceliac aorta has been encircled with an umbilical tape (lower right). The donor is prepared for systemic heparin, crossclamp, and organ cold perfusion.
to the splenic flexure of the colon. The distal pylorus is encircled and transected with a GIA-55 stapling device (United States Surgical Corporation, Norwalk, CT). Attention to preservation of the left gastric artery is critical, particularly in the setting of a replaced left hepatic artery. The left gastric artery is then divided between suture ligatures at the pylorus, and the stomach is retracted superiorly and laterally, out of the operative field.11 Preparation of the intestinal allograft continues with division of the terminal ileum immediately proximal to the ileocecal valve. The inclusion of ascending colon
with multivisceral allografts is controversial17; to date, we have not adopted this practice. Maximal preservation of terminal ileum is emphasized with a careful dissection performed so as not to disrupt any vascular arcade or create a mesenteric hematoma before intestinal division with a GIA-55 stapling device. Vascular
Figure 3. Liver/intestine allograft after cold perfusion. The diaphragm has been divided, and the aortic clamp is in position (yellow/blue/yellow tagged clamp). The liver has been freed from its attachments and rests superiorly in the right chest. The stomach is divided at the pylorus and is retracted superolaterally out of the abdomen. The pancreas has been divided, and the distal pancreas has been retracted with a forceps. The splenic artery has been ligated and retracted with a silk suture (upper left). A towel is placed around the intestine after verification of mesentery orientation. The stapled terminal ileum is apparent (lower left).
Multivisceral Procurement Techniques
dissection proceeds laterally and distally along the mesocolon outside of the ileocolic–superior mesenteric arterial arcade containing the cecal and appendicular arterial origins. The right and transverse mesocolon are divided between silk sutures. The middle colic vessels are divided, and the dissection is carried beyond the splenic flexure to completely liberate the colon from the small bowel (Fig. 1). Unlike the University of Pittsburgh protocol,11,12 we do not separate the colon from the donor. Inclusion of the pancreas is dependent on the individual needs of the recipient and may be indicated for recipients suffering from endocrine or exocrine pancreatic insufficiency as well as for recipients requiring pancreas extirpation for technical reasons or malignancy. If the recipient requires pancreatic function, en bloc removal of the pancreas must include the spleen (Fig. 2). If the multivisceral procurement is to only include the head of the pancreas to preserve the integrity of the biliary system,11,16 the pancreas is transected just medial to the superior mesenteric artery and vein with a vascular TA-30 stapling device (United States Surgical Corporation). The donor is administered 30,000 U heparin, the abdominal aorta below the inferior mesenteric artery is cannulated, and the supraceliac abdominal aorta is cross-clamped followed by organ cold perfusion and external cooling. Organ cold perfusion is performed with University of Wisconsin (UW) solution (Viaspan, Pomona, NY) at 4°C through the aortic and inferior mesenteric venous cannulas. Infusion volumes average 50 to 100 mL/kg or approximately 2,000 to 3,000 mL via the aortic cannula and 1,000 mL via the inferior mesenteric venous cannula for adults. The organs are carefully evaluated for blanching, softness, and temperature to assess cold perfusion. On completion of cold perfusion, the left diaphragm and crus are divided medial to the esophagus. The right diaphragm and crus are transected lateral to the right triangular ligament (Fig. 3), leaving the liver/intestine allograft anchored by its vascular attachments. The configuration of the mesentery is verified before wrapping the intestinal allograft in a surgical towel secured with silk sutures12 to preserve orientation and minimize trauma during transport, ex vivo preparation, and implantation (Fig. 3). Division of the inferior vena cava and aorta are determined by the recipient’s need for augmented renal function. For multivisceral allografts that include kidneys (right preferred if single kidney), the inferior vena cava is divided below the renal vein orifices and the aorta at the bifurcation. The ureters are procured full-
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length by removing both as a single unit with the dome of the urinary bladder. When renal function is not required, the inferior vena cava is divided above the renal vein orifices. The intestines are then lifted superiorly to reveal the origin of the superior mesenteric artery. The abdominal aorta is transected just distal to the superior mesenteric artery take-off to preserve the renal artery orifices, and the aorta is freed proximal to the thoracic aorta to maintain continuity with the celiac trunk. Division of the midthoracic aorta permits removal of the multivisceral allograft for packaging and storage in UW solution at 4°C (Fig. 4). Precise retrieval of arterial and venous conduits is an integral component of multivisceral procurement. Donor conduit retrieval should include as a minimum: thoracic aorta, remnant vena cava, and entire common and external iliac artery and vein with a substantial segment of internal iliac.10 Ex vivo preparation of the multivisceral allograft includes creation of a conduit from donor thoracic aorta, preparation of the allograft aorta, separation of the diaphragm from the liver, oversewing of the transected pancreas, and ligation of transected vessels.10 Donor thoracic aorta is used to create a conduit for anastomosis to recipient abdominal aorta (supraceliac or infrarenal, former is preferred), thus facilitating anastomosis of the allograft aorta at the level of the wound as described by Sudan et al.16 Arterial branches are suture ligated before sharp transection of the conduit edges and storage in cold UW solution. The allograft aorta is prepared for anastomosis to the conduit by closure of the distal abdominal aorta beyond the superior mesenteric artery orifice (or renal orifices) through simple running suture or arterial patch. Lumbar branches are oversewn, and the supraceliac donor abdominal aorta is transected sharply 4 cm above the celiac. The liver bare area is exposed by complete removal of remnant diaphragm, and the suprahepatic vena cava is freed from its diaphragmatic attachments. Phrenic vein orifices are identified and ligated. The edge of transected pancreas is carefully inspected and oversewn. In multivisceral allografts that include the entire pancreas, the inferior mesenteric venous cannula is used for flushing the liver with 2.5% albumin in isotonic saline solution before reperfusion; however, in multivisceral allografts that contain only the head of the pancreas, the splenic vein must be cannulated to facilitate flushing of UW solution before reperfusion. The distal inferior vena cava is ligated to complete allograft preparation.
Figure 4. Completed procurement of liver/intestine allograft. (A) Left lateral view. The intestine is enclosed within the blue towel. The splenic vein is apparent for cannulation, and the splenic artery has been ligated with a silk suture (cut long). The pancreas and pylorus have been divided with a surgical stapling device. The aorta has been procured from distal to the superior mesenteric artery (left) to the thoracic aorta (right). (B) Superior view. In this view, the inferior vena cava is apparent, with the right adrenal gland. The pancreas has been transected, and the pyloric division is apparent. The intestine is wrapped in a blue towel. (C) Left lateral view. This multivisceral allograft includes the en bloc pancreas that has been rotated medially 180°. Cannulation of the inferior mesenteric vein is apparent, and the aorta has been procured from the superior mesenteric artery to the thoracic aorta. Note how cumbersome the intestine is, and how susceptible to malrotation it is in the absence of the blue towel.
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Figure 5. Vascular pedicle of isolated intestine allograft. (A) Cadaver dissection of the mesenteric root medial to the ligament of Treitz and below the transverse mesocolon, showing the superior mesenteric artery (yellow vessel loop) and superior mesenteric vein (blue vessel loop). (B) Isolated vascular pedicle of the intestine allograft after dissection. The surgical stapling device is placed immediately below the middle colic vessels to maintain the vascular integrity of the pancreas. The intestinal vessels will be sharply transected below the surgical stapling device, with donor-procured conduit vessels used as necessary.
Procurement of Isolated Intestinal Allografts Procurement of isolated intestinal allografts proceeds in a fashion similar to the technique above; however, the proximal intestinal dissection is initiated at the ligament of Treitz. The small bowel is divided approximately 2 cm below the ligament of Treitz using a GIA-55 stapling device with preservation of mesenteric vascular arcades. The duodenum is preserved for procurement of the pancreas for transplantation into another patient. The remaining dissection is identical
to above through organ cold perfusion. After cold perfusion, the root of the mesentery at the bisected ligament of Treitz is dissected medially to isolate the superior mesenteric artery and vein immediately below the take-off of the middle colic vessels (Fig. 5A). Great care is exercised to maintain the vascular integrity of the pancreas through preservation of the inferior pancreaticoduodenal arcades. The intestinal allograft remains attached by its vascular pedicle, and is separated by using a TA-60 stapling device just distal to the middle
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colic vessels (Fig. 5B) followed by sharp transection to create an intestinal allograft vascular cuff. The complete intestinal allograft is wrapped in a surgical towel before removal en bloc, leaving the pancreas free for isolated procurement. Ex vivo preparation simply involves the creation of extension arterial and venous conduits, if necessary, through donor-procured vessels and ligation of the inferior mesenteric vein.
Discussion This article details technical modifications in multivisceral and isolated intestinal allograft procurement that have been routinely applied by our recovery teams at donor facilities without additional equipment or impedance to concomitant thoracic and abdominal organ procurements. To date, these techniques have been applied to 35 multivisceral/isolated intestinal procurements with excellent organ quality at transplantation. Time to cross-clamp is routinely less than 2 hours with total organ procurement lasting less than 3 hours. No complication related to procurement has occurred, and all organs have been successfully retrieved except when a significant size mismatch was encountered at surgery. Although founded on procurement techniques originally developed by the University of Pittsburgh,8-12 we minimize ex vivo allograft preparation through increased dissection and organ separation in situ. This reduces total cold ischemia time as well as potential injury from extended ex vivo manipulations and inadvertent rewarming using previously described techniques.12,16 Furthermore, we postulate that in situ separation promotes organ sharing among centers through direct shipment from the donor facility. Using the duodenal-sparing composite liver/intestine technique of Bueno et al11 and Sudan et al16 maintains the superior mesenteric artery–portal venous axis, prevents malrotation, and precludes the need for a biliary drainage procedure in the recipient. Preservation of the hepatic hilum eliminates the need for biliary dissection and an anastomosis, thereby reducing the risk of a postoperative biliary complication. Although this excludes the use of pancreas for clinical transplantation, the remaining distal pancreas can be used for islet cell procurement. Through the use of interposition conduits, our isolated intestinal procurement technique does not require sacrifice of the pancreas as mandated by previous investigators.16,18
References 1. Farmer D, McDiarmid S, Yersiz H, Cortina J, Amersi F, Vargas J, et al. Outcome after intestinal transplantation: Results from one center’s 9 year experience. Arch Surg 2001;136:1027-1031. 2. Abu-Elmagd K, Reyes J, Bond G, Mazariegos G, Wu T, Murase N, et al. Clinical intestinal transplantation: A decade of experience at a single center. Ann Surg 2001;234:404-417. 3. Nishida S, Levi D, Kato T, Nevy J, Mittal N, Hadjis N, et al. Ninety-five cases of intestinal transplantation at the University of Miami. J Gastrointest Surg 2002;6:233-239. 4. Goulet O, Lacaille F, Colomb V, Jan D, Canioni D, Cezard JP, et al. Intestinal transplantation in children: Paris experience. Transplant Proc 2002;34:1887-1888. 5. Langnas A, Chinnakotla S, Sudan D, Horslen S, McCashland T, Schafer D, et al. Intestinal transplantation at the University of Nebraska Medical Center: 1990 to 2001. Transplant Proc 2002; 34:958-960. 6. Reyes J, Mazariegos G, Bond G, Green M, Dvorchik I, Kosmach-Park B, Abu-Elmagd K. Pediatric intestinal transplantation: Historical notes, principles and controversies. Pediatr Transpl 2002;6:193-207. 7. United Network for Organ Sharing. Available at: http:// www.UNOS.org 2003. Accessed January 3, 2003. 8. Starzl TE, Hakala T, Shaw B, Hardestry R, Rosenthal T, Griffith B, et al. A flexible procedure for multiple cadaveric organ procurement. Surg Gynecol Obstet 1984;158:223-230. 9. Starzl TE, Miller CM, Bronznick B, Makowka L. An improved technique for multiple organ harvesting. Surg Gynecol Obstet 1987;165:343-348. 10. Starzl TE, Todo S, Tzakis A, Alessiani M, Casavilla A, AbuElmagd K, Fung JJ. The many faces of multivisceral transplantation. Surg Gynecol Obstet 1991;172:335-344. 11. Bueno J, Abu-Elmagd K, Mazariegos G, Madariaga J, Fung J, Reyes J. Composite liver–small bowel allografts with preservation of donor duodenum and hepatic biliary system in children. J Pediatr Surg 2000;35:291-295; discussion 295-296. 12. Abu-Elmagd K, Fung J, Bueno J, Martin D, Madariaga J, Mazariegos G, et al. Logistics and technique for procurement of intestinal, pancreatic, and hepatic grafts from the same donor. Ann Surg 2000;232:680-687. 13. Farmer D, McDiarmid S, Yersiz H, Cortina J, Vargas J, Maxfield A, et al. Outcomes of intestinal transplantation: A single center experience over a decade. Transplant Proc 2001;34:896-897. 14. Yersiz H, Busuttil RW. Surgical techniques in liver transplantation. In: Norman DJ, Turka LA, eds. Primer on Transplantation. Mt. Laurel: American Society of Transplantation, 2001: 544-550. 15. Cattell R, Braasch J. A technique for the exposure of the third and fourth portions of the duodenum. Surg Gynecol Obstet 1960;111:379. 16. Sudan D, Iyer K, Deroover A, Chinnakotla S, Fox I, Shaw B, Langnas A. A new technique for combined liver/small intestinal transplantation. Transplantation 2001;72:1846-1849. 17. Goulet O, Auber F, Fourcade L, Sarnacki S, Jan D, Columb V, et al. Intestinal transplantation including the colon in children. Transplant Proc 2002;34:1885-1886. 18. Sindhi R, Fox I, Heffron T, Shaw BW, Langnas A. Procurement and preparation of human isolated small intestinal grafts for transplantation. Transplantation 1995;60:771-773.
Multivisceral and Isolated Intestinal Procurement Techniques Hasan Yersiz, John F. Renz, Garrett M. Hisatake, Sherylin Gordon, Bob H. Saggi, Nicholas J. Feduska Jr, Ronald W. Busuttil, and Douglas G. Farmer Improved outcomes in multivisceral and isolated intestinal transplantation have generated increased demand for these procedures. Enhanced recognition of potential multivisceral/intestinal donors and widespread application of advanced organ procurement techniques is necessary in the current climate of organ scarcity. This manuscript details the multivisceral and isolated intestinal procurement techniques currently performed at the University of California Los Angeles. (Liver Transpl 2003;9:881-886.)
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mproved outcomes after multivisceral and isolated intestinal transplantation1-6 have renewed interest in these techniques as evidenced by United Network for Organ Sharing (UNOS) data showing annual increases in isolated intestinal and multivisceral transplantation since 1998.7 In an era of limited cadaver-donor supply, enhanced recognition of potential multivisceral/intestinal cadaver-donors is necessary. This article details the techniques applied by our donor recovery team in performing multivisceral and isolated intestinal procurements. The procurement techniques herein are a modification of the original descriptions of Starzl et al,8-10 Bueno et al,11 and Abu-Elmagd et al12 of the University of Pittsburgh. Our technique has been routinely used at donor medical facilities without specialized equipment and has not precluded additional abdominal and thoracic organ retrieval. Multivisceral organ procurement requires tailoring the donor procedure for the individual needs of a recipient. Donor selection is restricted to optimal candidates according to widely recognized criteria6,13 including ABO compatibility, appropriate size-match, minimal vasopressor requirements, absent/scant arrest period, serum sodium ⬍ 160 mEq/dL. Preparation of the donor before procurement includes selective intestinal decontamination using neomycin, erythromycin, and amphotericin B, in addition to intravenous antibiotic prophylaxis with a third-generation cephalosporin at the time of surgery.12
Procurement of Multivisceral and Liver/Intestine Allografts All procedures begin with the standard techniques of abdominal organ procurement.14 A thorough celiot-
omy is performed with particular attention to evidence of traumatic injury, the presence of mesenteric or retroperitoneal hematoma, and assessment of organ perfusion. The round ligament is divided, and the falciform is dissected to the hepatic vein/inferior vena cava confluence. Medially, the left coronary and triangular ligaments are released and the gastrohepatic ligament is assessed for aberrant hepatic arterial anatomy. The supraceliac dissection proceeds with division of the gastrohepatic ligament as well as the right diaphragmatic crus to expose the supraceliac aorta.14 Infrarenal aortic dissection is initiated with medial rotation of the colon and duodenum en bloc as described by Cattel-Braash et al.15 The inferior mesenteric vein is isolated and cannulated to begin a pre-cool perfusion with isotonic (donor serum sodium ⬍ 150 mEq/dL) or hypotonic (donor serum sodium ⱖ 150 mEq/dL) saline solution. The abdominal aorta, below the take-off of the inferior mesenteric artery, is exposed and prepared for cannulation. The gallbladder is evacuated, and the biliary system is flushed with normal saline. The above steps ensure that unanticipated donor instability can default to rapid heparin administration, aortic cannulation, cross-clamp, and organ cold perfusion. The essential element of multivisceral and liver/intestine allograft procurement is maintenance of the superior mesenteric artery–portal vein axis. In cases in which the liver is a component of a multivisceral allograft, our preference is to preserve the integrity of the biliary system through inclusion of donor duodenum and pancreas (head) as described by Bueno et al11 and Sudan et al.16 The gastrocolic ligament is divided from the pylorus From the Dumont-UCLA Transplant Center, Department of Surgery, University of California at Los Angeles, Los Angeles, CA. Address reprint requests to Hasan Yersiz, MD, Dumont-UCLA Transplant Center, Room 77-120 CHS 10833 Le Conte Ave, Los Angeles, CA 90095-7054. Telephone: 310-267-0391; FAX: 310-267-0392; E-mail: [email protected] Copyright © 2003 by the American Association for the Study of Liver Diseases 1527-6465/03/0908-0018$30.00/0 doi:10.1053/jlts.2003.50155
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Figure 2. Multivisceral allograft with inclusion of the pancreas. Inclusion of the pancreas is dependent on the individual needs of the recipient. En bloc inclusion of the pancreas with multivisceral allografts must include the spleen to preserve the tail of the pancreas as depicted. The spleen will be carefully separated from the pancreas during ex vivo graft preparation. Note the cannula in the inferior mesenteric vein for pre-cool perfusion and portal vein cold perfusion.
Figure 1. Combined liver/intestine allograft before aortic cross-clamp. (A) Anterior view. The round ligament has been ligated, the falciform ligament has been divided, and the liver has been completely mobilized. The colon has been liberated to the splenic flexure and retracted out of the surgical field. The stapled terminal ileum is apparent in the lower left corner, and the aortic cannula has been positioned. (B) Superolateral view. The supraceliac dissection is complete, and the stomach is retracted out of the surgical field (lower right). The colon has been mobilized to the splenic flexure and also has been removed from the surgical field (lower left). The stapled terminal ileum is apparent (middle left), and the gallbladder had been evacuated. The aortic cannula is in position, and the supraceliac aorta has been encircled with an umbilical tape (lower right). The donor is prepared for systemic heparin, crossclamp, and organ cold perfusion.
to the splenic flexure of the colon. The distal pylorus is encircled and transected with a GIA-55 stapling device (United States Surgical Corporation, Norwalk, CT). Attention to preservation of the left gastric artery is critical, particularly in the setting of a replaced left hepatic artery. The left gastric artery is then divided between suture ligatures at the pylorus, and the stomach is retracted superiorly and laterally, out of the operative field.11 Preparation of the intestinal allograft continues with division of the terminal ileum immediately proximal to the ileocecal valve. The inclusion of ascending colon
with multivisceral allografts is controversial17; to date, we have not adopted this practice. Maximal preservation of terminal ileum is emphasized with a careful dissection performed so as not to disrupt any vascular arcade or create a mesenteric hematoma before intestinal division with a GIA-55 stapling device. Vascular
Figure 3. Liver/intestine allograft after cold perfusion. The diaphragm has been divided, and the aortic clamp is in position (yellow/blue/yellow tagged clamp). The liver has been freed from its attachments and rests superiorly in the right chest. The stomach is divided at the pylorus and is retracted superolaterally out of the abdomen. The pancreas has been divided, and the distal pancreas has been retracted with a forceps. The splenic artery has been ligated and retracted with a silk suture (upper left). A towel is placed around the intestine after verification of mesentery orientation. The stapled terminal ileum is apparent (lower left).
Multivisceral Procurement Techniques
dissection proceeds laterally and distally along the mesocolon outside of the ileocolic–superior mesenteric arterial arcade containing the cecal and appendicular arterial origins. The right and transverse mesocolon are divided between silk sutures. The middle colic vessels are divided, and the dissection is carried beyond the splenic flexure to completely liberate the colon from the small bowel (Fig. 1). Unlike the University of Pittsburgh protocol,11,12 we do not separate the colon from the donor. Inclusion of the pancreas is dependent on the individual needs of the recipient and may be indicated for recipients suffering from endocrine or exocrine pancreatic insufficiency as well as for recipients requiring pancreas extirpation for technical reasons or malignancy. If the recipient requires pancreatic function, en bloc removal of the pancreas must include the spleen (Fig. 2). If the multivisceral procurement is to only include the head of the pancreas to preserve the integrity of the biliary system,11,16 the pancreas is transected just medial to the superior mesenteric artery and vein with a vascular TA-30 stapling device (United States Surgical Corporation). The donor is administered 30,000 U heparin, the abdominal aorta below the inferior mesenteric artery is cannulated, and the supraceliac abdominal aorta is cross-clamped followed by organ cold perfusion and external cooling. Organ cold perfusion is performed with University of Wisconsin (UW) solution (Viaspan, Pomona, NY) at 4°C through the aortic and inferior mesenteric venous cannulas. Infusion volumes average 50 to 100 mL/kg or approximately 2,000 to 3,000 mL via the aortic cannula and 1,000 mL via the inferior mesenteric venous cannula for adults. The organs are carefully evaluated for blanching, softness, and temperature to assess cold perfusion. On completion of cold perfusion, the left diaphragm and crus are divided medial to the esophagus. The right diaphragm and crus are transected lateral to the right triangular ligament (Fig. 3), leaving the liver/intestine allograft anchored by its vascular attachments. The configuration of the mesentery is verified before wrapping the intestinal allograft in a surgical towel secured with silk sutures12 to preserve orientation and minimize trauma during transport, ex vivo preparation, and implantation (Fig. 3). Division of the inferior vena cava and aorta are determined by the recipient’s need for augmented renal function. For multivisceral allografts that include kidneys (right preferred if single kidney), the inferior vena cava is divided below the renal vein orifices and the aorta at the bifurcation. The ureters are procured full-
883
length by removing both as a single unit with the dome of the urinary bladder. When renal function is not required, the inferior vena cava is divided above the renal vein orifices. The intestines are then lifted superiorly to reveal the origin of the superior mesenteric artery. The abdominal aorta is transected just distal to the superior mesenteric artery take-off to preserve the renal artery orifices, and the aorta is freed proximal to the thoracic aorta to maintain continuity with the celiac trunk. Division of the midthoracic aorta permits removal of the multivisceral allograft for packaging and storage in UW solution at 4°C (Fig. 4). Precise retrieval of arterial and venous conduits is an integral component of multivisceral procurement. Donor conduit retrieval should include as a minimum: thoracic aorta, remnant vena cava, and entire common and external iliac artery and vein with a substantial segment of internal iliac.10 Ex vivo preparation of the multivisceral allograft includes creation of a conduit from donor thoracic aorta, preparation of the allograft aorta, separation of the diaphragm from the liver, oversewing of the transected pancreas, and ligation of transected vessels.10 Donor thoracic aorta is used to create a conduit for anastomosis to recipient abdominal aorta (supraceliac or infrarenal, former is preferred), thus facilitating anastomosis of the allograft aorta at the level of the wound as described by Sudan et al.16 Arterial branches are suture ligated before sharp transection of the conduit edges and storage in cold UW solution. The allograft aorta is prepared for anastomosis to the conduit by closure of the distal abdominal aorta beyond the superior mesenteric artery orifice (or renal orifices) through simple running suture or arterial patch. Lumbar branches are oversewn, and the supraceliac donor abdominal aorta is transected sharply 4 cm above the celiac. The liver bare area is exposed by complete removal of remnant diaphragm, and the suprahepatic vena cava is freed from its diaphragmatic attachments. Phrenic vein orifices are identified and ligated. The edge of transected pancreas is carefully inspected and oversewn. In multivisceral allografts that include the entire pancreas, the inferior mesenteric venous cannula is used for flushing the liver with 2.5% albumin in isotonic saline solution before reperfusion; however, in multivisceral allografts that contain only the head of the pancreas, the splenic vein must be cannulated to facilitate flushing of UW solution before reperfusion. The distal inferior vena cava is ligated to complete allograft preparation.
Figure 4. Completed procurement of liver/intestine allograft. (A) Left lateral view. The intestine is enclosed within the blue towel. The splenic vein is apparent for cannulation, and the splenic artery has been ligated with a silk suture (cut long). The pancreas and pylorus have been divided with a surgical stapling device. The aorta has been procured from distal to the superior mesenteric artery (left) to the thoracic aorta (right). (B) Superior view. In this view, the inferior vena cava is apparent, with the right adrenal gland. The pancreas has been transected, and the pyloric division is apparent. The intestine is wrapped in a blue towel. (C) Left lateral view. This multivisceral allograft includes the en bloc pancreas that has been rotated medially 180°. Cannulation of the inferior mesenteric vein is apparent, and the aorta has been procured from the superior mesenteric artery to the thoracic aorta. Note how cumbersome the intestine is, and how susceptible to malrotation it is in the absence of the blue towel.
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Figure 5. Vascular pedicle of isolated intestine allograft. (A) Cadaver dissection of the mesenteric root medial to the ligament of Treitz and below the transverse mesocolon, showing the superior mesenteric artery (yellow vessel loop) and superior mesenteric vein (blue vessel loop). (B) Isolated vascular pedicle of the intestine allograft after dissection. The surgical stapling device is placed immediately below the middle colic vessels to maintain the vascular integrity of the pancreas. The intestinal vessels will be sharply transected below the surgical stapling device, with donor-procured conduit vessels used as necessary.
Procurement of Isolated Intestinal Allografts Procurement of isolated intestinal allografts proceeds in a fashion similar to the technique above; however, the proximal intestinal dissection is initiated at the ligament of Treitz. The small bowel is divided approximately 2 cm below the ligament of Treitz using a GIA-55 stapling device with preservation of mesenteric vascular arcades. The duodenum is preserved for procurement of the pancreas for transplantation into another patient. The remaining dissection is identical
to above through organ cold perfusion. After cold perfusion, the root of the mesentery at the bisected ligament of Treitz is dissected medially to isolate the superior mesenteric artery and vein immediately below the take-off of the middle colic vessels (Fig. 5A). Great care is exercised to maintain the vascular integrity of the pancreas through preservation of the inferior pancreaticoduodenal arcades. The intestinal allograft remains attached by its vascular pedicle, and is separated by using a TA-60 stapling device just distal to the middle
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colic vessels (Fig. 5B) followed by sharp transection to create an intestinal allograft vascular cuff. The complete intestinal allograft is wrapped in a surgical towel before removal en bloc, leaving the pancreas free for isolated procurement. Ex vivo preparation simply involves the creation of extension arterial and venous conduits, if necessary, through donor-procured vessels and ligation of the inferior mesenteric vein.
Discussion This article details technical modifications in multivisceral and isolated intestinal allograft procurement that have been routinely applied by our recovery teams at donor facilities without additional equipment or impedance to concomitant thoracic and abdominal organ procurements. To date, these techniques have been applied to 35 multivisceral/isolated intestinal procurements with excellent organ quality at transplantation. Time to cross-clamp is routinely less than 2 hours with total organ procurement lasting less than 3 hours. No complication related to procurement has occurred, and all organs have been successfully retrieved except when a significant size mismatch was encountered at surgery. Although founded on procurement techniques originally developed by the University of Pittsburgh,8-12 we minimize ex vivo allograft preparation through increased dissection and organ separation in situ. This reduces total cold ischemia time as well as potential injury from extended ex vivo manipulations and inadvertent rewarming using previously described techniques.12,16 Furthermore, we postulate that in situ separation promotes organ sharing among centers through direct shipment from the donor facility. Using the duodenal-sparing composite liver/intestine technique of Bueno et al11 and Sudan et al16 maintains the superior mesenteric artery–portal venous axis, prevents malrotation, and precludes the need for a biliary drainage procedure in the recipient. Preservation of the hepatic hilum eliminates the need for biliary dissection and an anastomosis, thereby reducing the risk of a postoperative biliary complication. Although this excludes the use of pancreas for clinical transplantation, the remaining distal pancreas can be used for islet cell procurement. Through the use of interposition conduits, our isolated intestinal procurement technique does not require sacrifice of the pancreas as mandated by previous investigators.16,18
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