Introduction: Hirschprung’s disease is a common cause of intestinal failure in children. Multivisceral transplant is a lifesaving procedure when irreversible liver disease is present. Absence of ganglions in the colon limit the ability to restore the intestinal continuity; hence, an end ostomy is the most common choice. A small pull-through is a common procedure used in pediatric surgery but very rarely used for transplant patients.

Methods: We are describing the first sigmoid pull-through operation performed in a Multivisceral transplant recipient with preservation of the donor inferior mesenteric artery (IMA) for inclusion of the entire colon as part of the graft. A review of literature was performed and six cases of pull-through in intestinal transplants recipients were found. Four of the cases were Liver-Intestine recipients, one stomach-pancreas-intestine and one isolated intestine.

Results: 18 months old diagnosed with Hirschsprung’s disease on the first week of life by serial full thickness biopsies.  Aganglionic small bowel was found in addition to the entire colon. After resection 56cm of small bowel was left from ligament of treitz to end jejunostomy.  However, thereafter bowel was found to have significant dysmotility with inability to wean PN. Intestinal failure course was complicated by severe PN Associated Liver Disease with total bilirubin of 16 mg/dl at time of referral. Patient was listed for multivisceral transplant with a weight of 12kg. A 5 kg donor became available and due to small size the kidneys were not allocated. Due to size mismatch, there was a concern the donor right colon would not be long enough to perform a pull-through operation and a definitive ostomy would be necessary. Since the kidneys were not harvested we included the entire aorta with preservation of the IMA and the entire colon in the graft.  A small modification from our standard technique in the recipient operation was necessary with aortic inflow being placed supraceliac.  A temporary ostomy was performed at the end of the transplant and only skin was closed at that time. Few days later the resection of the remaining rectum and a pull-through operation  was carried on. A loop ileostomy was done to protect the sigmoid-anal anastomosis and graft surveillance.

Conclusion: The use of very small donors for Multivisceral transplantation requiring pull-through operation is feasible with the preservation of the inferior mesenteric artery and inclusion of the entire colon. Aortic anastomosis must be performed supraceliac. Inclusion of the IMA enhances blood supply to the distal colon making the anastomosis much safer.