2017 - CIRTA

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3- Donor Selection and Technical Aspects of Intestine Transplantation

27.6 - Innovative Sphincter Preserving pull-through technique with en bloc Colon and Small Bowel Transplantation

Presenter: Ajai, Khanna, Pittsburgh, United States
Authors: Ajai Khanna, Masato Fujiki, Mohammed Osman, Kareem Eid, Koji Hashimoto, Guillerme Costa, Kareem Abu El Magd

Innovative Sphincter Preserving pull-through technique with en bloc Colon and Small Bowel Transplantation

Ajai Khanna1, Masato Fujiki1, Mohammed Osman1, Kareem Eid1, Koji Hashimoto1, Guillerme Costa1, Kareem Abu El Magd1.

1Center For Gut Rehabilitation and Transplantation, The Cleveland Clinic, Cleveland, OH, United States

With improved intestinal allograft survival, colon transplantation is becoming increasingly common. A new technique of sphincter-preserving pull-through operation with colo-intestinal transplantation (CIT) was done in five patients. 3 of the five patients had their stomas closed with good continence. All patients are nutritionally independent with functioning allografts.

Between 2008 and 2016, 5 patients underwent sphincter preserving pull-through technique with en bloc CIT. 4 had shortgut syndrome related to endstage Crohn’s disease and one was transplanted for dysmotility related to Ehler-Danlos syndrome. Immunosuppression consisted of alemtuzumab induction followed by tacrolimus and steroid. Arterial inflow was provided by infrarenal aortic graft. Venous drainage was portal (n=3) or systemic (n=2).

Donor procurement: Middle colic artery was ligated proximal to its bifurcation to preserve continuity of arterial arcades and avoid injury to the inferior pancreaticoduodenal artery to allow for use of pancreas as a solitary allograft. IMA was ligated close to its origin. Small bowel and colon were retrieved en bloc. Ileocolic and right colic arteries were the main axial blood supply via the marginal arcades.

Allograft implantation: After anastomosing the vascular conduits to the recipient infrarenal aorta and superior mesenteric vein or IVC, vascular anastomoses were accomplished to the respective conduits followed by revascularization. Proximal jejunum was anastomosed to the native duodenum (Figure). The abdomen was closed with an end-colostomy in 4 patients. In 1 patient creation of an end stoma was deferred.

Intersphincteric resection of the rectum with colo-anal anastomosis

Between 2nd and 11th postoperative day all 5 patients underwent intersphincteric resection of the rectum with colo-anal anastomosis. In stirrup position with a transabdominal assist, the rectal segment was fully excised through a transanal intersphincteric approach leaving the external anal sphincter intact. Transplanted large bowel was delivered through the pelvic hiatus with no tension or malrotation and anastomosed to the anal verge. The abdomen was closed and a simple loop ileostomy 20 cm proximal to the ileocecal valve was created (Figure 1). Ileostomy was closed in 3/5 patients between 4 and 11 months post transplantation. 2 patients 3 and 14 month post transplantation are are awaiting stoma closure.

Results: All patients currently are doing well with good allograft function between 3 months and 8 years post-transplant. All are nutritionally independent. 2/3 patients who underwent stoma closure have full continence. One patient is partially continent 23 months following transplantation. This novel technique of CIT improves allograft’s absorptive capacity and quality of life in select patients with preserved anal sphincter.

Wiley Periodicals Inc. for Figure.

[1] Am J Transplant. 2010 Aug;10(8):1940-6.

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