Introduction: Biopsy and histologic evaluation is the gold standard for graft assessment in intestinal transplantation. Usually a temporary ostomy is created to facilitate graft evaluation. Ostomy biopsies can be performed without sedation and the risk of complication is minimal. Ostomies are often associated with episodes of dehydration, low patient satisfaction, readmissions and social limitations. Our group has been selectively performing multivisceral transplants without ostomy. However, patients need sedation for colonoscopies, a not well tolerated colon preparation, and the graft cannot be evaluated for few weeks due to increased risk of perforation. Potential delays in the diagnosis of rejection may be another risk of not performing an ostomy.  For all these reasons, we developed the Hybrid Ostomy. This technique associates the benefits of easy graft evaluation of a regular ostomy without the hurdles of having one.

Method: Our group first described the Hybrid Ostomy Technique using the transplanted colon Add Reference 1 . It is well known the terminal ileum is the first part of the graft to present any pathological finding. It is not uncommon to simultaneously have normal transplanted colon and rejection in the terminal ileum biopsy. To maximize the graft evaluation, we abandoned the initial technique and redesigned the Hybrid Ostomy utilizing the terminal ileum. Our goal is to describe the evolution of this Technique.

Results:  After reperfusion, proximal and distal anastomosis are performed in the standard way. Terminal ileum is divided 15 cm from the ileocecal valve using GIA stapler. Another GIA stapler is fired 15 cm proximally from the initial division. The mesentery is divided up to the base making sure vascular supply is preserved. Excluded 15 cm of ileum is moved medially and a side to side anastomosis in two layers is performed in the standard way between the two sides of the ileum (Figure 1). Defect in the mesentery is closed to prevent internal hernias. Ostomy is brought out to the skin and matured in standard fashion (Figure 2).  Video is available demonstrating an ileoscopy with biopsy in the Hybrid Ostomy.
 
Conclusions:  Hybrid Ostomy combines all the benefits of not having a real ostomy with the advantage of histological evaluation of the graft without the risks and preparation of a colonoscopy. It is technically easy, patient satisfaction is high, and episodes of dehydration are rare. Ostomy takedown does not affect the intestinal function and hospitalization is not required. Hybrid Ostomy has become a standard procedure in our center.

[1] 1. Beduschi T, Garcia J, Ruiz P, Tekin A, Selvaggi G, Nishida S, Fan J, Vianna R. Hybrid Ostomy – New Technique in Intestinal Transplantation [abstract]. Am J Transplant. 2015; 15 (suppl 3).