2017 - CIRTA

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3- Donor Selection and Technical Aspects of Intestine Transplantation

27.12 - Preservation of the Stomach, Pancreas and Spleen during Liver and Small or Isolated Bowel Transplantation for Portal and Mesenteric Vein Thrombosis

Presenter: Neil, Russell, Cambridge, United Kingdom
Authors: Andrew Butler, Neil Russell, Irum Amin, Lisa Sharkey

Preservation of the Stomach, Pancreas and Spleen during Liver and Small or Isolated Bowel Transplantation for Portal and Mesenteric Vein Thrombosis

Andrew Butler1, Neil Russell1, Irum Amin1, Lisa Sharkey1.

1Cambridge Intestinal Failure and Transplant, Addenbrookes, Cambridge, United Kingdom

Introduction: Widespread mesenteric and portal vein thrombosis is an increasing indication for multivisceral transplantation. Full multivisceral transplantation with splenectomy and gastric replacement is associated with a number of complications including increased risk of aspiration, pneumonia, sepsis and GVHD.
In addition patients with non cirrhotic portal hypertension with structurally normal liver but complications associated with portomesenteric thrombosis may be candidates for small bowel transplantation without the need for liver replacement.

Methods: We describe a modified procedure that allows use of either a liver and small bowel transplant or isolated bowel transplant for these patients that negates the need for splenectomy and gastric transplantation and may allow preservation of the native liver (in the context of non cirrhotic portal hypertension).

Results: In a series of 4 patients with widespread porto mesenteric thrombosis we performed a stomach, pancreas and spleen preserving enterectomy and subsequent liver and small bowel transplant.
For technical reasons there was no capacity to perform a porto caval shunt and the native stomach, pancreas and splenic venous drainage was maintained via mesenteric collaterals (the small bowel mesentery being preserved).
In 3 patients with widespread porto mesenteric thrombosis requiring small bowel transplantation an explant procedure leaving the native liver, stomach, spleen, duodenum and proximal jejunum was undertaken. One patient required transplant for complications of short gut, one for uncontrollable GI haemorrhage and one for an otherwise irresectable pancreatic lesion.
In all 7 patients there was adequate mesenteric venous drainage of the residual native gastrointestinal organs and there were no enteric anastomotic complications.
One patient (who received an isolated small bowel transplant) developed encephalopathy 6 years post transplant. One of the liver small bowel recipients died as a consequence of graft SMA occlusion, the cause of which was unclear.

Conclusions: These cases demonstrate the safety of limited enterectomy in the context of portomesenteric venous thrombosis for both isolated bowel transplant and also liver small bowel transplant. This reduces the morbidity of both the transplant procedure and also the postoperative course.

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