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Preoperative Vascular Interventions in Complex Visceral Transplantation

2017; Wolters Kluwer; Volume: 101; Issue: 6S2 Linguagem: Inglês

10.1097/01.tp.0000521448.99508.5b

1534-6080

Ajai Khanna, Ihab Haddadin, Mohammed Osman, Masato Fujiki, Koji Hashimoto, Guillerme Costa, Kareem Abu El Magd,

Clinical Nutrition and Gastroenterology

Multivisceral transplantation (MVT) is indicated in patients with portal hypertension, endstage liver disease and diffuse portal system thrombosis (PST). Successful transplantation in these patients can be limited by problems of venous access, severe portal hypertension and a hostile abdomen. But for transplantation these patients would die of multiple complications related to liver failure and sepsis. We have adopted some pre and perioperative vascular interventions to ensure safety and success of MVT. The role of a dedicated anesthesia and interventional radiology team cannot be overemphasized. Absent venous access: It is not uncommon to have patients with extensive thrombosis of the upper extremity veins. These patients have no venous access above the diaphragm, precluding transplant candidacy. In these patients we have adopted a strategy of cannulation of radial artery for perioperative fluid and blood resuscitation. PST with frozen abdomen: A 54 year old patient with history of necrotizing pancreatitis, secondary biliary cirrhosis and extensive thrombosis of portal mesenteric circulation was listed for MVT. A suitable set of organs became available for him and he was brought in for transplantation. Upon entry into the abdomen we encountered extensive adhesions and venous collaterals related to portal hypertension. Transplant was aborted. His medical management was optimized. 7 weeks later he was offered a set of organs. In preparation for transplantation this time, he underwent splenic and gastroduodenal artery embolization to reduce portal flow and portal hypertension associated bleeding. In addition, vascular sheaths were placed in the aorta in preparation for occlusion of superior mesenteric and celiac artery respectively to limit bleeding during native enterectomy and hepatectomy. He underwent successful MVT to include stomach, pancreas, duodenum, liver and small bowel. Vascular inflow was provided from a supraceliac aortic graft using the donor thoracic aorta and outflow was through the suprahepatic cava. The liver was implanted in a piggyback fashion. Foregut was reconstructed by donor to recipient gastrogastric anastomosis. Hindgut reconstruction was deferred due to prolonged operation. Vascular sheaths were removed during the postoperative period. An end ileostomy was created. A week post transplant the patient underwent exploratory laparotomy, takedown of ileostomy, ileosigmoid anastomosis and a chimney ileostomy. The patient is currently doing well with full nutritional autonomy and excellent liver and pancreas allograft function. Conclusion: Proper preoperative planning with a multidisciplinary approach involving anesthesia and interventional radiology expertise is essential to ensure a successful outcome in these complex patients in need of visceral transplantation. The above mentioned interventions can lead to successful outcomes in select group of patients.Figure