Clinical intestinal transplantation: Experience in Miami

Abstract Intestinal transplantation can be a life-saving procedure for patients with intestinal failure and life-threatening complications of the underlying disease or total parenteral nutrition (TPN). The transplantation techniques at the University of Miami were based on our Pittsburgh experience and the organs were separated as needed following Starzl's cluster principle. According to the latter all intra-abdominal organs are like a grape cluster. They are all hanging from a central stem consisting of the superior mesenteric artery (SMA), superior mesenteric vein (SMV), celiac axis, and portal vein (PV). Individual clumps can be removed without jeopardizing the integrity of the remaining organs. The three main variants of this concept are the isolated intestinal, the combined liver-intestinal, and multivisceral grafts. Common goals in all variants during the implantation procedure are to prevent injury of the organs to be preserved and resect damaged ones without contamination of the peritoneal cavity. In the isolated intestinal transplant the arterialization of the graft is from the infrarenal aorta by end-to-side anastomosis to the donor SMA. The graft portal or SMV can be anastomosed either to the inferior vena cava (IVC) or to the portal system. In the absence of IVC thrombosis, anastomosis to the IVC is technically easier. Anastomosis to the portal system provides hepatopetal flow and is more physiologic but technically more demanding if there have been previous surgeries involving the mesentery. In combined liver-intestine transplantation the native hepatectomy is usually performed with preservation of the native IVC. The native PV is anastomosed end-to-side to the native IVC in order to provide decompression of the retained viscera. This anastomosis can be taken down after the graft is implanted. The native PV can later be anastomosed end-to-side onto the donor portal or end-to-end to the donor splenic vein. More commonly the portocaval shunt is left in place permanently. A short interposition arterial graft, usually a segment of the thoracic aorta of the donor, is placed end-to-side onto the infrarenal aorta to facilitate the arterialization of the graft. Arterialization of the graft is achieved by anastomosis of the donor celiac and SMA with a common Carrel patch to the distal end of the arterial interposition graft. The outflow of the graft is usually provided by anastomosis of the suprahepatic IVC of the graft to the joined ostia of the native suprahepatic veins (piggyback). In multivisceral transplantation the first objective of the resection is to disconnect the visceral blood supply early in the dissection in order to avoid unnecessary bleeding. Various approaches can be utilized. When the lower abdomen is frozen, transection of the esophagus at the esophagogastric junction facilitates exposure of the celiac axis and SMA and early disconnection. The retroperitoneal structures (kidneys, ureters, bladder, the aorta, IVC, and iliac vessels) are carefully preserved as well as the distal esophageal and colonic stumps. Arterial inflow to the graft is with an interposition graft to the suprarenal or more commonly infrarenal aorta. The venous outflow is to the joined ostia of the native suprahepatic veins. A Mikulicz pyloroplasty is routinely performed. The donor esophagogastric junction is oversewn. The esophago(native)gastro(graft)-stomy is performed in two layers to the dome of the stomach. No biliary reconstruction is necessary.