**4. Types of intestinal transplant**

The choice of transplant type depends on the underlying cause of IF, quality of native organs, state of liver disease (if present) and history of previous abdominal surgeries. The main types of ITx are:


**Figure 1.** Small bowel transplant (SBTx).

**3. Contraindications**

Failure of TPN

acceptance of TPN

or inability to function

in adults)

Congenital mucosal disorders

sepsis

Impending or overt liver failure

Central venous thrombosis of 2 central veins Frequent and severe central venous catheter-related

intravenous fluids in addition to TPN

Frequent episodes of severe dehydration despite

Intestinal failure with high morbidity and low

Ultra-short bowel syndrome (<10 cm in infants, <20 cm

Need for frequent hospitalization, narcotic addiction

Patient's unwillingness to accept long-term TPN

**Table 2.** Intestinal transplantation guidelines.

**1.** significant comorbidities;

eration significantly; and

of ITx are:

**4. Types of intestinal transplant**

transplant process;

and are frequently reassessed. These include:

**North America Europe**

292 Organ Donation and Transplantation - Current Status and Future Challenges

Intra-abdominal invasive desmoids tumour Intra-abdominal desmoids

The contraindications of intestinal transplantation are the same as for all other transplants

failure

High risk of death attributable to underlying disease CVC-related multiple venous thrombosis (in appropriately

selected patients)

Impending or overt liver failure due to IFALD-related liver

Individual case by case decision for patients with IF with

high morbidity or low acceptance of TPN

**2.** active uncontrolled infections or malignancies that are not totally resectable during the

**4.** anatomical challenges that can prove the operation high risk such as inferior vena cava (IVC) and portal vein (PV) thrombosis. Previous laparotomies can also complicate the op-

The choice of transplant type depends on the underlying cause of IF, quality of native organs, state of liver disease (if present) and history of previous abdominal surgeries. The main types

**5.** opiate dependence is very common and rehabilitation should be considered early.

**3.** psychosocial factors (e.g. lack of post-operative support network);

**Figure 2.** Liver and small bowel transplant (SBLTx).

In all the above ITx types, the right hemicolon can be included depending on the patient's native anatomy. Since 2000, there has been a sixfold increase in the inclusion of a colon segment resulting in a current inclusion rate of 30% [7]. The registry analysis has shown that inclusion of the colon did not adversely affect survival and recipients with a colon segment had a 5% higher rate of independence from supplemental parenteral nutrition (PN), as the retention of the ileocecal valve and the right colon enhance gut function through better fluid

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It's sometimes possible to carry out a small bowel transplant using a section of bowel donated by a living family member and the first standardized technique was reported by Gruessner

Because of previous surgery resulting in loss of abdominal wall domain and integrity, patients undergoing ITx face a problem with primary abdominal wall closure [25]. Surgical techniques such as reduction of the liver portion (left or right lobe) within the composite allograft [26], transplantation of composite abdominal wall tissue graft (**Figure 5**) [27, 28], the use of vascularized rectus sheath [29] and non-vascularized abdominal rectus fascia [30] have revolution-

absorption and uptake of free fatty acids [23].

**Figure 4.** Modified multivisceral transplant (MMVTx).

ized abdominal wall reconstruction.

and Sharp [24].

**Figure 3.** Multivisceral transplant (MVTx).

**Figure 4.** Modified multivisceral transplant (MMVTx).

**Figure 3.** Multivisceral transplant (MVTx).

**Figure 2.** Liver and small bowel transplant (SBLTx).

294 Organ Donation and Transplantation - Current Status and Future Challenges

In all the above ITx types, the right hemicolon can be included depending on the patient's native anatomy. Since 2000, there has been a sixfold increase in the inclusion of a colon segment resulting in a current inclusion rate of 30% [7]. The registry analysis has shown that inclusion of the colon did not adversely affect survival and recipients with a colon segment had a 5% higher rate of independence from supplemental parenteral nutrition (PN), as the retention of the ileocecal valve and the right colon enhance gut function through better fluid absorption and uptake of free fatty acids [23].

It's sometimes possible to carry out a small bowel transplant using a section of bowel donated by a living family member and the first standardized technique was reported by Gruessner and Sharp [24].

Because of previous surgery resulting in loss of abdominal wall domain and integrity, patients undergoing ITx face a problem with primary abdominal wall closure [25]. Surgical techniques such as reduction of the liver portion (left or right lobe) within the composite allograft [26], transplantation of composite abdominal wall tissue graft (**Figure 5**) [27, 28], the use of vascularized rectus sheath [29] and non-vascularized abdominal rectus fascia [30] have revolutionized abdominal wall reconstruction.

Vascular access is of utmost importance and is assessed by magnetic resonance or computed tomography venogram. Securing upper-body vascular access is mandatory in cases where IVC occlusion is anticipated. Many patients will have central venous stenosis or obstruction and will mandate interventional radiology and/or vascular reconstruction

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Manometry of the esophagus, stomach and rectum should be considered in patients with

While on the waiting list, patients should be frequently reassessed, with specific attention given to any change in medical status, deterioration in liver function or vascular access.

• Wide access to the abdominal cavity is needed and can be achieved via a midline incision

• The ascending colon and hepatic flexure are mobilized by using right-sided medial visceral rotation (Cattel-Braasch maneuver) that will expose the third and fourth portions of the

• First, achieve control of the right common iliac artery or the distal abdominal aorta, which

• The structures of the hepatoduodenal ligament will have to be identified and slung for

• Depending on the type of transplant, sling the esophagus, the antrum or proximal jejunum.

• In case of MMVTx, the celiac axis has to be retrieved along with the left gastric and splenic arteries. This should be discussed with the liver implanting team in case of a left aberrant

• Transect the gastrocolic ligament and, in case of large bowel retrieval, identify the middle colic vessels. Mark the transverse colon just distal to the vessels for the insertion of the gastrointestinal anastomosis (GIA) stapler. For small bowel, sling the ileum near the ileocecal valve. • Expose the mesenteric root, abdominal aorta and infrahepatic IVC, including entry of the

• If the pancreas is to be retrieved, the splenic flexure, spleen, and body and tail of pancreas

• Perform proximal control for supraceliac cross-clamping, either above or below the dia-

are mobilized to allow adequate subsequent cooling of the pancreas.

phragm, depending on the presence of a cardiothoracic team.

from the suprasternal notch down to the symphysis pubis.

small bowel alone or modified multivisceral transplants.

need to be mobilized for subsequent insertion of the infusion cannula.

before listing.

dysmotility disorders.

**6. Surgical technique**

**6.1. Intestinal retrieval**

duodenum.

artery.

renal veins.

**Figure 5.** Abdominal wall transplant.
