Abu-Elmagd, K

Casavilla, A

Selby, R

Starzl, TE

Todo, S

Tzakis, A

English

PubMed

Name not available

Donor selection and surgical technique for en bloc liver-small bowel graft procurement

D-Scholarship@Pitt

/5110 Donor Selection and Surgical Technique for en Bloc Liver-Small Bowel Graft Procurement A. Casavilla, R. Selby, K. Abu-Elmagd, A. Tzakis, S. Todo, and T.E. Starzl COMBINED liver-small bowel retrieval has been suc-cessfully performed in 12 cadaveric donors over a 19-month period. Eight allografts were implanted en bloc. while the remainder were separated after retrieval and implanted independently. This report details the important aspects of donor selec-tion and procurement that ensure the yield of quality organs and facilitate later implantation. METHODS Three adults (mean age, 34.7 years; range, 21 to 47 years) and nine children (mean age. 2.9 years; range. 8 days to 16 years) with a broad range of causes of death were selected as cadaveric donors (Table I). Two other candidates were accepted and explored but rejected after peritonitis (one case) and mesenteric lymphadenop-athy (the second case) were encountered. Initially. our preference was for infant and juvenile donors with stable hemodynamic parameters.' However. the age range was expanded. provided the patients exhibited hemodynamic stability on minimal vasopressor support (::;10 ~kglmin of dopamine). Size considerations were given special attention (Table I). In elective circumstances we chose donors who were 15% to 40% smaller than the designated liver-small bowel recipient. Superim-posed liver failure in one case forced the urgent assignment of a larger donor. Preoperative liver function was evaluated with the standard criteria for liver donor selection. Because of time constraints. no functional assessment of the small bowel could be penormed. It can only be inferred that young hemodynamically stable patients with acceptable liver function tests will have normal intestinal function and anatomy. Decontammation of the donor small bowel. using a combination of oral nonabsorbable and intravenous anti-biotics. was accomplished. Table 1. Donor Data: Causes of Death and Donor-Reclplent Size Matches Case F. 36 Y F. 2.7 Y M. 16 Y F. 1.2 Y M. 1.8 Y M.Sd F. 0.5 Y F. 0.9 Y M.21 Y M.2y M. 1.S Y F.47y Cause of Dealll Intracranial bleeding Bactenal meningitis Closed head injury Drowning Smoke inhalation Intracranial bleeding Closed head injury Drowning Closed head injury Closed head injury Drowning Intracranial bleeding Donor/Recipient WeigI'It (Ib) 119/141· 26.4127.3t 100/117f 20/44t 2S.6I3O.St 7.s/15t 13.8/21.3t 18124.2t 198/154T 28.6131· 26.4I1S· 1PT~p· The essence of the retrieval technique entails a hepatic hilar dissection followed by an ascending and transverse colon mobili-zation and division of the proximal and distal small bowel. Next, a duodenopancreatectomy strips away unnecessary tissues and prepares the target organs for selective cooling. We limit the cold perfusion of the composite graft to avoid small bowel edema. Additional cold flushing of the liver alone is penormed as neces-Sary' The composite graft is removed after the thoracic organs and packed in University of Wisconsin solution for transport. Kid-neys. and in some cases the pancreas for islets. are subsequently removed. Eight of 12 composite organs have been procured and trans-planted en bloc. whereas the remaining four allografts were procured en bloc and separated at the back table for independent allocation. RESULTS Assurance of gross anatomic integrity of the grafts was provided by the intraoperative appearance in both the donor and the recipient. and by postoperative stomal characteristics and serous effluent. Seven of the eight patients who received a combined intestine and liver graft remain alive from 164 to 557 days posttransplant (mean, 338 days). One patient died 23 days after transplantation from graft-vs-host disease. All of the isolated small bowel grafts (n = 4) functioned with minimal ischemic injury. Patient follow-up is 35 to 642 days (mean. 202 days). Of the four liver allografts. two failed and required early retransplantation. one from unsuspected hemochromato-sis. and the other from hepatic artery thrombosis. DISCUSSION Donor age, hemodynamic stability, and donor-recipient size match should be primary donor considerations for liver-small bowel retrieval. Selecting a stable donor increases the likelihood of obtaining quality organs and permits a meticulous dissec-tion that often takes 2.5 hours by an experienced trans-plant surgeon. This in vivo dissection allows complete hemostasis of smaller vessels that can lead to meddlesome bleeding or lymphorrhea after engraftment. and permits From the Pittsburgh Transplantation Institute, University of Pins· burgh, Pittsburgh, Pennsylvania. Supported by research grants from the Veterans AdministratIOn and Project Grant DK 29961 from the National Institutes of Health. Address repnnt requests 10 Thomas E. Slarzl. MD, PhD. 3601 Fifth Avenue. SiC Falk CliniC. Pittsburgh, PA 15213. ,S) 1993 by Appleton & Lange 0041-13451931$3.00/+0 2622 Transplantation ProceedingS. Vol 25. No 4 (August), 1993: pp 2622-2623 LlVER-SMALL BOWEL GRAFT PROCUREMENT visualization of critical anatomic structures that might be easily injured when dissecting ex vivo. Judgment about the donor-recipient size match is im-portant. The majority of recipients have had extensive visceral resections. leading to progressive volume reduc-tion of the abdominal cavity. Therefore. the selected donors were generally of lesser size and weight. Problems with the use of smaller donors and consequent discrepancy of the great veins can be obviated by engrafiing the liver with the "piggyback" techniqueK~ When the donor is of nearly equal size or larger than the recipient. staged 2623 abdominal wall closure may be necessary, as in one case at our center. We have demonstrated a successful approach to donor selection and liver-small bowel retrieval. The procedure has yielded quality organs without major anatomic or microscopic preservation injury. REFERENCES I. Casavilla A. Selby R. Abu·Elmagd K. et ai: Ann Surg 216:85. 1992 2. Tzakis A. Todo S, Starzl TE: Ann Surg 210:649. 1989 

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Donor selection and surgical technique for en bloc liver-small bowel graft procurement

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