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Case Studies
Dr. Richard Mangus - Multivisceral transplantation consists of the simultaneous transplantation of the liver, stomach, pancreas, duodenum and small intestine. At our center, these organs are procured as a cluster graft and transplanted into a recipient who has had all of these same native organs resected. Read More...
Dr. Bijan Eghtesad - The patient is a 56-year-old woman with a history of chronic pancreatitis. She developed hepatic artery aneurysm and underwent repair of the aneurysm with subsequent thrombosis of the artery. Then she developed intrahepatic bilomas and repeated bouts of cholangitis and sepsis requiring hospitalization and chronic antibiotherapy. Read More...
James V. Guarrera, MD. - The patient is a 60-year old man with a history of Hepatitis C cirrhosis complicated by encephalopathy, ascites, variceal bleeding and splenomegaly with thrombocytopenia.
A 42-year old blood group compatible donor was identified in Tennessee. The donor had a history of polycystic kidney disease. Read More...
Doctors go the "distance" - CIT clock is ticking...
Multivisceral transplantation consists of the simultaneous transplantation of the liver, stomach, pancreas, duodenum and small intestine. At our center, these organs are procured as a cluster graft and transplanted into a recipient who has had all of these same native organs resected. Though this is a strenuous surgical undertaking, our average cold ischemia time for multivisceral transplantation is less than 10 hours.
One Spring day, we received an offer for a multivisceral donor in San Juan, Puerto Rico. Though this was a long procurement distance, the donor was a healthy teenager and we accepted the organs for an elderly gentleman. Our team traveled to Miami, where we changed planes, and then went on to San Juan. As we arrived, the donor operation was already in progress. We informed the local procurement coordinator that we preferred to use histidine-tryptophan-ketoglutarate (Custodiol® HTK) preservation solution for the organ flush. The other team procuring the kidneys had no objection to this, and the organ procurement went uneventfully.
We then retraced our trip back through Miami, again changed planes, and then went on towards home. Unfortunately, as we approached our home city, we hit a late season snow storm and were diverted to another city. We were picked up at the airport by an ambulance, and we expected to be rushed to our hospital, as the recipient operation was well underway. Within 5 minutes of leaving the airport, the ambulance informed us that they had instructions to take us to the nearest hospital, because the roads were unsafe for travel. They dropped us off at a local emergency room. We then called the state police, and a state highway patrolman was dispatched to assist us. He arrived, but was only willing to take one doctor and the organs. Our 45 minute drive lasted well over two hours as we weaved through snarled traffic caught in a roaring blizzard. I finally arrived at the operating room with the multivisceral graft, which now had 12 hours of cold ischemia time.
We performed the bench preparation of the organs, and then proceeded with the transplant. Reperfusion of the organs occurred with greater than 13 hours of cold ischemia time. Though we had used HTK in multivisceral and intestinal transplantation previously, this was the longest cold ischemia time with which we had tested HTK. The organs reperfused normally, and the patient remained stable throughout the remainder of the transplant. The recipient is now more than 2 years out from his transplant and is doing well. Each time I see this patient, I recall one very long trip to Puerto Rico.
En-bloc liver/pancreas transplantation
The patient is a 56-year-old woman with a history of chronic pancreatitis. She developed hepatic artery aneurysm and underwent repair of the aneurysm with subsequent thrombosis of the artery. Then she developed intrahepatic bilomas and repeated bouts of cholangitis and sepsis requiring hospitalization and chronic antibiotherapy. She underwent a left hepatectmy (the predominantly diseased lobe) with Roux-en-Y biliary reconstruction to fix her biliary stricture problem. Over the next one year she developed secondary biliary cirrhosis, and in addition to insulin dependent diabetes she developed exocrine pancreatic insufficiency secondary to repeated attacks of pancreatitis. She was placed on the waiting list for en-bloc liver and pancreas transplantation.
A suitable donor (45-year-old) became available and en-bloc liver duodenum and pancreas with intact portal vein, splenic vein, superior mesenteric vein and artery, bile duct and celiac axis were recovered. The abdominal organs were flushed with eight liters of Custodiol® HTK solution in situ and 2 liters on the back-table through the portal vein via the superior mesenteric vein.
The recipient operation was completion hepatectomy without bypass, with piggyback implantation of the enblock liver/duodenum/ pancreas. Hepatic venous outflow was through the anastomosis between suprahepatic inferior vena cava of the graft and confluence of hepatic veins of the recipient. Portal vein of the recipient was anastomosed to the stump of the superior mesenteric vein of the en-bloc organs. The organs were reperfused through the portal vein with cold ischemia time of seven hours and thirty-five minutes. For arterialization of the grafts we anastomosed common patch of the celiac and superior mesenteric arteries of the donor to the pre-place donor aortic conduit on the infrerenal aorta of the recipient. This conduit was passed through the meso-transverse colon to the en-bloc graft. After successful arterialization of the graft we focused on biliary reconstruction. Since the bile duct was intact in the en-bloc graft we just needed to make an anastomosis between the duodenal patch of the donor to the previously made Roux limb of the recipient. After completion of this anastomosis, thorough irrigation of the operative field, and placement of appropriate drains, abdominal cavity was closed.
Postoperatively, the liver enzymes peaked at AST 6200, and ALT 2700, which rapidly came down and by day 4 they were 166 and 430 respectively. Blood sugar stayed in mid 100's for the next several days requiring insulin supplements. On day 2 after transplantation, because of the presence of bile in the drain we decided to re-explore the patient. The bile leak was from the duodeno-jejunal anastomosis which the anastomosis was revised. An intraoperative cholangiogram through the cystic duct stump of the donor bile duct showed no leak. A laceration in the body of the pancreas was found which was concerning for possible future leak. Because of the plan to re-explore the patient after 3 days for further evaluation of organs abdominal cavity was irrigated but not closed.
After three more interval explorations abdominal cavity was closed and the patient was transferred to regular floor and from there to rehabilitation program. During this period we noticed a low-volume pancreatic fistula which closed spontaneously. The patient required no more pancreatic exocrine supplements and no more insulin. Her liver function tests remained normal except some elevation of canalicular enzymes which eventually returned to normal (Alkaline phosphatase 74) three month after transplantation. Her abdominal wound healed completely.
Extended cold ischemia time for liver transplant
The patient is a 60-year old man with a history of Hepatitis C cirrhosis complicated by encephalopathy, ascites, variceal bleeding and splenomegaly with thrombocytopenia.
A 42-year old blood group compatible donor was identified in Tennessee. The donor had a history of polycystic kidney disease. The liver showed some small cysts but was otherwise normal. The liver was procured and flushed with Custodiol® HTK, 4 liters in aorta and 2 liters in portal vein with an additional backtable flush of 1 liter. The graft was imported to NY.
The patient underwent orthotopic liver transplantation without venovenous bypass which was uncomplicated. The cold and warm ischemia times were 11 hours and 39 minutes respectively. The biliary reconstruction was duct to duct without a T-tube. In addition a spontaneous splenorenal shut was taken down by left renal vein ligation.
The patient received 4 units of packed red cells, 1 unit cellsaver, 6 units of fresh frozen plasma, and 3500cc of crystalloid. There was good immediate graft function with intraoperative bile production.
The patient did well with excellent graft function and only mild reperfusion injury. The peak serum AST was 2530 IU/L which normalized rapidly and was 30 IU/L by post transplant day 5. He was discharged home on POD 14. He is currently doing well without complications and normal liver function tests at 3 months post transplant. |
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