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Spectrum of Imaging Findings After Intestinal, Liver-Intestinal, or Multivisceral Transplantation: Part 1, Posttransplantation Anatomy

¹ Department of Pediatrics, Leopold-Franzens University, Anichstrasse 35, Innsbruck A-6020, Austria.
² Department of Radiology, Leopold-Franzens University, Innsbruck, Austria.
³ Department of General Surgery and Transplantation Surgery, Leopold-Franzens University, Innsbruck, Austria.

Received December 27, 2003; accepted after revision March 9, 2004.

 
Address correspondence to K. M. Unsinn.

Introduction

Top Introduction Intestinal Transplantation Multivisceral Transplantation Liver-Intestinal Transplantation References

 
Intestinal transplantation is an alternative in patients with irreversible chronic intestinal failure in order to restore enteral absorption of ingested food and fluid. In adults, the most common cause of chronic intestinal failure results from extensive resection of the small bowel because of occlusion of the superior mesenteric vessels, inflammatory bowel disease, or abdominal trauma. In children, the causes of short-bowel syndrome are midgut volvulus, gastroschisis, intestinal atresia, and necrotizing enterocolitis. Intestinal failure infrequently results from permanent intestinal dysfunction despite normal intestinal length. This occurs more frequently in children and includes aganglionosis; malabsorption syndromes, particularly microvillus inclusion disease; and motility disorders, particularly intestinal pseudoobstruction [1].

Intestinal transplantation with cyclosporine-based immunosuppression started in the 1980s in North America [2] and Europe [3] and was followed by multivisceral transplantation [4, 5] and liver-intestinal transplantation [6]. Isolated intestinal transplantation is indicated for patients with irreversible intestinal failure without liver dysfunction and serious total parenteral nutrition-related complications, mostly lack of venous access due to recurrent thrombosis. Liver-intestinal transplantation is primarily indicated for patients with intestinal failure and total parenteral nutrition-related cholestatic liver failure. Multivisceral transplantation is indicated for patients with irreversible failure of the small bowel and liver combined with portomesenteric thrombosis or Gardner's syndrome with intraabdominal desmoid tumor [7].

Proper interpretation of imaging studies after transplantation depends on familiarity with surgical anatomy [8-11]. For this reason, this pictorial essay schematically illustrates the intraoperative appearance during the most important steps of the main intestinal transplantation procedures performed in children and adults. Each procedure is supplemented with examples of typical anatomy as shown by various imaging techniques including sonography, CT, MRI, gastrointestinal contrast series, and angiography.

The various procedures of small-bowel transplantation are described and illustrated in the following order: intestinal, multivisceral, and liver-intestinal transplantation.

Intestinal Transplantation

Top Introduction Intestinal Transplantation Multivisceral Transplantation Liver-Intestinal Transplantation References

 
The postoperative anatomy of isolated transplantation of the small bowel in a cadaveric donor [7] is schematically shown in Figures 1A, 1B, 1C, although living related intestinal transplantation has already been performed [12]. During procurement, the size-matched donor small bowel and an arterial and venous main stem are excised. The ileum is transected proximal to the ileocecal valve, and the jejunum is divided close to the ligament of Treitz; especially the ileal branches of the ileocolic artery should be preserved.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Schematic illustrations of isolated intestinal transplantation. Ao = abdominal aorta, CIA = common iliac artery, d = donor, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, TI = temporary ileostomy, single arrow = duodenojejunal anastomosis, double arrows = ileocolonic anastomosis, open arrowhead = superior mesenteric vein stump, solid arrowhead = venous extension graft, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intestinal graft after explantation and ex situ preparation on back-table.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Schematic illustrations of isolated intestinal transplantation. Ao = abdominal aorta, CIA = common iliac artery, d = donor, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, TI = temporary ileostomy, single arrow = duodenojejunal anastomosis, double arrows = ileocolonic anastomosis, open arrowhead = superior mesenteric vein stump, solid arrowhead = venous extension graft, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after heterotopic intestinal transplantation. End-to-side anastomosis of recipient common iliac artery to donor superior mesenteric artery and donor superior mesenteric vein to recipient inferior vena cava are also depicted.

View larger version (87K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —Schematic illustrations of isolated intestinal transplantation. Ao = abdominal aorta, CIA = common iliac artery, d = donor, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, TI = temporary ileostomy, single arrow = duodenojejunal anastomosis, double arrows = ileocolonic anastomosis, open arrowhead = superior mesenteric vein stump, solid arrowhead = venous extension graft, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after orthotopic intestinal transplantation. End-to-side anastomosis of recipient infrarenal abdominal aorta to donor superior mesenteric artery and donor superior mesenteric vein to recipient superior mesenteric vein stump utilizing venous extension graft are depicted.

If the pancreas is not to be used as a graft, the origin of the superior mesenteric artery is excised. The splenic vein is transected next to the venous confluence, and the portal vein is transected above the confluence of the superior mesenteric and splenic veins. In cases of pancreas procurement, the superior mesenteric vein is transected at the lower rim of the pancreas. In the recipient, all adhesions from previous surgical procedures are dissected and the infrarenal abdominal aorta and the venous confluence or inferior vena cava are exposed.

In cases of orthotopic transplantation, the intestinal allograft is revascularized in an end-to-side fashion to connect the donor superior mesenteric artery to the recipient infrarenal abdominal aorta above the origin of the inferior mesenteric artery and the donor superior mesenteric vein to the recipient superior mesenteric vein or portal vein.

In cases of heterotopic transplantation, vascular continuity is restored in an end-to-side fashion to connect the donor superior mesenteric artery to the recipient infrarenal abdominal aorta below the origin of the inferior mesenteric artery or common iliac artery and the donor superior mesenteric vein to the recipient inferior vena cava or common iliac vein. Proximal intestinal continuity is established between the most distal level of the recipient upper gastrointestinal remnant and the donor jejunum, duodenum, or stomach. A gastrojejunal anastomosis is usually performed in an end-to-side fashion. The type of duodenojejunal or jejunojejunal anastomosis, either end-to-end or side-to-side, is dictated by anatomic and surgical considerations. The distal enteric anastomosis varies depending on the anatomy of the recipient.

In patients with an intact terminal ileum, an ileoileal anastomosis can be performed, which preserves the ileocecal valve. In patients with only parts of the colon remaining, the donor ileum can be anastomosed to the residual recipient colon. In every case, a temporary ileostomy is performed for direct inspection of graft mucosa and for access of surveillance endoscopy and biopsies; it is surgically closed 3-6 months after transplantation. For patients with previous proctocolectomy, a terminal ileostomy is performed.

View larger version (74K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —Schematic illustrations of multivisceral transplantation. d = donor, L = liver, P = pancreas, r = recipient, ST = stomach, TI = temporary ileostomy, single black arrow = gastrogastric anastomosis, white arrows = cavocaval anastomosis, double black arrows = ileocolonic anastomosis, open arrowheads = aortic segment together with celiac trunk and superior mesenteric artery, solid single arrowheads = inferior vena cava segment together with hepatic veins, solid double arrowheads = aortoaortic anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows multivisceral graft on back-table after explantation.

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —Schematic illustrations of multivisceral transplantation. d = donor, L = liver, P = pancreas, r = recipient, ST = stomach, TI = temporary ileostomy, single black arrow = gastrogastric anastomosis, white arrows = cavocaval anastomosis, double black arrows = ileocolonic anastomosis, open arrowheads = aortic segment together with celiac trunk and superior mesenteric artery, solid single arrowheads = inferior vena cava segment together with hepatic veins, solid double arrowheads = aortoaortic anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after implantation.

Typical examples of regular anatomy are shown using CT, catheter angiography, and gastrointestinal contrast studies (Figs. 2A, 2B, 2C, 2D, 2E, 2F, 3A, 3B, 3C, 3D, 4A, 4B, 5, 6).

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with only oral contrast material (A) and with oral and IV contrast material (B) show normal wall, mucosal folds, and contrast enhancement of intestinal graft.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with only oral contrast material (A) and with oral and IV contrast material (B) show normal wall, mucosal folds, and contrast enhancement of intestinal graft.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with oral and IV contrast application at level of arterial anastomosis (C) and at level of venous anastomosis (D) show donor superior mesenteric artery arising from recipient infrarenal aorta and donor superior mesenteric vein draining in recipient inferior vena cava.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with oral and IV contrast application at level of arterial anastomosis (C) and at level of venous anastomosis (D) show donor superior mesenteric artery arising from recipient infrarenal aorta and donor superior mesenteric vein draining in recipient inferior vena cava.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen. Selective catheter angiogram obtained during dominant arterial phase shows arterial anastomosis of donor superior mesenteric artery to recipient infrarenal aorta.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2F. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen. Selective catheter angiogram obtained during dominant venous phase displays venous anastomosis of donor superior mesenteric vein to recipient inferior vena cava.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric vein draining in recipient portal venous confluence.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric vein draining in recipient portal venous confluence.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric artery arising from recipient infrarenal aorta.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric artery arising from recipient infrarenal aorta.

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —Contrast-enhanced MDCT scans obtained 4 months after intestinal transplantation in 5-year-old girl with short-bowel syndrome. Ao = abdominal aorta, C = colon, CIA = common iliac artery, d = donor, D = duodenum, I = ileum, IMA = inferior mesenteric artery, IVC = inferior vena cava, J = jejunum, r = recipient, SMV = superior mesenteric vein, white asterisks = intestinal graft lumen, black arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node. Images show proximal intestinal end-to-end anastomosis (between white arrowheads, A) between recipient duodenum and donor jejunum (A) and distal intestinal end-to-end anastomosis (between white arrows, B) marked by hyperdense staple line between donor ileum and recipient ascending colon (B).

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —Contrast-enhanced MDCT scans obtained 4 months after intestinal transplantation in 5-year-old girl with short-bowel syndrome. Ao = abdominal aorta, C = colon, CIA = common iliac artery, d = donor, D = duodenum, I = ileum, IMA = inferior mesenteric artery, IVC = inferior vena cava, J = jejunum, r = recipient, SMV = superior mesenteric vein, white asterisks = intestinal graft lumen, black arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node. Images show proximal intestinal end-to-end anastomosis (between white arrowheads, A) between recipient duodenum and donor jejunum (A) and distal intestinal end-to-end anastomosis (between white arrows, B) marked by hyperdense staple line between donor ileum and recipient ascending colon (B).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5. —Upper gastrointestinal study with water-soluble contrast material obtained 4 weeks after intestinal transplantation in 39-year-old man with short-bowel syndrome. Image shows proximal intestinal side-to-end anastomosis (between arrows) between recipient duodenum and donor jejunum. d = donor, D = duodenum, J = jejunum, r = recipient, ST = stomach, asterisk = recipient duodenal stump, between arrows = proximal intestinal anastomosis, arrowheads = gastric tube.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6. —Retrograde intestinal enema study obtained 3 months after intestinal transplantation in 59-year-old man with short-bowel syndrome shows blocked Foley catheter (open arrowhead) within isolated donor intestinal loop (asterisk) and distal intestinal end-to-side anastomosis (between arrows) between donor ileum and recipient rectum. d = donor, I = ileum, J = jejunum, r = recipient, R = rectum, solid arrowhead = intestinal tube.

Multivisceral Transplantation

Top Introduction Intestinal Transplantation Multivisceral Transplantation Liver-Intestinal Transplantation References

 
A multivisceral graft usually uses the liver, the pancreas, part of the stomach, the duodenum, and the small bowel [4, 5]. During explantation, the various donor organs are mobilized en bloc without manipulation of the portal venous system. If the stomach is used, the greater gastric curvature is mobilized with preservation of the gastroepiploic arch; the short gastric vessels are transected, and the greater omentum is resected. Cholecystectomy and splenectomy are performed either in situ or ex situ on the back-table. During procurement, the donor liver is typically removed together with the inferior vena cava. For arterial revascularization, 10 cm of donor aorta is excised above the celiac trunk and directly below the superior mesenteric artery to preserve the origins of the renal arteries for further renal transplantation.

The procured aorta is closed with sutures below the origin of the superior mesenteric artery. This creates an aortic conduit with the celiac trunk and superior mesenteric artery; the proximal part of the aortic conduit is designated for aortoaortic anastomosis. Formerly, the combined origins of the celiac trunk and superior mesenteric artery were excised for arterial revascularization. This technique was abandoned because it was more technically demanding and unpredictable due to anastomotic scarring and ensuing arterial stenosis.

Transection of the small bowel is performed in a way similar to that used in intestinal transplantation except for dissection of venous and arterial vessels. In the recipient, exenteration of the abdominal organs is performed; this includes the liver together with or without the intrahepatic vena cava, the pancreas, the spleen, part of the stomach, and the small bowel. The infrarenal abdominal aorta is exposed. The arterial anastomosis is restored in an end-to-side fashion to connect the large donor aortic conduit to the recipient infrarenal abdominal aorta. The venous anastomosis is restored in an end-to-end fashion to connect the suprahepatic and infrahepatic inferior vena cava. Sometimes the piggyback technique is used as follows: In the recipient, the liver is removed without the inferior vena cava; after implantation, the infrahepatic portion of the vena cava of the graft is stapled resulting in a caval stump. The donor suprahepatic vena cava is anastomosed in an end-to-side fashion at the level of the hepatic veins or in a side-to-side fashion to the recipient vena cava.

Proximal gastrointestinal reconstruction of the multivisceral graft is performed by connecting the proximal portion of the recipient stomach to the donor stomach. Distal intestinal continuity of the multivisceral graft is established analogous to intestinal transplantation as described using one of the various types of intestinointestinal anastomosis. Also, pyloroplasty is performed to prevent gastric outlet obstruction resulting from denervation of the stomach.

Typical examples of the regular anatomy are shown using various imaging techniques after multivisceral transplantation in Figures 8A, 8B, 8C, 8D, 9A, 9B, 10.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8D. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A. —Contrast-enhanced helical CT scans obtained 7 days after multivisceral transplantation with piggyback technique in 67-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = aorta, d = donor, L = liver, r = recipient, ST = stomach, white asterisk = ascites, solid single arrow = donor inferior vena cava, open arrows = liver vein, solid double arrows = recipient inferior vena cava with hyperdense staple line, black arrowhead = gastric tube, solid arrowhead = subphrenic drain, open arrowhead = staple line of donor caval stump. Images obtained at level of hepatic veins show side-by-side location of donor and recipient inferior vena cava (A) and stapled caval stump caudally (B).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B. —Contrast-enhanced helical CT scans obtained 7 days after multivisceral transplantation with piggyback technique in 67-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = aorta, d = donor, L = liver, r = recipient, ST = stomach, white asterisk = ascites, solid single arrow = donor inferior vena cava, open arrows = liver vein, solid double arrows = recipient inferior vena cava with hyperdense staple line, black arrowhead = gastric tube, solid arrowhead = subphrenic drain, open arrowhead = staple line of donor caval stump. Images obtained at level of hepatic veins show side-by-side location of donor and recipient inferior vena cava (A) and stapled caval stump caudally (B).

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10. —Upper gastrointestinal study with water-soluble contrast material obtained 5 years after multivisceral transplantation in 41-year-old woman with Gardner's syndrome and intraabdominal desmoid tumor. Image shows normal postoperative anatomy after end-to-end gastrogastrostomy with normal intestinal contrast passage. Exact position of end-to-end gastrogastrostomy is not discernible. d = donor, r = recipient, ST = stomach, asterisks = intestinal graft, arrowheads = urethral drainage tube.

Liver-Intestinal Transplantation

Top Introduction Intestinal Transplantation Multivisceral Transplantation Liver-Intestinal Transplantation References

 
A combined liver-intestinal graft uses at least the small bowel attached to the liver. During the early period of liver-intestinal transplantation, only the portal vein was left intact; the bile duct was transected and its distal portion with the donor duodenum and pancreas was removed during back-table preparation to avoid donor pancreatitis [6]. This technique is not used today because of surgical problems related to difficult preparation in pediatric donors, bile leaks after biliary anastomosis, and the risk of torsion of the portal vein.

Nowadays the liver and small bowel with the attached, intact, proximal stapled duodenum and the adjacent rim of the pancreatic head are transplanted en bloc. This modification simplifies graft preparation, eliminates dissection of the bile duct within the hepatoduodenal ligament, omits biliary anastomotic complications, and obviates vascular torsion [13]. This technique also enables procurement of a reduced and size-matched liver and intestinal graft from donors who are larger than the recipient [14]. For this reason, the range of possible donors for children on the waiting list is extended.

Size reduction is achieved by resection of segments II and III or segments II, III, and IV or extended right hemihepatectomy and, if necessary, by resection of a distal segment of the ileum. In the recipient, the procedure starts with hepatectomy and preserves the stomach, duodenum, and pancreas. The residual native portal vein draining the remnant viscera is anastomosed to the native suprarenal inferior vena cava in an end-to-side fashion (Figs. 11A, 11B). After implantation the donor graft is revascularized analogous to multivisceral transplantation. Proximal intestinal continuity is established between the remaining recipient duodenum or jejunum and the donor proximal jejunum; distal intestinal continuity is established analogous to intestinal transplantation as described using one of the various types of intestinointestinal anastomosis.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A. —Schematic illustrations of liver-intestinal transplantation. CBD = common bile duct, CHA = common hepatic artery, CTr = celiac trunk, d = donor, D = duodenum, IMV = inferior mesenteric vein, IVC = inferior vena cava, LHV = left hepatic vein, LLHA = left lateral hepatic artery, LLHD = left lateral hepatic duct, P = pancreas, PV = portal vein, r = recipient, S = spleen, SA = splenic artery, SMA = superior mesenteric artery, SMV = superior mesenteric vein, ST = stomach, SV = splenic vein, TI = temporary ileostomy, single arrows = duodenoduodenal anastomosis, double arrows = ileocolonic anastomosis, black arrowhead = hepatocaval anastomosis, white arrowhead = portocaval anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration of intraoperative appearance of recipient site after removal of diseased liver in patient with short-bowel syndrome shows end-to-side anastomosis between portal vein and inferior vena cava.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B. —Schematic illustrations of liver-intestinal transplantation. CBD = common bile duct, CHA = common hepatic artery, CTr = celiac trunk, d = donor, D = duodenum, IMV = inferior mesenteric vein, IVC = inferior vena cava, LHV = left hepatic vein, LLHA = left lateral hepatic artery, LLHD = left lateral hepatic duct, P = pancreas, PV = portal vein, r = recipient, S = spleen, SA = splenic artery, SMA = superior mesenteric artery, SMV = superior mesenteric vein, ST = stomach, SV = splenic vein, TI = temporary ileostomy, single arrows = duodenoduodenal anastomosis, double arrows = ileocolonic anastomosis, black arrowhead = hepatocaval anastomosis, white arrowhead = portocaval anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after implantation of size-reduced liver-intestinal graft using extended right hemihepatectomy and distal segmental small-bowel resection.

Typical examples of regular anatomy are shown using sonography in Figures 12A, 12B.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A. —High-resolution sonograms obtained 3 months after liver-intestinal transplantation in 2-year-old girl with short-bowel syndrome. Ao = aorta, d = donor, L = liver, r = recipient, asterisk = intestinal graft. Axial image displays side-to-end arterial anastomosis (between arrowheads) between recipient abdominal aorta and donor aortic conduit (arrows).

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B. —High-resolution sonograms obtained 3 months after liver-intestinal transplantation in 2-year-old girl with short-bowel syndrome. Ao = aorta, d = donor, L = liver, r = recipient, asterisk = intestinal graft. Oblique image shows normal anatomy of portal vein (double arrows) and hepatic artery (single arrow).

References

Top Introduction Intestinal Transplantation Multivisceral Transplantation Liver-Intestinal Transplantation References

 

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