the overall surgical plan. The management of the stomach in these circumstances is somewhat controversial. The options include:

a. Doing nothing at the time of transplant and following the patient to see if gastric emptying remains a problem post transplant.

b. Performing a gastrojejunostomy—anastomosing proximal donor intestine to the stomach.

c. Performing a partial gastrectomy and gastrojejunostomy.

d. Performing a multivisceral transplant which would include stomach, duodenum, pancreas, intestine and, if necessary, liver.

Another area of controversy is whether a segment of colon should be transplanted with the small intestine or not. The primary advantage of transplanting the colon is that it helps to control the severe fluid and electrolyte imbalances which can occur posttransplant. The disadvantage is that it may predispose to a higher incidence of bacterial translocation and infectious complications.21

If the recipient has remaining healthy colon, its proximal end would be the ideal site for anastomosis to the distal end of the donor intestine. If the recipient has had a proctocolectomy, the distal end of the donor intestine can be brought out as an end colostomy or ileostomy. In certain circumstances it may be preferable to perform a pelvic pull-through with a colo-anal anastomosis, but this if often better left for a second operation. If an end-ileostomy is not created, a site for a loop ileostomy must be selected. An ileostomy of some form is essential to provide direct vision and direct endoscopic access to the small bowel for surveillance following the transplant. Some centers perform a Bishop-Koop type of ileo-stomy rather than a loop ileostomy.

Another important consideration in the recipient operation is the placement of a feeding jejunostomy tube. Because early establishment of enteral feeding is essential, and since the establishment of oral feeding is less predictable a feeding jejunostomy should be placed at the time of transplant. The safest approach is often to put a percutaneous gastrojejunal tube into the native stomach, passing it into the proximal jejunum of the intestinal allograft. This precludes any allograft-related problems compromising the integrity of the tube insertion site. In some circumstances, however, it may be preferable to place a jejunostomy tube directly into the donor jejunum.

Upon arrival of the donor team at the recipient hospital, implantation of the graft must begin as soon as possible. The patient should be fully heparinized prior to the vascular anastomosis. Overall the total cold and warm ischemia time should be kept less than 6 hours. The warm ischemia time should ideally be less than 30 minutes. After completion of the vascular anastomoses and reperfusion of the graft, if all segments are perfused well the proximal and distal intestinal anastomoses should be performed followed by the ileostomy. The patient can then be closed after the feeding jejunostomy is placed. The recipient should be left with a tube or combination of tubes that will both decompress the stomach and allow feeding in the jejunum.

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