Recipient Procedure

When a donor is first identified the recipient must be notified immediately so that their surgery can be coordinated with the donor procedure. The waiting recipient should at all times be prepared to transport themselves to the hospital within a couple of hours of notification. Preoperative blood work and other mandatory preoperative tests should be obtained immediately upon arrival to the hospital and broad spectrum antibiotics should be administered approximately 15 minutes prior to the opening incision. Since most intestinal transplant recipients have limited vascular access, the current TPN line may be utilized. The surgical team should inform the anesthesia team of potential available sites for other I.V. access, so that futile attempts to establish IV access are avoided.

The recipient is taken to the OR at an appropriate time dictated by the amount of surgery that is anticipated to be necessary to prepare for implantation of the donor graft. In some circumstances residual segments of diseased bowel will need to be removed from the potential recipient. Furthermore, a decision will have to be made as to which vessels the donor bowel will be anastomosed to. Ideally, if they are not diseased and are of satisfactory caliber, the recipient superior mesenteric artery and vein can be used. Alternative choices would be the infrarenal aorta for arterial input and the portal vein or inferior mesenteric vein for venous drainage. If the portal venous system is not accessible or useable, the inferior vena cava can also be used. Although anastomoses between a donor portal venous branch and the recipient cava are not physiological, in the instances where they have been performed, patients have had no adverse consequences.

For a liver-intestine graft, the caval anastomoses are performed as with a liver-only transplant. The recipient portal vein, which will still be draining the residual recipient visceral organs can either be anastomosed end-to-side to the recipient cava or to the donor portal vein. The aortic segment with its celiac and SMA trunks intact is then anastomosed end to side to the infrarenal aorta.

For a multivisceral graft, if the liver is included, the caval anastomoses are performed followed by the donor aortic segment to recipient infrarenal aortic anastomosis. If the liver is not included, the donor portal vein is anastomosed to the recipient portal vein or cava.20

In addition to preparing sites for the vascular anastomoses, appropriate sites for the proximal and distal intestinal anastomoses should also be identified. Ideally, the proximal end of the donor intestine will be anastomosed to the most distal and accessible segment of the recipient's remaining small intestine, which typically is at or distal to the ligament of Treitz. If in the pretransplant evaluation the recipient has been shown to have severe gastric dysmotility with delayed gastric emptying, consideration of what to do with the stomach must be included in

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