Small bowel transplantation is the most rapidly evolving area of the solid organ transplantation. Pathophysiologic nature of the intestinal failure leads various surgical options performing intestinal transplantation, e.g. isolated intestine, liver and intestine, and multivisceral transplantation. Because of high dosing of immunogenic tissue from the allograft, prevention and treatment of the acute rejection is still one of the main hurdles to improve clinical outcome after transplantation. With the contribution of refining surgical skills, novel immunosuppressive therapy, and upgraded patient management before and after transplantation, clinical outcome has been improved significantly for last decade. The indication of the intestinal transplantation, however, still remained to use this novel treatment option as a life- saving procedure in intestinal failure patients and not to be justified for pre-emptive intestinal transplantation. Intestinal or multivisceral transplantation has so many unveiled areas, which warrants additional vigorous study.
Allografts ; Humans ; Intestines ; Liver ; Organ Transplantation ; Transplants

When abdominal neoplasms originating from the pancreas or nearby organs locally involving the superior mesenteric artery (SMA), complete resection is still the only hope for cure. However, SMA resection and reconstruction is a complex surgical procedure associated with high postoperative morbidity and mortality. Intestinal autotransplantation has recently emerged in clinical practice as a treatment option for selected patients with neoplasms involving the SMA. The original procedure involved en bloc removal of a tumor together with the intestine, ex vivo resection and reconstruction of gastrointestinal tract by an intestinal autograft. To further refine this complex procedure, a modified method was developed in which a segmental bowel autograft is selected and harvested first during the initial stage of the operation, and radical resection of the neoplasm is carried out thereafter. The modification would better protect a healthy bowel autograft from potential damage due to prolonged warm ischemia and allow the subsequent lengthy process of dissection to be performed in an unrushed manner. Furthermore, this alteration would better adhere to the general principles of minimal tumor manipulation during operation and potentially decrease the risks of tumor implantation during in vitro organ perfusion. Although intestinal autotransplantation has expanded eligibility for resection of otherwise unresectable lesions involving the SMA, its operative complexity, high risks, and post-operative complications largely limit its clinical applications.
Humans ; Intestines ; Mesenteric Artery, Superior/surgery* ; Pancreatic Neoplasms ; Transplantation, Autologous

OBJECTIVETo report the first case of non-composite combined liver and intestinal allotransplantation in China. The technical aspects of the case and pros and cons of such an approach versus composite technique were discussed.

METHODSThe patient suffered from short bowel syndrome and TPN-related liver damage. A non-composite technique was used in this case. During operation, the whole 380 cm intestine was transplanted with systemic drainage and aortic inflow, while the liver graft was placed in a piggyback fashion. Warm ischemic time of donor graft was 2 min and 30 seconds, and cold ischemic duration for intestinal and liver graft was 6 hours and 40 and 8 hours and 7 utes respectively. Postoperative immunosuppression management includes tacrolimus, methylprednisolone, MMF and Zenapax.

RESULTSThe recipient recovered smoothly with no evidence of rejection on days' follow up. Now he is maintained well on enteral nutrition.

CONCLUSIONNon-composite technique should be considered in adult recipients, especially those with a history of abdominal infections or multiple laparotomies.

Adult ; Humans ; Intestines ; transplantation ; Liver Transplantation ; Male ; Short Bowel Syndrome ; therapy ; Transplantation, Homologous ; methods ; Treatment Outcome

The field of organ transplantation has undergone a continual evolution to become the standard treatment for patients with end-stage diseases in diverse organs including the kidney, liver, pancreas, intestine, heart, and lung diseases. The efforts to increase organ donation and clinical studies along with basic researches are very important for the progress of transplantation medicine. This review is focused on "What's new in transplantation surgery and medicine", addressing the current hot issues on the attempts at organ shortage, recent findings on antigen recognition, improved immunosuppressive strategies, and finally recent advancements in kidney and liver transplantation.
Heart ; Humans ; Intestines ; Kidney ; Liver ; Liver Transplantation ; Lung Diseases ; Organ Transplantation ; Pancreas ; Tissue and Organ Procurement ; Transplantation ; Transplants

OBJECTIVETo establish an porcine model of whole pancreaticoduodenal transplantation with portal venous drainage and enteric drainage for ensuring physiologically normal function without hyperinsulinemia and reducing postoperative complications.

METHODSTwenty sichuan native outbreding white pigs weighing 25-30 kg were divided equally into two groups to serve as the donors and recipients. Cooling of the grafts was accomplished with in situ flush with 4 degrees C UW preservation solution via an aortic cannula. A whole pancreatoduodenal graft with the segment of abdominal aorta and the portal vein was harvested from the donor pigs. Type I diabetes model was established by complete removal of the recipient pancreas. The whole pancreatoduodenal graft was preserved and shaped in UW solution, and the subphrenic abdominal aorta of the recipient was joined with the donor abdominal aorta via a side-to-end anastomosis, and venous reflux was reconstructed between the donor portal vein and the recipient superior mesenteric vein. Side-to-side intestinal anastomosis was performed between the donor duodenum and the recipient jejunum.

RESULTSTen pancreaticoduodenal transplantations (PVE+ED style) were done, and pancreatic graft thrombosis and embolism occurred only in 1 pig 6 days after transplantation.

CONCLUSIONThe model of whole pancreaticoduodenal transplantation with portal venous drainage and enteric drainage is stable and reliable.

Animals ; Drainage ; methods ; Duodenum ; transplantation ; Female ; Intestines ; surgery ; Male ; Models, Animal ; Pancreas Transplantation ; Portal Vein ; surgery ; Swine ; Transplantation, Homologous

OBJECTIVETo investigate operative techniques, treatment and precaution of common complications of orthotopic intestinal transplantation in the rats.

METHODSOrthotopic intestinal transplantation was performed in 120 rats by modified three cuffs method. The causes, treatment and precaution of common complications were analyzed retrospectively.

RESULTSThe 7-day survival rate of recipients was 82.5% and the 30-day survival rate was 68.3%. The average volume of bleeding in the recipient operation was less than 1 ml. The result obtained from the above 99 recipients was satisfactory. The main reasons of final failure and death were as follows: anastomotic bleeding(5 rats), portal vein thrombus(2 rats), arterial thrombus(4 rats), air embolism(1 rat), infection of abdominal cavity(4 rats), aspiration pneumonitis (2 rats), anesthetic accident(2 rats) and kinking of graft intestine(1 rat).

CONCLUSIONSThe sophisticated surgical technique and the delicate surgical manipulation are the prerequisite of preventing operational complication. Improving operative techniques and being familiar with the common complications can reduce the occurrence of complications and increase operative successful rate.

Animals ; Intestines ; transplantation ; Male ; Organ Transplantation ; adverse effects ; methods ; Postoperative Complications ; Rats ; Rats, Sprague-Dawley ; Transplantation, Homologous

Intestinal transplantation has been established as a treatment option for patients that suffer from intestinal failure with complications from total parenteral nutrition. It is still rapidly evolving and just reached a landmark of 1, 000 cases worldwide. Intestinal allografts can be transplanted as isolated, combined with the liver or as a part of a multivisceral allograft. Tacrolimus-based immunosuppression regimens have been used universally with improved outcomes. Clinical outcome in intestinal transplantation has improved significantly over time, impacted by refinement of surgical technique and novel immunosuppression. However rejection, infection, and technical complications still remain the most difficult barrier to improve patient and graft survival.
Acute Disease ; Graft Rejection/diagnosis ; Humans ; Immunosuppression ; Intestines/*transplantation ; Nutritional Support ; Organ Transplantation/methods ; Postoperative Care ; Viscera/*transplantation

OBJECTIVETo investigate the intestinal microflora status and bacterial translocation in rats after liver transplantation.

METHODSMale Brown-Norway (BN) rats were randomly divided into 4 groups: group I (n = 8) for liver transplantation; group II (n = 8) for simulated liver transplantation; group III (n = 8) for sham operation and group IV (n = 8) for normal group. Caecal bacterial counts, plasma endotoxin, intestinal mucosal ultrastructure and bacterial translocation to liver, spleen, kidney, and mesenteric lymph node were studied 24 h after surgery.

RESULTSThe numbers of Bifidobacterium and Lactobacillus per gram of wet feces were significantly decreased in group I compare with those in the group III and group IV, while Enterobacteriaceae and Enterococcus counts were increased markedly compare with those in the group III and group IV, but no different was found between group I and group II. Impaired intestinal mucosa integrity were found in the group I and group II. In group I, the levels of plasma endotoxin increased after the transplantation when compare with group III and group IV. Increased incidence of bacterial translocation to liver, spleen and mesenteric lymph node were also observed after the transplantation (compare with those in the group IV, P < 0.01; compare with those in the group III, P < 0.01, P < 0.01, P < 0.05, separately). The increased rate of the bacterial translocation in liver was also found in transplantation group as compare with group II (P < 0.05).

CONCLUSIONSLiver transplantation may lead to disturbance of intestinal microflora and impairment of intestinal mucosal barrier function, and this dysfunction might be caused by the process of intestinal ischemia-reperfusion injury in transplantation.

Animals ; Bacterial Translocation ; Endotoxins ; blood ; Intestines ; microbiology ; ultrastructure ; Liver Transplantation ; Male ; Random Allocation ; Rats

OBJECTIVESTo simplify the enteric drainage (ED) procedure and to decrease surgical and metabolic complications in simultaneous pancreas-kidney transplantation (SPK) patients.

METHODSBetween June 2000 and June 2002, nine patients with insulin-dependent diabetes mellitus (IDDM) and uremia underwent simultaneous pancreas-kidney transplantation. The arterial inflow of the pancreas was based upon the right external iliac artery, while venous drainage was systemic via the external iliac vein. The allografts' exocrine secretions were drained into the proximal jejunum via a two-layer hand sewn, side-to-side donor duodenum to proximal small bowel anastomosis after reperfusion. No Roux-en-Y an astomosis of the jejunum was performed. The kidney graft was placed in the left iliac fossa. Quadruple immunosuppressive therapy with antilymphocyte globulin or anti-CD25 monoclonal antibody (Zenapax), tacrolimus, mycophenolate mofetil and steroids was standard treatment in all patients.

RESULTSThis procedure was successfully applied in all 9 patients without complication referable to the technique. All patients had achieved euglycemia and excellent renal function, and stopped being dependent on an external insulin source. Fasting serum glucose fell from 9.5 preoperatively to 4.8 mmol/L and remained stable thereafter. At the time this paper was written, the grafts from eight patients were functioning well.

CONCLUSIONSOur primary experience suggests that SPK with ED without Roux-en-Y anastomosis represents a more physiologic milieu, and a viable alternation to replace the bladder (BD) as the primary route of drainage for exocrine secretions of the pancreas. It is a feasible and safer procedure.

Adult ; Amylases ; blood ; Drainage ; methods ; Female ; Humans ; Insulin ; blood ; Intestines ; Kidney Transplantation ; methods ; Male ; Pancreas Transplantation ; methods

In rat liver transplantation, the bile duct reconstruction has been consisted of either use of intraductal tubing or direct implantation into the intestine. In our consecutive liver transplant studies, neither of those techniques was properly adoptable because of repeated transplantation of the liver. In order to alleviate or to minimize the unseen problems with the conventional technique, the prospective candidates of the transplant recipients were subjected to bile duct ligation at the distal end three days prior to the transplant in order to obtain a dilated duct. This will enable the operator to readily anastomose the bile duct to the duodenum using continuous suture technique with a 9-0 nylon suture. In this study the partial heterotopic liver transplantation model was used with portal inflow only. Several months after the first transplantation severed bile duct from the duodenal mucosa which can be readily reanastomosed to the next recipient.
Animals ; Bile Ducts ; Bile* ; Duodenum ; Intestines ; Ligation ; Liver Transplantation* ; Liver* ; Mucous Membrane ; Nylons ; Rats* ; Suture Techniques ; Sutures ; Transplantation