Multivisceral Transplant for an Extensive Cystic Lymphangioma of the Mesenteric Root.

NESTOR PEDRAZA; LUIS MOULIN; CAROLINA RUMBO; PABLO ROMERO; DOLORES GARCIA HERVÁ ; GUILLERMO ORCE; JULIO TRENTADUE; DIEGO RAMISCH; GABRIEL E. GONDOLESI

Simposio; International Small Bowel Transplant Symposium 2015; 2015

Intestinal Transplant Association

Video Presentation: This is a 7 year old female, with intestinal failuresecondary to an extensive cystic lymphangioma that compromisedthe root of the mesentery, pancreas and hilum of theliver. Oncological treatment was attempted to reduce tumor size; lackof response and the progressive development of intestinal failurewere the main reasons to refer the patient for evaluation for a multivisceraltransplant.Procedure: A 6 year old ideal trauma donor was offered, andthe multivisceral block was procured. Recipient?s surgery started witha wide midline incision. The tumor mainly envolved the root of themesentery, compromising the venous structures, causing boweledema and progressive intestinal failure due to malabsortion. Theevisceration of the GI tract was started by mobilizing the right colonand the mesentery root to identify and encircle the SMA. This stepwas followed by the dissectiion and section the left colon. Hepaticmovilization was followed by transection of the short hepatic veinsto separate the cava vein from the liver in order to perform the piggyback technique. The stomach was trasected 5 cm distal to the esofaghealend, and the spleen and pancreas were carefully movilizedfrom the retroperitoneum to identify and serround the celiac trunk(CT). Finally the resection of the abdominal organs with the tumorwas achieved by transecting the SMA and the CT, leaving the entirelengh of the aorta free and a clamp on the common ostium of thesuprahepatic veins was placed. The engraftment of the multivisceralgraft (liver, stomach, duodenum-pancreas, spleen, and small bowelwith the right colon) was started by performing the venous reconstructionof the donor?s hepatic vein to the common ostium of thesuprahepatic veins. For the arterial inflow, an end-to-side anastomosisof an arterial aortic conduit was performed to the infrarenal aorta.Finally the donor?s aortic patch containing the SMA and CT wasanastomosed to the aortic graft. Reperfusion was achieved with aCIT of 8:45 hs, and a WIT of 30 minutes. A double layer gastro-gastricanastomosis with piloroplasty was made; finally an ileo-colic sideto-endanastomosis was used for the distal GI tract, requiring aBishop koop ileostomy for distal postsurgical endoscopic monitoring.Post Transplant Outcome: The patient was discharged on post-opday 35. She died due to EBV primary infection that evolved to PTLD,3 months after transplant. Details of the surgery and pitfalls of theprocedure are presented in the video.References:1. Intestinal Failure, Diagnosis, Management and Transplantation.1ra ed, Blackwell Publishing, 2008:2. Ann Surg. 2000; 232(5):680-687.3. Intensive Care Med. 2008;34(9):1570-9.