Use of Arterial Embolisation to Facilitate Exenteration during Multivisceral and Small Bowel Transplantation

Butler, Andrew; Russell, Neil; Amin, Irum; Cee, Teik

doi:10.1097/01.tp.0000521309.13589.b6

Cited by 5 publications

(5 citation statements)

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“…Nonetheless, MVT is the patients’ only hope for long‐term, meaningful survival. In intestinal re‐transplantation, preoperative arterial embolization of the visceral allograft facilitates explantation and lessens hemorrhage . However, embolization of native viscera was attempted in only a handful of reported cases with mixed results .…”

Section: Introductionmentioning

confidence: 99%

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Nicolau‐Raducu

Livingstone

Salsamendi

et al. 2019

Clinical Transplantation

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Multivisceral transplant (MVT) for cirrhosis, and portomesenteric vein thrombosis (PVT), is fraught with life-threatening thrombo-hemorrhagic complications.Embolization of native viscera has been attempted in a handful of cases with mixed results. We carried out a comparative analysis of angiographic, intra-operative, and pathological findings in three recipients of MVT who were deemed exceptionally high hemorrhagic risk and therefore underwent preoperative visceral embolization.All recipients were male with cirrhosis, PVT, and a surgical history indicative of diffuse visceral adhesions; status post-liver transplantation (n = 2) and proctocolectomy (n = 1). The first patient had two Amplatzer II embolization plugs placed 2 cm from the origins of celiac and superior mesenteric (SMA) arteries. Distal migration of the celiac plug into gastroduodenal artery (GDA) and ensuing ischemia reperfusion injury, presumably contributed to severe disseminated intravascular coagulation (DIC) and intra-operative mortality. In the other two recipients, distal Gelfoam embolization of the SMA, GDA, and splenic arteries was performed, and although remarkable hemorrhage and coagulopathy occurred, embolization, undoubtedly, facilitated exenteration and improved outcomes. Pathologic examination in these cases confirmed ischemic necrosis of eviscerated bowel. In conclusion, liver-sparing, preoperative distal embolization of native viscera with Gelfoam is beneficial, but entails several pitfalls. It should currently be reserved for MVT recipients who otherwise are at unacceptably high risk.

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Section: Introductionmentioning

confidence: 99%

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Nicolau‐Raducu

Livingstone

Salsamendi

et al. 2019

Clinical Transplantation

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“…It took up to 90 min to completely occlude all vascular side branches. In order to shorten the embolization time, the Cambridge team modified our technique and used vascular plugs instead of embolic agents (24). A vascular plug may also allow a more selective embolization, for example sparing the left gastric artery (or even the hepatic artery to preserve the stomach and the liver in modified MVTx).…”

Section: Discussionmentioning

confidence: 99%

“…Firstly, limiting the exenteration/ischemic phase is crucial to reduce the risk of acidosis and metabolic instability. The use of intra-operative renal replacement therapy has been advocated by Cambridge and Miami to eliminate circulating waste products from ischemic organs during exenteration, and better maintain metabolic homeostasis until the new graft is functioning properly (24,28). Equally important to the success of the procedure, is a short CIT (ideally < 5 h).…”

Section: Discussionmentioning

confidence: 99%

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Lessons Learned for Surgical Optimization

et al. 2021

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Background: Multivisceral transplantation entails the en-bloc transplantation of stomach, duodenum, pancreas, liver and bowel following resection of the native organs. Diffuse portomesenteric thrombosis, defined as the complete occlusion of the portal system, can lead to life-threatening gastrointestinal bleeding, malnutrition and can be associated with liver and intestinal failure. Multivisceral transplantation is the only procedure that offers a definitive solution by completely replacing the portal system. However, this procedure is technically challenging in this setting. The aim of this study is to describe our experience, highlight the challenges and propose technical solutions.Materials and Methods: We performed a retrospective analysis of our cohort undergoing multivisceral transplantation for diffuse portomesenteric thrombosis at our institution from 2000 to 2020. Donor and recipient demographics and surgical strategies were reviewed in detail and posttransplant complications and survival were analyzed.Results: Five patients underwent MVTx. Median age was 47 years (23–62). All had diffuse portomesenteric thrombosis with life-threatening variceal bleeding. Major blood loss during exenteration was avoided by combining two techniques: embolization of the native organs followed by a novel, staged extraction. This prevented major perioperative blood loss [median intra-operative transfusion of 3 packed red blood cell units (0–5)]. Median CIT was 330 min (316–416). There was no perioperative death. One patient died due to invasive aspergillosis. Four others are alive and well with a median follow-up of 4.1 years (0.3–5.9).Conclusions: Multivisceral transplantation should be considered in patients with diffuse portomesenteric thrombosis that cannot be treated by any other means. We propose a standardized surgical approach to limit the operative risk and improve the outcome.

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“…Splenic embolization was pursued to facilitate explant of the native viscera by decreasing venous flow in the collaterals formed around the native portal/splenic thrombosed veins. More recently, multiple centers including ours have reported the routine use of preoperative embolization of major mesenteric arterial vasculature (celiac axis and SMA), in order to prevent the clinical scenario experienced in this transplant procedure with difficult dissection due to extensive venous collateral formation [ 4 , 5 ].…”

Section: Discussionmentioning

confidence: 99%

Surgical Resection of Native Viscera to Manage Persistent Ascites after Multivisceral Transplant

Shaw

Barbas

Sudan

2020

Case Reports in Transplantation

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Multivisceral transplantation is the therapy of choice in patients with diffuse portomesenteric thrombosis. In the present case, we describe a patient who had persistent ascites after multivisceral transplant. The patient was initially diagnosed with a chyle leak which was cured via embolization. When this did not cure her ascites, reexploration proved the etiology to be at least partially attributable to persistent hypertension in the retained viscera. This was cured with the resection of her native viscera. This case highlights the importance of resection of all congested viscera at the time of transplantation in patients with diffuse portomesenteric thrombosis, the utility of preoperative embolization techniques in assisting this, and also the ability to perform delayed resection if necessary.

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Use of Arterial Embolisation to Facilitate Exenteration during Multivisceral and Small Bowel Transplantation

Cited by 5 publications

References 0 publications

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Lessons Learned for Surgical Optimization

Surgical Resection of Native Viscera to Manage Persistent Ascites after Multivisceral Transplant

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