EXPERIMENTAL AND CLINICAL TRANSPLANTATION

A 50-year-old man sustained blunt abdominal trauma in a motor vehicle accident. He underwent exploratory laparotomy on the day of trauma, and severe bleeding from the base of the small bowel mesentery was controlled by mass ligation and through-and-through suturing. After transfer to our center, repeat exploratory laparotomy showed ischemic small intestine, ischemic right colon, and severe pancreatic trauma. The severely injured organs were excised including the entire small bowel, pancreas, spleen, stomach, and right hemicolon. The next day, a modified multivisceral transplant was performed including stomach, pancreaticoduodenal complex, and small bowel transplant. Postoperative complications included an intra-abdominal collection that was drained percutaneously with ultrasonographic guidance and severe rejection that was treated with anti-thymocyte globulin. In summary, for select patients who have severe abdominal trauma may be treated with acute multivisceral transplant.

Key words : Ileum, Immunosuppression, Ischemic bowel, Pancreas, Stomach, Small intestine

Multivisceral, modified multivisceral, and isolated intestinal transplant are becoming common pro-cedures for varied problems. In children, these procedures are indicated for patients who have complications of short bowel syndrome or long-term total parenteral nutrition, such as venous access problems or cholestatic liver disease, and other congenital and acquired diseases such as intestinal atresia, gastroschisis, and necrotizing enterocolitis.^1,2 In adults, short bowel syndrome usually is caused by extensive bowel resection for Crohn disease, mesenteric vascular thrombosis, desmoid tumor, or abdominal trauma.

The pattern of traumatic injury may vary, and treatment of patients who have trauma has evolved because of improvements in surgical techniques. Solid-organ transplant can be used for treatment of the late sequelae of abdominal trauma such as intestinal or pancreatic failure.^3,4 However, a literature review showed no previous reports of multivisceral transplant in treating patients acutely for abdominal trauma. We used multivisceral transplant to treat a patient who had acute abdominal trauma.

A 50-year-old man (body weight, 80 kg; ABO blood group B+) sustained blunt abdominal trauma in a motor vehicle accident in July 2011. He underwent exploratory laparotomy on the day of trauma, and severe bleeding from the base of the small bowel mesentery was controlled by mass ligation and through-and-through suturing. He was transferred to our center, and he immediately had another exploratory laparotomy (12 hours after the first laparotomy). Surgical findings included ischemic small intestine, ischemic right colon, and severe pancreatic trauma. The severely injured organs were excised including the entire small bowel, pancreas, spleen, stomach, and right hemicolon, and multivisceral transplant was recommended.

The next day, a donor graft was available from a 23-year-old man who was killed in a motor vehicle accident. A modified multivisceral transplant was performed including stomach, pancreaticoduodenal complex, and small bowel transplant. An aortic patch containing both celiac and superior mesenteric arteries of the graft was anastomosed to the infrarenal aorta (graft inflow, end-to-side anastomosis), and the portal vein of the graft was anastomosed to the portal vein of the recipient (graft outflow, end-to-end anastomosis). Intestinal continuity was established by esophagogastrostomy, Brooke ileostomy, and ileocolostomy at 20 cm proximal to the ileostomy. A feeding jejunostomy was constructed. Operative time was 7 hours (cold ischemic time, 255 min; warm ischemic time, 40 min; estimated blood loss, 1700 mL). Immunosuppressive therapy included induction with alemtuzumab (Campath-1H) and methylprednisolone (2 g) and maintenance with tacrolimus (target level, 15-20 ng/mL) and prednisolone.

On postoperative day 20, the patient had an intra-abdominal collection that was drained percutaneously with ultrasonographic guidance. On postoperative day 30, the patient was diagnosed with severe rejection (grade 3) that was confirmed with histology and treated with anti-thymocyte globulin. The patient was followed with endoscopy and biopsy twice weekly during the acute hospitalization and once weekly after discharge from the hospital on postoperative day 50. At 2 months after transplant, he is alive and well.

Abdominal trauma may vary in injury pattern, and treatment of trauma may vary from nonoperative treatment to transplant. Liver transplant is an option for patients who have abdominal trauma that has caused nonsalvageable liver injury.^3,5 Multivisceral transplant and isolated organ transplant (primarily intestinal transplant) are cost effective treatment for patients who have chronic disability after severe trauma. These disabilities that are caused by trauma, such as intestinal failure and complications of long-term total parenteral nutrition, may cause long-term hospitalization, major economic difficulty, and diminished quality of life. Multivisceral transplant is an option in selected patients who have life-threatening complications induced by total parenteral nutrition^4,6,7 and children who have various problems.^1,2,8

The basic element of multivisceral transplant is the intestinal component. Intestinal graft rejection may be a severe complication, but improved immuno-suppressive regimens and endoscopic techniques to monitor for rejection have enabled further develop-ment of multivisceral transplant.^9,10 Daclizumab and alemtuzumab have improved outcomes after intestinal and multivisceral transplant.

The protective role of the liver may be an important aspect of multivisceral and modified multivisceral transplant (without liver transplant).^6,11 In patients who have nontraumatic conditions or long-term complications of trauma, the decision about the organs transplanted may depend on the presence of organ complications that can be evaluated preoperatively, such as metastasis, local infiltration by malignancy, congenital anomalies in multiple organs, complications of total parenteral nutrition, or irreversible cholestasis in the liver. In patients who have acute trauma, such as the present patient, the type of procedure and organs involved may depend on the operative findings at laparotomy, vascular status of the organs, hemodynamic stability of the patient, comorbid diseases, and physiologic changes after trauma. The timing of transplant surgery must be considered, and options include acute transplant or delayed transplant to enable treatment with total parenteral nutrition for intestinal failure or insulin and enzyme extract for pancreatic failure. Limited information is available about these issues, and the present case provides justification for further studies including randomized prospective studies. Time may be limited in patients who have acute trauma, and evaluation for transplant may include assessment of preoperative status and psychological and physical aspects of transplant including lifelong dependence on immuno-suppressive drugs.

Volume: 14 Issue: 2 April 2016

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