The Donor Operation: Recovery of Isolated Intestine or Intestine in Continuity with Other Organs
The donor operation for isolated intestine and other organs in continuity with the intestine is one that has developed over time, and modifications in technique made to try enhance its utilization. However, the immunogenicity of the graft and the long-term struggles after implantation have limited the field continuing to expand. In fact the number of intestinal transplants being performed currently has dropped (Mazariegos et al., Am J Transplant 10:1020–1034, 2010; Grant et al., Am J Transplant 15: 210–219, 2015), most likely due to improved intestinal rehabilitation and surgical care, but also as long-term outcomes, especially with the isolated intestine, have failed to improve significantly over time (Grant et al., Am J Transplant 15: 210–219, 2015). However, there always will remain patients in whom intestinal transplantation, either isolated or in combination with other organs, will be unavoidable and hence lifesaving. Given that, it is essential to try pick the ideal graft for each recipient. Many factors go into this equation, some obvious, some quite subjective, and often it is experience obtained in the field and a certain “gestalt” that determines if a particular graft is to be accepted.
Intestine donor selection criteria have not been thoroughly evaluated (Mazariegos et al., Am J Transplant 10:1020–1034, 2010). Clearly donor details such as blood group and donor/recipient size are obvious, although not absolute. Other details, including cause of donor death, medical history, donor “stability,” serological issues, and potentially even crossmatching come into consideration even before starting the process. The type of organ(s) needed and anatomical variations also play into the consideration. Cardiac arrest or significant vasopressor use in the donor has traditionally been an exclusion, although single center experience has demonstrated some utility in these circumstances (Matsumoto et al., Transplantation 86: 941–946, 2008).
Excellent communication between the organ procurement organizations (OPOs) and the various donor teams is essential, both before and during the procurement. Keeping the donor stable and in the best clinical condition is the aim. The actual surgical dissection for intestinal recovery can be a relatively long process. The type of organ recovery depends on what the recipient requires, but generally is an isolated intestine (+/− colon) or modified multivisceral or a liver containing composite graft.
In all cases, very careful dissection and care of the intestine is paramount. The intestine is prone to ischemia and easily traumatized, and this may set off an inflammatory response upon reperfusion in the recipient and increase the chance of rejection, hence the need for meticulous care during the recovery process. Obtaining excellent vascular interposition grafts from the donor is also essential for a successful recovery procedure.
The backtable preparation of the allograft likewise needs to be performed with great care and diligence to avoid issues on reperfusion. The short- and long-term success of the intestinal transplant recipient is very much dependent on the quality and preparation of the donor graft which is described subsequently.
KeywordsIntestinal transplantation Intestinal donation Intestinal perfusing solutions Donor operation
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