Technical aspects of intestinal transplantation

Vascular reconstruction of segmental intestinal grafts using autologous internal iliac vessels

Background

The aim of this study was to assess whether the autologous internal iliac artery and vein could be used as an interpositional graft for vascular reconstruction in segmental intestinal allografts and autografts.

Methods

Thirty-four intestinal transplants (19 living-related allografts and 15 autografts) were conducted in our programs between January 2011 and January 2019. Patient characteristics, type of vascular reconstruction, and post-operative complications were reviewed.

Results

There were 20 males and 14 females with a median age of 35 years. Of 34 grafts, 22 (64.7%) (11 allografts and 11 autografts) were revascularized using the autologous internal iliac artery and vein for reconstruction. Vascular reconstruction on the back table took 21 ± 6 min to complete. Both total operative time and cold ischemia time tended to be longer in the vascular-reconstruction group than in the direct-anastomosis group (530 ± 226 vs 440 ± 116 and 159 ± 49 vs 125 ± 66 min, respectively), but these differences were not significant. The incidence of vascular thrombosis tended to be higher in the direct-anastomosis group than in the vascular-reconstruction group (16.7% vs 0%, P = 0.118). At a median follow-up of 36.9 months, no stenosis or pseudoaneurysms developed. In 19 allografts, acute rejection occurred in 4 (21.1%) and chronic rejection occurred in 1 (5.2%).

Conclusions

Our results indicate that the use of an autologous internal iliac interposition graft greatly facilitates intestinal graft implantation and minimizes the risk of vascular complications.

Liver, pancreas and small bowel transplantation: current ethical issues

We describe the medical state of the art in liver, pancreas and small bowel transplantation, and portray the ethical issues. Although most ethical questions related to these transplantations are not specific for liver, pancreas and small bowel, they do challenge ethical analysis as well as new policies and clinical procedures. Firstly, outcomes continue to be of utmost concern, as information is only limited available, is developing over time and is surrounded by many uncertainties. Secondly, characteristics of donors and recipients should be carefully evaluated. The question of what qualifies a donor and a recipient should be considered against the background of a quest for extended criteria, embracing marginal cases, and a judgment with regard to what counts as a good enough outcome. Thirdly, ethical principles of autonomy and fairness are pushed, given the circumstance of severe scarcity, towards limits that can easily be crossed.