0041-1337/98/6604-489$03.00/0 TRANSPLANTATION Vol. 66, 489 – 492, No. 4, August 27, 1998 Copyright © 1998 by Williams & Wilkins Printed in U.S.A. REDUCED-SIZE ORTHOTOPIC COMPOSITE LIVER-INTESTINAL ALLOGRAFT 1 JORGE REYES, 2,3 THOMAS FISHBEIN, 4 JAVIER BUENO, 2 GEORGE MAZARIEGOS, 2 AND KAREEM ABU-ELMAGD 2 Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh Intestinal Care Center, Pittsburgh, Pennsylvania, and the Mount Sinai Medical Center, Division of Abdominal Organ Transplantation, New York, New York A composite graft consisting of a reduced left lateral hepatic segment in continuity with the small intestine was procured from an adult cadaveric donor using a modified in situ split technique. The primary recipient was a 3-year-old boy with hepatointestinal failure. The right side of the liver was transplanted into a 63-year- old man with a central hepatoma and hepatitis C cir- rhosis. This was accomplished with center-to-center sharing of the liver portion of the allograft. The in situ split technique was feasible, with good initial allograft function. However, both grafts failed subsequently be- cause of peri-operative recipient-related complica- tions. The adult patient died of an infected pseudoan- eurysm of the arterial graft, and the pediatric patient required repeat transplantation as a result of the late diagnosis of a native pancreatic fistula with choles- tatic damage to the reduced liver allograft. The child is currently alive 8 months after repeat transplanta- tion. The rapidly growing experience with intestinal and multi- visceral transplantation has demonstrated the feasibility and life-saving potential of this procedure (1–3). As with liver transplantation and more so with the larger composite grafts, size matching has limited the pool of donor organs for pediatric recipients. However, there is to date no accepted technique of split, living related, or reduced transplantation that is applicable to the transplantation of combined liver/ intestinal allografts. This population accounts for the major- ity of patients on the pediatric intestinal waiting list, and these patients are the most likely to die while waiting owing to their advanced liver disease (1). With this in mind, we have developed and performed a new technique for a reduced size composite liver-intestinal allograft using an in situ split technique. PATIENTS AND METHODS Donor surgical technique. We utilized the standard criteria for donor selection and preparation for intestinal graft procurement, which focuses on avoiding clinical circumstances that may precipi- tate intestinal ischemia, as described previously (4). This donor was a 22-year-old man weighing 75 kg, of the same blood type, hemody- namically stable, with no history of cardiac arrest. Conceptually, the operation is focused on isolation of the en bloc liver and small bowel in continuity, which would include the left lateral segment of liver, hepatic hilus, duodenum, and the entire small bowel for the pediatric recipient, thereby providing a usable “left-over” right lobe for use on an adult recipient. Initial exposure and isolation of the intestinal component. A cru- ciate abdominal incision with midline sternotomy was performed, after which the liver was mobilized by dividing the suspensory liga- ments. The right and left colon were mobilized from the retroperito- neal attachments, with division of the gastrocolic omentum. Vessels within the mesentery of the terminal ileum, right, transverse, and left colon were divided, thus rotating the entire colon to the left and out of the field. The duodenum was widely Kocherized, the right gastric and left gastroepiploic vessels were divided, and the pylorus was transected, which allowed the stomach to be reflected craniad. The distal pancreas and spleen were then mobilized and reflected medially, and the abdominal aorta was exposed. Further dissection of the body and neck of the pancreas was carried out up to the confluence of the superior mesenteric and splenic veins. The superior mesenteric and celiac arteries were identified. This was achieved by extending the dissection of the duodeno-pancreatic region and re- flecting the route of the mesentery off the retroperitoneal structures up to the origin of the superior mesenteric artery. Short branches draining the body of pancreas into the portal vein, if encountered, were divided at this time. The infrarenal aorta was isolated and prepared for cannulation. In situ splitting of the liver. The porta hepatis was evaluated for aberrant arteries by palpation. Operative cholangiography detailed a satisfactory biliary anatomy. Contrary to standard in situ liver split- ting, dissection of the right hilum was undertaken, as the emphasis was on maintaining hilar integrity to the left side. The hepatic artery was identified at the level of the bifurcation, with visualization and isolation of the right hepatic artery and right portal vein. This permitted visualization and isolation of the right hepatic duct. Iso- lation of the left hepatic vein and the left portal vein was as per standard in situ splitting, maintaining the entire retrohepatic vena cava with the “right” graft (5, 6). The liver parenchyma was transected along the minor fissure, thereby producing a left lateral segment graft (Couinaud segments II and III) in continuity with its extrahepatic vascular and biliary structures. The proximal aorta just below the diaphragm was encircled for later cross-clamping. En bloc removal. The pancreas was transected, leaving part of the pancreatic head and uncinate process in continuity with the duode- num preserving the inferior pancreaticoduodenal arcade. The portal dissection also spared the gastroduodenal artery with the graft. The distal ileum was divided, and the colon was removed from the oper- ative field. After systemic heparinization the distal donor aorta was cannulated. The proximal aorta was clamped with simultaneous infusion of 2.7 liters of cold University of Wisconsin preservation solution, and venting of the supra diaphragmatic vena cava. Division of the donor aorta containing the double arterial stem and the vena 1 This work was supported by research grants from the Veterans Administration and project grant DK 299621 from the National Institutes of Health, and financed in part by FIS 96/5147. 2 Thomas E. Starzl Transplantation Institute. 3 Address correspondence to: Jorge Reyes, MD, Associate Profes- sor of Surgery, Director Pediatric Transplant Surgery, Thomas E. Starzl Transplantation Institute, Children’s Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213. 4 Mount Sinai Medical Center. 489