Anaesthesia for intestinal transplantation

Question 1

Indications for intestinal transplantation

Answer 1

Intestinal failure due to…
- Short bowel syndrome (usually secondary to surgery, trauma, Crohn’s, volvulus)
- Motility disorders (Chronic pseudo-obstruction, unresectable slow-growing tumours)
- Impaired absorption (IBD, radiation enteritis)

With complications such as line sepsis, line thrombosis, and associated liver disease.

Question 2

Pre-assessment for intestinal transplantation

Answer 2

Bloods: Hb, U&Es, LFTs, X-match, Coag
Infection screen: HIV, Hep B, C, CMV, EBV
Cardio: ECG, ECHO, CPET, +/- angiogram
Resp: Pulm function tests
Haem: often on anticoagulants due to recurrent CVC thrombosis
Psychological assessment
CT venogram- these patients will need CVC access for 6/12 post-op and must have a patent SVC

Question 3

Types of Intestinal Transplantation Surgery

Answer 3

• Multi-visceral transplant: small bowel with pancreas, +/- liver
• Isolated bowel transplant

Question 4

Stages of Intestinal Transplantation Surgery

Answer 4

Dissection Phase
- Around 2 hrs
- Can be associated with significant blood loss
Vascular Anastomosis Phase
- Donor superior mesenteric artery -> recipient infrarenal aorta
- Donor superior mesenteric vein -> recipient portal vein or IVC
- This stage involves aorta cross-clamping
Post-reperfusion phase
- Intestinal reconstruction proximal donor bowel to stomach or jejunum and then plumbed into large bowel if available
- Often due to repeated surgeries primary abdominal wall closure is non-viable and patients will need grafts or abdominal wall transplantation from a donor

Question 5

Anaesthetic considerations for intestinal transplant surgery

Answer 5

• Need CVC, wide bore PVC, arterial line
• Often IV access is extremely challenging
• Large fluid shifts so some form of cardiac output monitoring is recommended
• Broad-spectrum antibiotics and antifungal medications given intra-op
• Rapid infusers
• X-Match multiple blood products
• TEG and temperature maintenance
• Expect hypotension on removal of aortic cross-clamp
• Acid-base/ electrolyte disturbances common

Question 6

Immunosuppression for intestinal transplant surgery

Answer 6

Given at induction combination of steroids, mycophenolate and a monoclonal antibody

Question 7

Post-operative considerations for intestinal transplant surgery

Answer 7

• Generally managed in ICU due to ongoing SIRS response, large fluid shifts and acid-base imbalance
• Pain is a common issue, many of these patients suffer with chronic pain and are on opioids pre-op
• Feeding is started via a gastric or jejunal tube and increased very carefully

Question 8

Complications following intestinal transplant surgery

Answer 8

• Abdominal compartment syndrome due to massive bowel oedema is common
• Acute rejection- more common than in other organs as the bowel is very immunogenic
• Infections
• Post-transplant lymphoproliferative disease
• Recurrence of IBD