Operative Techniques in Transplantation Surgery [1 ed.]

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Editor Michael J. Englesbe MD Associate Professor of Surgery Department of Surgery University of Michigan Medical School Ann Arbor, Michigan

Editor-in-Chief Michael W. Mulholland MD, PhD Professor of Surgery and Chair Department of Surgery University of Michigan Medical School Ann Arbor, Michigan

Contributing Authors Peter L. Abt, MD Associate Professor of Surgery Director Kidney Transplantation The Children's Hospital of Philadelphia Department of Surgery Division of Transplant Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Jose L. Almeda, MD Assistant Professor of Surgery University of Texas Health Science Center at San Antonio Organ Transplantation Center University Transplant Center San Antonio, Texas Jefferson A. Alves, MD Liver Transplant Surgeon Hospital Israelita Albert Einstein São Paulo, Brazil Christopher D. Anderson, MD Associate Professor of Surgery and Medicine Chief, Transplant and Hepatobiliary Surgery University of Mississippi Medical Center Jackson, Mississippi Jean F. Botha, MD Director

Liver Transplant Program Division of Transplant Surgery Wits Donald Gordon Medical Center Parktown, Johannesburg, South Africa Philip W. Carrott Jr, MD Fellow Department of Surgery Section of Thoracic Surgery University of Michigan Health System Ann Arbor, Michigan Andrew C. Chang, MD Associate Professor of Surgery Section of Thoracic Surgery University of Michigan Medical Center Ann Arbor, Michigan Kenneth D. Chavin, MD, PhD Professor Department of Surgery Division of Transplant Medical University of South Carolina Charleston, South Carolina Ronald T. Cotton, MD Chief Resident in General Surgery Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas Kris P. Croome, MD, MS Fellow in Liver Transplantation Department of Surgery London Health Sciences Centre Western University, Canada London, Ontario, Canada Leigh Anne Dageforde, MD Resident, General Surgery Department of Surgery Vanderbilt University Medical Center Nashville, Tennessee Juan S. Danobeitia, MD, PhD Candidate

Assistant Researcher Department of Surgery Division of Transplantation University of Wisconsin-Madison Madison, Wisconsin Narasimham L. Dasika, MD Associate Professor of Radiology Department of Radiology Division of Vascular and Interventional Radiology University of Michigan Health System Ann Arbor, Michigan Derek DuBay, MD Assistant Professor of Surgery Department of Surgery Liver Transplant and Hepatobiliary Surgery University of Alabama at Birmingham School of Medicine Birmingham, Alabama Ty B. Dunn, MD, MS Assistant Professor of Surgery Division of Transplantation University of Minnesota Minneapolis, Minnesota Michael J. Englesbe, MD Associate Professor of Surgery Department of Surgery University of Michigan Medical School Ann Arbor, Michigan Annie Fecteau, MD Associate Professor Department of Surgery Division of Pediatric Surgery The Hospital for Sick Children University of Toronto Toronto, Ontario, Canada Elyssa J. Feinberg, MD Clinical Instructor Multiorgan Transplantation Department of Surgery Stanford University Stanford, California

Luis A. Fernandez, MD Associate Professor of Surgery Department of Surgery Division of Transplantation University of Wisconsin-Madison Madison, Wisconsin Sergio P. Meira Filho, MD Liver Transplant Surgeon Hospital Israelita Albert Einstein São Paulo, Brazil Anand Ghanekar, MD, PhD Division of General Surgery & Multi-Organ Transplant Program University Health Network Toronto General Hospital University of Toronto Toronto, Ontario, Canada P.viii Michael J. Goldstein, MD Department of Surgery Medical Director New York Organ Donor Network Director Kidney and Pancreas Transplantation Recanati/Miller Transplantation Institute Mount Sinai Medical Center New York, New York Christie W. Gooden, MD, MPH Clinical Assistant Professor University of Missouri-Kansas City School of Medicine Abdominal Transplant Surgeon Henry & Marion Bloch Liver Disease Management and Transplant Center Saint Luke's Hospital of Kansas City Kansas City, Missouri John A. Goss, MD Professor and Division Chief Department of Surgery Division of Abdominal Transplantation Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston, Texas

Tyler R. Grenda, MD House Officer Section of General Surgery Department of Surgery University of Michigan Medical Center Ann Arbor, Michigan James V. Guarrera, MD, FACS Surgical Director Adult Liver Transplant Program New York-Presbyterian Hospital Assistant Professor of Surgery Columbia University Medical Center New York, New York Jacfranz J. Guiteau, MD Chief Resident in General Surgery Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas Karim J. Halazun, MD Assistant Professor of Surgery Department of Surgery Division of Transplantation Emory University School of Medicine Atlanta, Georgia Roberto Hernandez-Alejandro, MD Assistant Professor Department of Surgery London Health Sciences Centre Western University, Canada London, Ontario, Canada Gerardo Kahane, MD General Surgery Resident The Brooklyn Hospital Center Brooklyn, New York Igal Kam, MD Professor Department of Surgery Division of Transplant Surgery University of Colorado Denver

Aurora, Colorado Joohyun Kim, MD, PHD Assistant Professor Department of Surgery Division of Transplant Surgery Medical College of Wisconsin Milwaukee, Wisconsin Masaru Kubota, MD Abdominal Transplant Surgery Fellow Department of Surgery New York-Presbyterian Hospital Columbia University Medical Center New York, New York Sean C. Kumer, MD, PhD Surgical Director Liver Transplantation Department of Surgery Division of Transplant Surgery University of Kansas Medical Center Kansas City, Kansas David Lee, MD Assistant Professor Transplant Center Mayo Clinic, Florida Jacksonville, Florida Matthew H. Levine, MD, PhD Assistant Professor of Surgery Division of Transplant Surgery Department of Surgery University of Pennsylvania Philadelphia, Pennsylvania Bonnie E. Lonze, MD, PhD Fellow Department of Surgery Division of Transplantation Johns Hopkins University School of Medicine Baltimore, Maryland John C. Magee, MD Professor of Surgery

Chief of Transplantation University of Michigan Health System Ann Arbor, Michigan Joseph F. Magliocca, MD Assistant Professor of Surgery Department of Surgery Emory University School of Medicine Atlanta, Georgia David P. Mason, MD Chief of Thoracic Surgery Surgical Director of Lung Transplantation Baylor University Medical Center Dallas, Texas Amit K. Mathur, MD Clinical Lecturer Transplant Fellow Section of Transplantation Surgery Department of Surgery University of Michigan Health System Ann Arbor, Michigan Erin C. Maynard, MD Assistant Professor of Surgery Division of Transplantation Department of Surgery University of Kentucky Lexington, Kentucky John W. McGillicuddy, MD Assistant Professor Department of Surgery Division of Transplant Medical University of South Carolina Charleston, South Carolina Greg J. McKenna, MD Director Transplant Surgical Research Informatics Associate Professor of Surgery Texas A&M Health Science Center Simmons Transplant Institute Baylor Health Care System

Dallas, Texas Roberto F. Meirelles Jr, MD, PhD Liver Transplant Surgeon Hospital Israelita Albert Einstein São Paulo, Brazil Marc L. Melcher, MD, PhD, FACS Assistant Professor Program Director Stanford Surgery Residency Multiorgan Transplantation Department of Surgery Stanford University Stanford, California Derek E. Moore, MD, MPH Assistant Professor of Surgery Department of Surgery Divisions of Kidney, Pancreas, and Liver Transplantation Vanderbilt University Medical Center Nashville, Tennessee Bassem N. Mora, MD Department of Thoracic and Cardiovascular Surgery The Cleveland Clinic Foundation Cleveland, Ohio P.ix Jaimie D. Nathan, MD Surgical Director Intestinal Transplant Program Assistant Professor of Surgery Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati, Ohio Christine A. O'Mahony, MD Assistant Professor Department of Surgery Division of Abdominal Transplantation Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston, Texas Brian S. Pan, MD

Assistant Professor of Surgery Division of Pediatric Plastic Surgery Cincinnati Children's Hospital Medical Center Cincinnati, Ohio Flavio Paterno, MD Assistant Professor of Surgery Department of Surgery Division of Transplantation University of Cincinnati Cincinnati, Ohio Richard V. Perez, MD, FACS Professor of Surgery Department of Surgery Division of Transplantation UC Davis School of Medicine Sacramento, California Susan C. Pitt, MD Transplant Surgery Fellow Section of Abdominal Transplant Surgery Washington University in St. Louis St. Louis, Missouri James J. Pomposelli, MD, PhD Surgical Director of Transplantation Department of Transplantation and Hepatobiliary Diseases Associate Professor of Surgery Tufts University School of Medicine Lahey Hospital & Medical Center Burlington, Massachusetts Rishindra M. Reddy, MD Assistant Professor Department of Surgery Section of Thoracic Surgery University of Michigan Health System Ann Arbor, Michigan Marcelo B. Rezende, MD Liver Transplant Surgeon Hospital Israelita Albert Einstein São Paulo, Brazil Jeffrey Rogers, MD

Department of General Surgery Section of Transplantation Wake Forest School of Medicine Winston-Salem, North Carolina Vinayak S. Rohan, MD Fellow Department of Surgery Division of Transplant Medical University of South Carolina Charleston, South Carolina Paolo R. Salvalaggio, MD, PhD Liver Transplant Surgeon Hospital Israelita Albert Einstein São Paulo, Brazil Universidade Positivo Paraña, Brazil Benjamin Samstein, MD Assistant Professor of Surgery Department of Surgery Director Living Donor Liver Transplant Program New York-Presbyterian Hospital Columbia University Medical Center New York, New York Dorry L. Segev, MD, PhD Associate Professor Department of Surgery Division of Transplantation Johns Hopkins University School of Medicine Baltimore, Maryland David Shaffer, MD Chief Division of Kidney and Pancreas Transplantation Vanderbilt University Medical Center Professor of Surgery Vanderbilt University School of Medicine Nashville, Tennessee Malay B. Shah, MD Assistant Professor of Surgery Surgical Director

Liver Transplantation Department of Surgery Division of Transplantation University of Kentucky Lexington, Kentucky Shimul A. Shah, MD, MHCM Director Liver Transplantation and Hepatobiliary Surgery Associate Professor of Surgery University of Cincinnati Cincinnati, Ohio Shant Shekherdimian, MD, MPH Clinical Fellow Department of Surgery Division of Pediatric Surgery The Hospital for Sick Children University of Toronto Toronto, Ontario, Canada Ashish Singhal, MBBS, DNB Department of Surgery Division of Transplantation University of Cincinnati Cincinnati, Ohio Christopher J. Sonnenday, MD, MHS Surgical Director Liver Transplantation Assistant Professor of Surgery Assistant Professor of Health Management & Policy Section of Transplantation University of Michigan Health System Ann Arbor, Michigan Zoe A. Stewart, MD, PhD Surgical Director Kidney, Pancreas, and Living Donor Transplantation Department of Surgery Division of Transplantation and Hepatobiliary Surgery University of Iowa Organ Transplant Center Iowa City, Iowa Robert J. Stratta, MD Department of General Surgery

Section of Transplantation Wake Forest School of Medicine Winston-Salem, North Carolina Randall S. Sung, MD Surgical Director Kidney and Pancreas Transplantation Associate Professor of Surgery Department of Surgery Section of Transplantation Surgery University of Michigan Health System Ann Arbor, Michigan Greg M. Tiao, MD Surgical Director Liver Transplantation Associate Professor of Surgery Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center Cincinnati, Ohio Christoph Troppmann, MD, FACS Professor of Surgery Department of Surgery Division of Transplantation University of California Davis School of Medicine Sacramento, California P.x Lisa Taylor VanHouwelingen, MD Senior Resident Department of Surgery London Health Sciences Centre Western University, Canada London, Ontario, Canada Ranjith Vellody, MD Assistant Professor of Radiology Division of Vascular and Interventional Radiology Department of Radiology University of Michigan Health System Ann Arbor, Michigan Seth Waits, MD Department of Surgery University of Michigan Health System

Ann Arbor, Michigan W. Kenneth Washburn, MD Professor of Surgery University of Texas Health Science Center at San Antonio Organ Transplantation Center University Transplant Center San Antonio, Texas Theodore H. Welling, MD Assistant Professor of Surgery Co-Director Multidisciplinary Liver Tumor Program Department of Surgery Section of Transplantation Surgery University of Michigan Health System Ann Arbor, Michigan Kenneth J. Woodside, MD Director Live Kidney Donor Evaluation Assistant Professor of Surgery Department of Surgery Division of Transplant Surgery University Hospitals Case Medical Center Cleveland, Ohio Carlton J. Young, MD Professor of Surgery Department of Surgery Division of Transplantation Director Pancreas Transplantation Director Pediatric Kidney Transplantation University of Alabama at Birmingham School of Medicine Birmingham, Alabama Yuriy Yushkov, PhD, MBA Director Donor Sourcing National Disease Research Interchange Philadelphia, Pennsylvania Michael A. Zimmerman, MD Associate Professor Department of Surgery Division of Transplant Surgery

University of Colorado Denver Aurora, Colorado

2015 Lippincott Williams & Wilkins Philadelphia 530 Walnut Street, Philadelphia, PA 19106 USA 978-1-4511-8874-5

Acquisitions Editor: Keith Donnellan Product Development Editor: Brendan Huffman Production Project Manager: David Saltzberg Design Coordinator: Doug Smock Senior Manufacturing Manager: Beth Welsh Marketing Manager: Daniel Dressler Prepress Vendor: Absolute Service, Inc. Copyright © 2015 Wolters Kluwer Health All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Operative techniques in transplantation surgery / editor, Michael J. Englesbe; editor-in-chief, Michael W. Mulholland. p. ; cm. Includes bibliographical references. ISBN 978-1-4511-8874-5 I. Englesbe, Michael J., editor. II. Mulholland, Michael W., editor. [DNLM: 1. Transplantation—methods. 2. Tissue and Organ Procurement. 3. Transplants—surgery. WO 660] RD120.7 617.9′54—dc23 2014029298 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals' examination of

each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contradictions, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com

Dedication I dedicate this book to my father, William Englesbe, and my mentor, Darrell Campbell, Jr, MD. You two have given me every opportunity. I would also like to dedicate this book to my wife, Audrey Wu, and my children Mia, Ava, and William. It was lovely to have you sitting next to me as I worked on this. Thank you! Michael J. Englesbe

Series Preface Operative therapy is complex, technically demanding, and rapidly evolving. Although there are a number of standard textbooks that cover aspects of general, thoracic, vascular, or transplant surgery, Operative Techniques in Surgery is unique in offering a comprehensive treatment of contemporary procedures. Open operations, laparoscopic procedures, and newly described robotic approaches are all included. Where alternative or complementary approaches exist, all are provided. The scope and ambition of the project is one of a kind. The series is organized anatomically in sections covering thoracic surgery, upper gastrointestinal surgery, hepato-pancreatico-biliary surgery, and colorectal surgery. Breast surgery, endocrine surgery, and topics related to surgical oncology are included in a separate volume. Modern approaches to vascular surgery and transplantation surgery are also covered in separate volumes. The series editors are renowned surgeons with expertise in their respective fields. Each is a leader in the discipline of surgery, each recognized for superb surgical judgment and outstanding operative skill. Breast surgery, endocrine procedures, and surgical oncology topics were edited by Dr. Michael Sabel of the University of Michigan. Thoracic and upper gastrointestinal surgery topics were edited by Dr. Mary Hawn of the University of Alabama at Birmingham, with Dr. Steven Hughes of the University of Florida directing the volume on hepatopancreatico-biliary surgery. Dr. Daniel Albo of Baylor College of Medicine directed the volume dedicated to colorectal surgery. Dr. Ronald Dalman of Stanford University edited topics related to vascular surgery, including both open and endovascular approaches. The discipline of transplantation surgery is represented by Dr. Michael Englesbe of the University of Michigan. In turn, the editors have recruited contributors that are world-renowned; the resulting volumes have a distinctly international flavor. Surgery is a visual discipline. Operative Techniques in Surgery is lavishly illustrated with a compelling combination of line art and intraoperative photography. The illustrated material was all executed by a single source, Body Scientific International, to provide a uniform style emphasizing clarity and strong, clean lines. Intraoperative photographs are taken from the perspective of the operating surgeon so that operations might be visualized as they would be performed. The result is visually striking, often beautiful. The accompanying text is intentionally spare, with a focus on crucial operative details and important aspects of postoperative management. The series is designed for surgeons at all levels of practice, from surgical residents to advanced practice fellows to surgeons of wide experience. The incredible pace at which surgical technique evolves means that the volumes will offer new insights and novel approaches to all surgeons.

Operative Techniques in Surgery would be possible only at Wolters Kluwer Health, an organization of unique vision, organization, and talent. Brian Brown, executive editor, Keith Donnellan, acquisition editor, and Brendan Huffman, product development editor, of Wolters Kluwer Health deserve special recognition for vision and perseverance. Michael W. Mulholland, MD, PhD

Preface As part of the series, Operative Techniques in Surgery, this volume focuses on the detailed technical aspects in the field of transplantation surgery. This book should serve as a guide to anyone interested in transplantation, including medical students, transplant physicians and physician extenders, surgical trainees, as well as practicing transplant surgeons. The craft of transplant surgery combines the domains of urology, vascular, hepatobiliary, and general surgery, with a unique emphasis on technical efficiency. The contributors to this text are surgeons well known for their technical expertise, with a specific focus on innovative approaches to the challenging practice of transplantation. The textbook covers in great detail the surgical techniques of pediatric and adult solid organ transplantation. Topics include chapters on deceased and living donation as well as liver, kidney, pancreas, and lung transplantation. In addition, the book details the management of complex portal hypertension in children and adults. The book succinctly describes preoperative, intraoperative, and postoperative clinical decision-making. The readers should find this text useful in updating their knowledge, and it will serve as a practical guide in transplantation surgery. I would like to thank Dr. Michael Mulholland, Brendan Huffman, and Keith Donnellan for their mentorship and guidance. I hope this book will help us to better care for organ donors and the recipients of their precious gifts. Furthermore, I hope this book will inspire young surgeons to enter the amazing and humbling field of transplantation surgery. Michael J. Englesbe, MD

Chapter 1 Standard Deceased Donor Kidney Procurement Christie W. Gooden

DEFINITIONS In the case of deceased donor kidney procurements, often the surgeon who will be transplanting the organ is not the surgeon who is procuring the organ. Therefore, it is incumbent on the procuring surgeon to take responsibility and ensure transplantability of the organ they are charged to obtain. This chapter is meant to facilitate an error-free procurement. Deceased donors can be categorized as: Donation after brain death: Donor has been clinically declared brain dead. Physiologic stability is usually maintained by medical measures (i.e., mechanical ventilation and vasopressors). Procuring these types of donors is what this chapter will focus on. Some also call it death by neurologic criteria.

Table 1: Definition of Standard and Expanded Criteria Donor Age Categories Donor Condition 1.5

X

X

CVA + HTN

X

X

CVA + Creat >1.5

X

X

HTN + Creat >1.5

X

X

CVA

X

HTN

X

Creatinine >1.5

X

None of the above

X

X, meets definition for Expanded Criteria Donor; CVA, CVA was cause of death; HTN, history of hypertension at any time; Creat >1.5 = creatinine >1.5 mg/dL. U.S. Department of Health and Human Services. OPTN Policy 7: allocation of deceased kidneys. http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_7.pdf-

application/pdf. Donation after cardiac death: Donor who is not brain dead has nonsurvivable injuries. Cardiac function ceases prior to organ procurement.

DONOR HISTORY Donors are not only characterized by their manner of death. They are further distinguished by their medical history. To the procuring surgeon, the most relevant distinction is standard criteria donor versus extended criteria donor (SCD vs. ECD). ECD procurements often require the surgeon to perform additional tasks. Standard criteria donor: Brain dead donors who do not meet any of the criteria for an ECD. Expanded criteria donor: Donors with a medical history that is positive for predefined variables that indicate an increased risk of graft failure by 70% (relative hazard ratio, 1.70) compared with an SCD kidney (Table 1).1 Donor surgeons are often asked to biopsy these kidneys and sometimes place them on pump.

SURGICAL MANAGEMENT Preoperative Planning Check the consent. Check for appropriate documentation of brain death and be aware of the clinical history and testing. Verify that the donor name and United Network for Organ Sharing (UNOS) number match.

Positioning Check the donor's name with donor's ID and conduct a “time-out” with all members of the operative team. Position the donor supine with arms securely tucked. Assure that the anesthesia team has access to all monitors and intravascular catheters. Make sure they are working properly after the donor has been positioned. The donor should be prepped from chin to pubis.

TECHNIQUES EXPOSURE OF AORTA AND INFERIOR VENA CAVA Make a midline laparotomy and sternotomy. Perform a Cattell-Braasch maneuver to expose the inferior vena cava (IVC). This dissection should be carried from the reflection of the right colon continued superiorly to mobilize the duodenum (Kocher maneuver) and laterally to the inferior mesenteric vein (IMV) at the ligament of Treitz. Take care to preserve the IMV, as some centers cannulate this for a portal flush (see Liver Procurement). Place intestines in a sterile towel creating a “bowel bag” (FIG 1) and have the assistant reflect the bowel up and to the donor's left. This facilitates exposure of the left and right renal veins. Dissect the fine tissue on top of the IVC to expose the left renal vein (FIG 2A). Then carefully dissect along the anterior lateral IVC to identify the right renal vein. It is important to identify both renal veins to determine where to transect the IVC later in the operation (FIG 2B).

The superior mesenteric artery (SMA) is anterior to the left renal vein. Optional maneuver: Identify and mark SMA (FIG 3). P.2

FIG 1 • Bowel bag to isolate the bowel and mesentery. Using a right angle, carefully dissect the often dense fibrous or nerve tissue surrounding the SMA until the right angle can be passed around it. Take care when encircling the SMA, as the celiac artery can be close behind. Once around the SMA, pass an umbilical tape or vessel loop. The SMA is a landmark for the aortic transection later in the case. Again, this step is optional (although it is a great teaching maneuver). If the dissection proves to be difficult, the author will often abandon this maneuver as one can inadvertently injure the celiac or cause bleeding at an inopportune time.

FIG 2 • A. Dissection of the tissue anterior to the IVC (indicated by the white probe) and identification of the right renal vein. B. Close-up of the renal veins.

FIG 3 • SMA marked with yellow vessel loop.

PREPARE INFRAHEPATIC AORTA FOR CANNULATION Palpate the aorta next to the IVC. It is often covered by a layer of adipose and connective tissue. In an obese donor, this layer can be thick. Feel for the bifurcation and start to dissect the overlying tissue just proximal to the bifurcation in order to expose the anterior surface of the aorta. Dissect distally to expose the iliac bifurcation (FIG 4). Look for additional renal arteries when exposing the iliacs. They are usually noted on the lateral side of the common iliac artery. These are rare but important to preserve. Circumferentially, dissect the aorta just proximal to the iliacs and mark with a heavy silk. During this dissection, be aware of lumbar branches; they are usually paired. P.3 They can either be tied off (either ligated or just clipped so that they do not cause back-bleeding during the aortic cannulation) or avoided. The author often ignores them as they are easily dealt with once cold perfusion starts.

FIG 4 • Exposure of aorta at iliac bifurcation. Continue the aortic dissection superiorly for 2 cm and place another 0 silk tie or umbilical tape around the aorta. During this upper aortic dissection, avoid the inferior mesenteric artery (IMA). There is often enough room between the iliacs and the IMA to place your superior tie. Only 1.5 cm in length is needed between the two ties, although it does not hurt to have more (FIG 5). If there is not enough space for the cannula, the IMA can be ligated.

FIG 5 • Dissected infrarenal aorta with upper and lower ties. If an accessory renal artery is found coming from the iliac artery, circumferentially dissect both iliacs. Cannulate the contralateral iliac (if possible) and clamp the ipsilateral iliac distal to the renal artery.

PREPARE UPPER ABDOMINAL AORTA FOR CROSS-CLAMP Take down left triangular ligament of the liver by distracting the left lateral segment away from the diaphragm. With Bovie electrocautery, take down the gossamer layers of the ligament (FIG 6). Be wary as you approach the IVC. A large phrenic vein and often the left hepatic vein can be hidden by the triangular ligament. Reflect the liver to the right. Open the pars flaccida and palpate for a replaced or accessory left hepatic artery. (Please see Chapter 14, Procurement of Liver for Transplantation.)

FIG 6 • Mobilization of the left lateral segment. Identify the aorta by palpation. Have the assistant retract the esophagus laterally. Using a right angle and Bovie electrocautery, incise the crura until the aorta is exposed. Some surgeons use a large right angle to dissect under the aorta and pass an umbilical tape to facilitate clamping. There is often dense tissue surrounding the aorta. Blunt dissection is often very useful to facilitate this task. Pull the umbilical tape upward gently and ensure that the vascular clamp will be large enough to completely encircle the aorta. The author prefers a large Kocher clamp as it is often the appropriate size and has the added benefit of deep grooves that prevent slippage of the clamp. Alternatively, circumferential dissection is avoided to avoid injuring lumbar arteries while passing the right angle behind the aorta. In this case, just enough of the aorta is dissected to facilitate confident aortic crossclamping. P.4

CROSS-CLAMP When all surgical teams are ready, 30,000 units of heparin is given intravenously by the anesthesia team. After 3 minutes, the aorta is ligated just above the iliac bifurcation (using the most distal silk or umbilical tape). Pinch (or clamp) the aorta just above the proximal heavy silk. Using a Metzenbaum scissor, cut the aorta just proximal to where the iliacs are tied off, and pass the cannula into the aorta (FIG 7). The clamp will have to be flashed to advance the cannula; this is why pinching works best in many cases. Tie the proximal heavy silk around the cannula. If there is bleeding from a lumbar branch or around the cannula, a Kocher (or another smaller vascular clamp) can be used to clamp the aorta beneath the cannula. Attention is then turned to the supraceliac aorta. When all surgical teams are ready, clamp the aorta with the large Kocher clamp. The cold perfusate should start at this time. If there are no other teams present, vent the flush via a hole in the right atrium.

FIG 7 • Aorta with cannula in place.

PROCURING THE KIDNEYS Once the cold perfusion begins, apply slush to both paracolic gutters to cool the kidneys. Mobilize the left colon medially to facilitate cooling of the left kidney. Once the flush is complete (3 to 7 L is usually used for the abdominal flush in an adult) and other abdominal organs are removed, the kidneys can be procured. Note, there are maneuvers during the liver procurement that are important to safe procurement of the kidneys. The plane of dissection between the right kidney and the liver should be through the adrenal gland. The plane of transection is through the adrenal gland. This will avoid injury to both the kidney and the liver. Divide the IVC to ensure a decent cuff of IVC; the transplanting team may need this cava for extension of the right renal vein. Divide the IVC two fingerbreadths (approximately 1 cm) above the right renal vein, as long as it does not compromise the infrahepatic cava (FIG 8).

FIG 8 • Partially transected IVC above the renal veins. Divide the aorta at the level of the SMA. The renal arteries are very close to the SMA. These arteries can be injured if care is not taken; as long as the division of the aorta is at the level of the SMA, injury to the

renal arteries will not occur. Identify the right ureter and mobilize the right kidney. Remove ice from the right paracolic gutter and pelvis. Identify the right ureter. With the index finger, encircle all of the tissue from the psoas, above the right common iliac to the midline (FIG 9). In that P.5 tissue will be the ureter. This maneuver is to ensure that there is more than enough tissue surrounding the ureter (do not strip the ureter of tissue). Using curved Mayo scissor, cut lateral and medial to the encircled tissue toward the pelvis. Give the held tissue a wide berth in order to avoid injury to the ureter. Once down to the pelvic wall or bladder, take the back end of the scissor and push against the pelvic wall as far as possible. Then transect this tissue containing the ureter. Find the cut end of the ureter in the tissue and place a hemostat on the tip of it (FIG 10).

FIG 9 • Index finger around ureter containing tissue.

FIG 10 • Cut end of ureter. Mobilize the right kidney by extending the dissection laterally from the exposed psoas cranially. The assistant gently pulls the kidney and the hemostat on the ureter medially. The goal is to mobilize the kidney to the midline by dissecting away the retroperitoneal attachments. Stop at the upper pole. Identify the left kidney and mobilize medially. There tends to be thicker tissue around the left ureter and it can be difficult to identify. To facilitate isolating the left ureter, fully mobilize the descending colon medially. Then, staying close to the bowel, divide the colonic mesentery away from the colon (FIG 11A,B). Position the colon medially, away from the lateral wall of the abdomen. Similar to the dissection on the right, expose the left psoas and gather the tissue from the psoas, to the tissue overlying the left common iliac to the midline with one finger. Perform the same wide dissection. Once transected deep in the pelvis, identify the left ureter and place a hemostat on the distal end. Depending on local policy, tag the left ureter with the suture or clamp of their choice. Again, perform the same medialization of the kidney. Have the assistant cut the retroperitoneal attachments while the kidney and ureter are held medially. Mobilizing the left kidney can be more difficult due to the close proximity of the upper pole of the kidney to the splenic flexure of the colon and the spleen (FIG 12). These attachments can be adherent. Avoid injury to the renal vein, an upper pole renal artery, and the upper pole of the kidney.

FIG 11 • A. Divide the descending colon mesentery close to the colon. B. The mobilized descending colon. P.6

FIG 12 • Dissection of upper pole of left kidney. Transect the vessels Once the kidneys are fully mobilized, the aorta and IVC are transected. First, cut the tubing to the aorta cannula then cut the IVC at approximately the same level (FIG 13). Use a Kocher to grasp the aorta and IVC.

FIG 13 • Cut major vessels. Have an assistant first gather the kidneys toward the midline. Then reflect the hemostats marking the ureter cranially and medially (making sure they are on adequate tension). Then the surgeon should lift the Kocher on the aorta and IVC and cut underneath the clamps with tips facing upward (toward the heart) (FIG 14). The goal is to expose the spine as the posterior attachments of the aorta and IVC are incised. Keeping the ureters up and the kidneys midline is the key to this maneuver. The assistant must notify the surgeon if positioning is not optimal so that the proper adjustments can be made. When the surgeon reaches the level of the upper pole of the kidneys, have the assistant direct the ureters back to their anatomic position. Gently retract the upper poles of the kidneys caudally. From the donor's right, cut any remaining attachments to the liver (if it was not procured) including the IVC to the level of the aorta. Make sure the appropriate amount of cuff is maintained on the IVC above the renal veins (approximately 1 cm). From the donor's left, divide any remaining attachments cranial to the upper pole to the level of the aorta. If the liver has been procured, the aorta should already be partially transected and the final attachments of the aorta should be incised to release the kidneys. If the liver has not been procured, cut the aorta at the level of the SMA or higher to release the kidneys.

FIG 14 • Exposing the spine and dividing the tissue posterior to the aorta and IVC.

SEPARATING THE KIDNEYS The en bloc kidneys should be cradled and placed in a bowl filled with slush. To facilitate separation, the kidneys are placed on a towel or in a bowel bag on top of the slush, taking care to ensure the kidneys remain cool. Orient the kidneys as if they were in the body. Start by finding the left renal vein where it crosses the aorta and enters the IVC. Tension on the top and bottom of the aorta is critical for this dissection (FIG 15). Divide P.7 the left renal vein in an elliptical fashion, leaving a small cuff of cava with the renal vein (some regions prefer a small cuff of left renal vein stay on the IVC). Reflect the vein toward the left kidney.

FIG 15 • Find the left renal vein where it crosses the aorta and enters the IVC. Tension on the top and bottom of the aorta is critical for this dissection. Clean off the anterior aorta exposing the renal arteries (FIG 16). Be aware of possible accessory arteries and/or aberrant veins crossing the aorta and the left renal vein. Divide the aorta down the center, leaving aortic cuff for both renal arteries. With the intima exposed, the ostia of aortic branches may be noted. Probe any arteries to confirm their identity as renal arteries. Once satisfied with the anatomy, divide the aorta down the center (FIG 17). Divide the remaining subcutaneous tissues looking for aberrant anatomy.

FIG 16 • Exposed aorta with renal arteries revealed.

FIG 17 • Aorta divided to separate the kidneys. Leave a cuff of aorta on both renal arteries.

CLEANING THE KIDNEY Choose one kidney to clean, inspect, and measure. The other kidney should be submerged in the slush. With the hemostat still on the ureter, place the organ in anatomic position. Distract the ureter downward and feel for the lower pole of the kidney superiorly. Incise Gerota's fascia with Metzenbaum scissors overlying where the lower pole was palpated until the lower pole of the kidney is exposed. Continue this dissection from the lower pole to the upper pole just lateral to the hilar fat. Never be too aggressive cleaning the fat (the transplanting surgeon can further clean the kidney if he or she prefers) and do not enter the hilum (FIG 18). The goal of removing the fat from the kidney is to see as much of the kidney as possible to assure no anatomic abnormality. Inspect the kidneys for damage to the capsule, cysts, and/or ill-perfused areas,

indicated by discoloration. Any cysts that are larger than 1 cm or appear complex should be sent separately for biopsy. Any damage should be documented. Measure the kidneys Measure the length and width of the kidney and vessels (from the hilum to the ostia) (FIG 19). In the presence of multiple arteries and/or veins, each individual vessel should be measured. The location of these accessory vessels and their distance away from the main renal artery or vein should be indicated as well. The length of the ureter should be documented and the amount of tissue procured around the ureter should be quantified. P.8

FIG 18 • Completed back table of the kidney.

FIG 19 • Measuring the kidney and renal vessels.

PEARLS AND PITFALLS Positioning

▪

Hospitals have varying experience with procurement operations.

▪

Ensure before the donor is in the operating room (OR) that there are two Bovies, at least two suctions (three if thoracic team), and any other equipment necessary.

▪

For kidney-only donors, still prep from chin to pubis. Opening the chest with a sternal saw facilitates exposure during the procurement as well as expedites cross-clamping of the aorta and venting of the cava.

▪

If an accessory renal artery is found coming from the iliac artery, circumferentially dissect both iliacs. Cannulate the contralateral iliac (if possible) and clamp the ipsilateral iliac distal to the renal artery.

▪

Keep in mind that if aberrant anatomy is found during any part of the dissection, there may be other aberrancies.

Procurement of the kidneys

▪

Identification of the SMA takeoff facilitates the dissection and transection of the aorta later in the case.

Separating the kidneys

▪

If an injury is found, provide adequate detail, including pictures if warranted. Information such as the transplantability of the organ after an injury is found is extremely helpful.

Exposure of aorta and IVC

REFERENCE 1. U.S. Department of Health and Human Services. OPTN Policy 7: allocation of deceased kidneys. http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_7.pdf-application/pdf.

Chapter 2 Procurement of Pediatric En Bloc Kidneys Christoph Troppmann

DEFINITION This chapter describes the recovery of pediatric donor kidneys as a single anatomic unit (i.e., leaving them attached to the donor's abdominal aorta and inferior vena cava [IVC]) in preparation for transplanting these kidneys as a single unit (“en bloc”) into one recipient. The weight of pediatric en bloc kidney donors ranges typically from 2.5 kg to 25 kg. The goal of this surgical approach is to provide adult recipients with sufficient graft nephron mass while minimizing the technical challenges and complication rates that would result from transplanting these small kidneys as single grafts. The decision to allocate kidneys from small pediatric donors as single versus en bloc kidneys is made by the hosting local organ procurement organization (OPO). Nearly all kidneys from donors weighing less than 10 kg are transplanted en bloc.1,2,3 The majority of kidneys from donors between 10 and 20 kg of weight are transplanted en bloc. In selected cases, however, kidneys recovered en bloc can be split for transplantation as single kidney into two recipients (for instance, when kidney length exceeds 6 cm). In doing so, one must carefully weigh the principles of maximizing kidney graft availability (i.e., splitting the kidneys and providing a graft for two recipients) versus minimizing technical-vascular complications (i.e., leaving kidneys en bloc).1,2,3,4,5,6 En bloc graft back-table preparation and hypothermic pulsatile perfusion as well as donor and recipient selection criteria are described in Chapter 10.

SURGICAL MANAGEMENT The principles and recovery techniques outlined in this chapter apply to both brain-dead and donation after cardiac death (DCD) donor recoveries, unless specifically noted otherwise. En bloc kidney grafts have limited functional reserve until they have grown to meet the recipients' needs. This limited reserve may be further compounded by other nonmodifiable factors (e.g., preterminal acute kidney injury, DCD donor status, extended warm and cold ischemia time). Hence, organ preservation must be optimized. Use University of Wisconsin (UW) preservation solution (SPS-1®; Organ Recovery Systems, Inc, Itasca, IL) for recovery of en bloc kidneys from both brain-dead and DCD pediatric donors whenever possible. Other preservation solutions, for instance, histidine-tryptophan-ketoglutarate solution (HTK) (Custodiol® HTK; Essential Pharmaceuticals, Newtown, PA), have been associated with less favorable outcomes in kidney transplantation, particularly in conjunction with longer preservation times.7,8,9 Particularly for small and very small (40 years), high BMI, cerebrovascular cause of brain death, and prolonged cold ischemia are considered key determinants of outcome in pancreas transplantation and remain important barriers to pancreas organ recovery.

▪

In cases of systemic venous drainage or retroperitoneal portal venous drainage, the arterial interposition Y-graft does not have to be particularly long.

▪

Vascular size match usually results in anastomosis of the external iliac artery to the SMA and the internal iliac artery to the splenic artery.

▪

For nonretroperitoneal portal venous drainage, a long Y-graft is required. The best way to maximize length is to perform anastomoses between the longer limb of the external iliac artery to the shorter splenic artery and the shorter limb of the internal iliac artery to the longer SMA.

Positioning

▪

Supine position and a midline incision

Dissection of the recipient vessels

▪

Depending on the size of the SMV, one may not necessarily need to perform a circumferential dissection as it can be controlled with a small side-biting vascular clamp.

▪

Care must be taken not to injure the left common iliac vein or distal vena cava if the common iliac artery is encircled; both of these venous structures may be adherent to the artery because of atherosclerosis.

▪

After completion of the venous anastomosis, a spring clamp is placed on the graft portal vein and all clamps are released from the SMV to restore venous outflow in the native mesenteric circulation.

▪

Pretest the anastomoses: After completion of the arterial anastomosis, a vascular clamp is placed on the conduit and vascular clamps are released from the native arterial circulation to ensure adequate distal flow and to test the integrity of the arterial anastomosis.

▪

Place the enteric anastomosis on the posterior aspect of the third or fourth portion of the graft duodenum to take advantage of dependent drainage of the denervated,

Allograft back-table preparation

Vascular anastomosis

Enteric drainage

atonic graft duodenum when the patient is either in the supine or erect position. Placement of the kidney during an SPK transplant

▪

Place in the pelvis on the right side, leaving the left side available for future transplant procedures.

▪

Take care not to retract on the pancreas during the kidney transplant.

OUTCOMES With improvements in organ retrieval and preservation technology, refinements in diagnostic and therapeutic technologies, advances in clinical immunosuppression and antimicrobial prophylaxis, and increased experience in donor and recipient selection, success rates for pancreas transplantation have steadily improved.1,2,3 For recipients of primary deceased donor pancreas transplants, 1-year patient survival is more than 95% in all three categories; unadjusted 5-year patient survival rates are 87% in SPK, 83% in PAK, and 89% in PTA recipients; and more than 70% of patients are alive at 10 years posttransplant.1,3 One-year pancreas graft survival (insulin-free) rates are 85.5% in SPK (93% kidney graft survival), 80% in PAK, and 78% in PTA recipients, which translates to pancreas graft half-lives approaching 14 years in SPK and 10 years in solitary pancreas transplant recipients.1,2,3 Purported benefits of pancreas transplantation with portal venous outflow include technical, metabolic, and immunologic “advantages.” 4,5,6,7,8,9,10,11,29,30,31 However, these benefits have not been confirmed by either prospective cohort studies, randomized controlled trials, or large analyses based on registry databases. Alternatively, there are likewise no well-controlled studies to suggest any major disadvantages or unique risks associated with portal venous outflow other than the technical considerations, concerns, and contraindications discussed in this chapter. Although numerous variations exist in the basic surgical techniques of pancreas transplantation and nuances continue to be described, current philosophy dictates that the most appropriate technique to be performed is the one with which the individual surgeon feels most comfortable.

COMPLICATIONS The complication profile of pancreas transplantation with portal venous outflow is similar to systemic drainage. The most common is early graft thrombosis, which occurs 5% to 10% of the time following the SPK procedure. A major advantage of portal venous outflow is that it is primarily a midabdominal rather than a pelvic procedure, which is beneficial in patients who have had previous transplants or pelvic procedures. Disadvantages, however, are that the arterial anastomosis may be difficult and require a long interposition Y-graft (especially in patients with central, omental, or mesenteric obesity), and the pancreas graft is surrounded by bowel loops and may be poorly accessible for ultrasonographic imaging, percutaneous biopsy, and potentially at risk for venous torsion. Consequently, we usually attempt to

anchor the tail of the pancreas graft to the anterior abdominal P.275 wall with interrupted nonabsorbable sutures and “mark” this area externally by having one of the drains exit the abdominal wall at this location. These disadvantages can also be minimized by approaching the SMV from the lateral retroperitoneal aspect instead of from the anterior route, with the pancreas graft eventually situated posterior to the right colon. Because the distance between the graft and right iliac artery is not influenced by the thickness of the mesentery and there are no interposing bowel loops (other than the right colon) between the graft and lateral abdominal wall with this approach, the arterial anastomosis can be performed using a shorter interposition Y-graft and the pancreas is more easily visualized and accessible for ultrasonographic imaging and percutaneous biopsy.

REFERENCES 1. Gruessner AC. 2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the twenty-four years at the International Pancreas Transplant Registry (IPTR). Rev Diab Stud. 2011;8:6-16. 2. Opelz G. President's address. The Transplantation Society—Berlin 2012. Transplantation. 2013;95:4-7. 3. Kandaswamy R, Stock PG, Skeans MA, et al. OPTN/SRTR 2011 Annual Data Report: pancreas. Am J Transplant. 2013;13(Suppl 1):47-72. 4. Gaber AO, Shokouh-Amiri H, Grewal HP, et al. A technique for portal pancreatic transplantation with enteric drainage. Surg Gynecol Obstet. 1993;177:417-419. 5. Boggi U, Vistoli F, Signori S, et al. A technique for retroperitoneal pancreas transplantation with portalenteric drainage. Transplantation. 2005;79:1137-1142. 6. Newell KA, Bruce DS, Cronin DC, et al. Comparison of pancreas transplantation with portal venous and enteric exocrine drainage to the standard technique utilizing bladder drainage of exocrine secretions. Transplantation. 1996;62:1353-1356. 7. Petruzzo P, Da Silva M, Feitosa LC, et al. Simultaneous pancreas-kidney transplantation: portal versus systemic venous drainage of the pancreas allografts. Clin Transplant. 2000;14:287-291. 8. Cattral MS, Bigam DL, Hemming AW, et al. Portal venous and enteric exocrine drainage versus systemic venous and bladder exocrine drainage of pancreas grafts: clinical outcome of 40 consecutive transplant recipients. Ann Surg. 2000;232:688-695. 9. Stratta RJ, Gaber AO, Shokouh-Amiri MH, et al. A prospective comparison of systemic-bladder versus portal-enteric drainage in vascularized pancreas transplantation. Surgery. 2000; 127:217-226. 10. Stratta RJ, Shokouh-Amiri MH, Egidi MF, et al. A prospective comparison of simultaneous kidney-pancreas transplantation with systemic-enteric versus portal-enteric drainage. Ann Surg. 2001;233:740-751.

11. Philosophe B, Farney AC, Schweitzer EJ, et al. Superiority of portal venous drainage over systemic venous drainage in pancreas transplantation: a retrospective study. Ann Surg. 2001;234: 689-696. 12. Fridell JA, Rogers J, Stratta RJ. The pancreas allograft donor: current status, controversies, and challenges for the future. Clin Transplant. 2010;24:433-449. 13. Fridell JA, Powelson JA, Sanders CE, et al. Preparation of the pancreas allograft for transplantation. Clin Transplant. 2011;25:E103-E112. 14. Mühlbacher R, Gnant MF, Auinger M, et al. Pancreatic venous drainage to the portal vein: a new method in human pancreas transplantation. Transplant Proc. 1990;22:636-637. 15. Gil-Vernet JM, Fernandez-Cruz L, Andreu J, et al. Clinical experience with pancreaticopyelostomy for exocrine pancreatic drainage and portal venous drainage in pancreas transplantation. Transplant Proc. 1985;17:342-345. 16. Calne RY. Paratopic segmental pancreas grafting: a technique with portal venous drainage. Lancet. 1984;1:595-597. 17. Rosenlof LK, Earnhardt RC, Pruett TL, et al. Pancreas transplantation: an initial experience with systemic and portal drainage of pancreatic allografts. Ann Surg. 1992;215:586-597. 18. Sutherland DE, Goetz FC, Moudry KC, et al. Use of recipient mesenteric vessels for revascularization of segmental pancreas grafts: technical and metabolic considerations. Transplant Proc. 1987;19:2300-2304. 19. Doudzjian VK, Gugliuzza KK. The impact of midline versus transverse incision on wound complications and outcome in simultaneous pancreas-kidney transplants: a retrospective analysis. Transplant Int. 1996;9:62-67. 20. Barone GW, Sailors DM, Ketel BL. Combined kidney and pancreas transplants through lower transverse abdominal incisions. Clin Transplant. 1996;10:316-319. 21. Zibari GB, Aultman DF, Abreo KD, et al. Roux-en-Y venting jejunostomy in pancreatic transplantation: a novel approach to monitor rejection and prevent anastomotic leak. Clin Transplant. 2000;14:380-385. 22. Losanoff JE, Harland RC, Thistlethwaite JR, et al. Omega jejunoduodenal anastomosis for pancreas transplant. J Am Coll Surg. 2006;202:1021-1024. 23. De Roover A, Coimbra C, Detry O, et al. Pancreas graft drainage in recipient duodenum: preliminary experience. Transplantation. 2007;84:795-797. 24. Hummel R, Langer M, Wolters HH, et al. Exocrine drainage into the duodenum: a novel technique for pancreas transplantation. Transplant Int. 2008;21:178-181. 25. Shokouh-Amiri MH, Zakhary JM, Zibari GB. A novel technique of portal-endocrine and gastric-exocrine drainage in pancreatic transplantation. J Am Coll Surg. 2011;212:730-739.

26. Lam VW, Wong K, Hawthorne W, et al. The linear cutting stapler for enteric anastomosis: a new technique in pancreas transplantation. Transplant Int. 2006;19:915-918. 27. Fridell JA, Milgrom ML, Henson S, et al. Use of end-to-end anastomotic circular stapler for creation of the duodenoenterostomy for enteric drainage of the pancreas allograft [corrected]. J Am Coll Surg. 2004;198:495497. 28. Fridell JA, Shah A, Milgrom ML, et al. Ipsilateral placement of simultaneous pancreas and kidney allografts. Transplantation. 2004;78:1074-1076. 29. Hughes TA, Gaber AO, Amiri HS, et al. Kidney-pancreas transplantation. The effect of portal versus systemic venous drainage of the pancreas on the lipoprotein composition. Transplantation. 1995;60:14061412. 30. Carpentier A, Patterson BW, Uffelman KD, et al. The effect of systemic versus portal insulin delivery in pancreas transplantation on insulin action and VLDL metabolism. Diabetes. 2001;50:1402-1413. 31. Petruzzo P, Badet L, Lefrançois N, et al. Metabolic consequences of pancreatic systemic or portal venous drainage in simultaneous pancreas-kidney transplant recipients. Diabet Med. 2006;23:654-659.

Chapter 42 Enteric and Bladder Drainage of the Exocrine Pancreas and Enteric Conversion Ty B. Dunn

DEFINITION Successful pancreas transplantation requires management of the gland's exocrine secretions. From the first pancreas transplant until present, the management of the exocrine pancreas has evolved through a variety of operative techniques (end stoma, duct ligation, open duct, duct injection, ureteral anastomosis, bladder and enteric drainage), each with their own complications and utility. Enteric or bladder drainage of the duodenal cuff are the currently preferred methods. Knowledge of other techniques is required for optimal care of the pancreas transplant recipient, as they may be used in rare cases to salvage a technical problem or have been used in a patient transplanted in an earlier era. Exocrine leak is a major cause of surgical complications after pancreas transplantation.

PATIENT HISTORY AND PHYSICAL FINDINGS As enteric drainage emulates normal physiology, it is associated with decreased complications compared to bladder drainage technique. Enteric drainage of the pancreas allograft has increased in popularity in the recent era, as compared to bladder drainage, as first described by Sollinger in 1984 and modified by Corry.1,2,3 However, for recipients of solitary pancreas transplants (pancreas after kidney [PAK] or pancreas transplant alone [PTA]) or simultaneous kidney and pancreas (SPK) with perceived high risk of rejection or technical problem, some centers prefer bladder drainage due to lower early posttransplant intraabdominal infection rate, thrombosis, and enhanced ability for graft monitoring for rejection.4 The choice of technique used to accomplish drainage of exocrine secretions is impacted by several key issues including consideration of recipient comorbidities such as gastroparesis or neurogenic bladder, the type of pancreas transplant, and the estimated immunologic risk.5,6 Some diabetics have gastroparesis or diabetic colopathy, which may manifest as delayed gastric emptying, vomiting, or alternating diarrhea and constipation. These conditions can increase the risk of early enteric leak, graft pancreatitis, and inconsistent absorption of immunosuppression. This subset of patients may be better suited for bladder drainage. If bladder drainage is considered, it is important to ensure normal bladder function. Long-standing diabetics often have increased bladder capacity and incomplete bladder emptying, which increases the risk of stasis and infection as well as the possibility of reflux graft pancreatitis. Significant urologic dysfunction can usually be ascertained by a careful history. A history of recurrent infections, bladder outlet obstruction (prostatic hypertrophy or urethral stricture), pretransplant dehydration or acute kidney injury episodes, and neurogenic bladder are relative contraindications for bladder drainage. In some cases, obtaining urodynamic studies may be helpful.

IMAGING AND OTHER DIAGNOSTIC STUDIES The exocrine pancreas is first affected by rejection yet isletitis can be seen on histology. Hyperglycemia occurs later in the or with severe cases of rejection. Elevations of serum amylase and lipase cause concern for potential rejection and can trigger a graft biopsy. Unfortunately, biopsies can cause significant complications, and elevations of serum amylase and lipase are not specific for allograft rejection.7,8 Serial testing of posttransplant serum amylase and lipase levels will establish a posttransplant “normal” range. Deviations (>25% of baseline) from this range may indicate rejection or inflammation caused by relative obstruction (reflux) of exocrine secretions. A sustained increase in serum amylase or lipase not resolved by treatment of constipation (enteric drained), Foley catheter drainage (bladder drained), or when observed in the absence of native pancreatitis should prompt a pancreas graft biopsy. Discordant rejection (of one organ and not the other) in SPK has been reported as high as 38%, so pancreas graft dysfunction cannot be reliably inferred from kidney graft function or biopsy.9 As the incidence of rejection in the nonuremic solitary pancreas transplant recipient is higher than in SPK and can be difficult to diagnose by elevations in serum amylase and lipase alone, the use of bladder drainage may afford an increased ability to detect rejection in this subset of recipients. Newer techniques that enable endoscopic biopsy of entericdrained grafts have been recently reported.10,11,12 Calculation of urinary amylase (units per hour) is done by urine collection (8 hours) to monitor pancreas exocrine function of a bladder-drained graft. Serial monitoring will define the usual range observed in an individual; with each pancreas allograft having a unique normal range. A sustained 25% decrease in urinary amylase excretion signifies exocrine pancreas dysfunction. Cystoscopy for duodenal mucosal biopsy has a low complication rate compared to percutaneous biopsy. It can be particularly useful when allograft parenchyma is not accessible due to overlying bowel. As bladder drainage can be associated with metabolic and urologic complications refractory to medical management, enteric conversion may become indicated in up to 25% of bladder-drained grafts. These complications include Fluid and bicarbonate loss (recurrent dehydration and metabolic acidosis) Change in bladder pH, with recurrent infections P.277 Inflammation causing cystitis, urethritis, and hematuria Foreign body (exposed suture/staple) as a nidus for infection, hematuria Reflux pancreatitis due to the bladder/bladder outlet dysfunction When indicated, enteric conversion is usually performed after the first year of transplant when the morbidity of complications outweighs the risk of missed rejection. The procedure involves disconnecting the duodenocystostomy, closure of the bladder, and anastomosing the graft duodenum to the small intestine. Enteric conversion can also be performed to treat posttransplant acquired native pancreatic exocrine insufficiency, which can present as refractory diarrhea exacerbated by dietary fat intake and confirmed by fecal elastase or fat quantification.

SURGICAL MANAGEMENT

Preoperative Planning The graft duodenum should be prepared during procurement by instillation of amphotericin B or Betadine solution (via the nasogastric tube) in order to decrease microbial burden and subsequent operative field contamination. Preoperative urine culture should be negative. Preoperative antibiotics are chosen to empirically target enteric bacteria and yeast, both during pancreas transplantation and enteric conversion operations. Most surgical complications of pancreas transplant are related to donor-derived issues (anatomic, physiologic, and reperfusion related). As such, careful graft selection is paramount.

Positioning Patient position is supine with both arms out. Use a three-way Foley catheter in all cases; the use of the bladder drainage technique may be planned or unexpected. In rare cases of vascular insufficiency of the head of the pancreas after reperfusion, bladder drainage could be useful because management of a bladder leak is less morbid (decreased rates of intraabdominal infection, reoperation, and graft loss) compared to an enteric leak.

TECHNIQUES PLACEMENT OF INCISION Modern approach to pancreas transplant is through a midline incision: Low midline for systemic venous and enteric- or bladder-drained grafts Periumbilical for portal venous and enteric-drained grafts The retroperitoneal approach is rarely done due to an increased risk of peripancreatic abscess and pancreatitis due to proteinaceous fluid loculation in the retroperitoneal space. If a retroperitoneal approach is chosen, the peritoneum should be opened at the conclusion of the procedure and/or the graft widely drained.

ENTERIC DRAINAGE Exposure Small bowel adhesions should be lysed and proximal/distal orientation of the bowel confirmed. Select a proximal segment of small bowel that reaches the pancreas without tension or kinking for anastomosis to the graft duodenum. Control duodenal secretions to avoid unnecessary soilage of the operative field. This spillage may cause a peripancreatic abscess or mycotic aneurysm. Anastomosis The anastomosis can be accomplished using a number of techniques, selected by surgeon preference or dictated by anatomy: duodenoenterostomy (jejunum, duodenum, stomach, ileum), hand sewn or stapled, usually without a Roux limb. Proximal bowel is usually selected as it avoids diarrhea commonly seen after ileal anastomosis, as well as affords the possibility of facilitating an endoscopic biopsy.

A hand-sewn duodenoenterostomy (FIG 1). Place a 3-cm seromuscular row of nonabsorbable sutures to join the graft duodenum and the recipient bowel (outer layer, posterior row). Open the recipient bowel using electrocautery. Create a corresponding opening in the graft duodenum. Complete the inner layer using running absorbable suture with good mucosal approximation. Complete the anterior aspect of the outer layer using a running Lembert suture. Trim any excess duodenum with a gastrointestinal anastomosis (GIA) stapler. An end-to-end anastomosis (EEA) circular stapled anastomosis (FIG 2) Create an antimesenteric enterotomy in the recipient bowel and insert the anvil and secure it with a pursestring suture. Insert the lubricated stapler through the distal end of the graft duodenum. P.278

FIG 1 • Transplant duodenoenterostomy—hand-sewn technique. Creation of the back wall of the anastomosis. Completion of the anastomosis and trimming of the duodenum. Align the bowel segments, with particular attention to orientation. Advance the spike and engage with the anvil and fire the stapler. Reinforce the staple line with interrupted seromuscular sutures.

FIG 2 • Transplant duodenoenterostomy—stapled technique. Placement of a lubricated EEA stapler through the open end of the transplant duodenum with anvil placement in the recipient small bowel. Firing of the stapler with creation of the anastomosis. Resect the excess distal graft duodenum and oversew the staple line. If the pancreas is placed on the left iliac system, make a small window in the sigmoid mesentery corresponding to the planned duodenoenterostomy site. Tack the mesenteric defect to the recipient bowel to prevent internal hernia. P.279

BLADDER DRAINAGE Exposure The bench preparation of the allograft is done before recipient incision and should include sequential ligation and division of the mesentery of the third and fourth portions of the duodenum to allow for postreperfusion, shortening the duodenal cuff to decrease bicarbonate loss, fluid loss, and stasis within the transplant duodenum. Distend the bladder by instillation of fluid through a three-way Foley catheter. Widely mobilize the bladder; this step is key to facilitate the creation of a duodenocystostomy. Ligate and divide the lateral false ligament/peritoneal reflection of the bladder. Select an area in proximity to the graft duodenum over the dome of the bladder for the anastomosis and incise the peritoneal covering (FIG 3). Enterocystostomy Creation Place a 3-cm seromuscular row of nonabsorbable sutures to join the graft duodenum and the bladder (posterior row, outer layer) (FIG 4). These sutures must not penetrate the lumen or there is risk of leak and stone formation. Open the bladder using electrocautery.

FIG 3 • Location of the duodenocystostomy. Note, the bladder is generously mobilized.

FIG 4 • The duodenocystostomy posterior wall. Create a corresponding opening in the graft duodenum. Join the graft duodenum and bladder using absorbable suture (inner layer), taking full-thickness bites with good mucosal opposition. Complete the anterior aspect of the outer layer using a running Lembert suture (FIG 5). The previously separated distal duodenum is then resected, with a resulting small duodenal cuff.

FIG 5 • The completed duodenocystostomy prior to resection of third and fourth portions of the duodenum.

ENTERIC CONVERSION Exposure Via a low midline approach, enter the abdomen and free the small bowel from adhesions. The Dense adhesions may involve the graft. Note the appearance and texture of the graft and avoid injuring the graft duodenum, the vascular “Y” graft, or the capsule of the pancreas. Pack the bowel cephalad. If the patient also has a kidney transplant, avoid diathermy or traction injury to the ureter. Take Down of the Duodenocystostomy Distend the bladder with sterile saline. Identify and encircle the duodenocystostomy with a loop to facilitate further dissection (FIG 6). Mobilize the head of the pancreas medially and anteriorly in a limited fashion, enough to make the new anastomosis tension free. Use gentle traction on the duodenal segment using the loop and sharp dissection. Incise the bladder immediately adjacent to the duodenocystostomy (FIG 7A,B). The interface of the bladder and duodenal mucosa is readily visualized and serves as a guide for the line of transection, which is completed circumferentially. Avoid traumatizing the duodenum, which can be thin and friable. Remove foreign bodies (suture, staples, stones) from the bladder. The character of the bladder mucosa should be noted. If the patient has a kidney transplant, identify the location of the ureterocystostomy (FIG 8). P.280

FIG 6 • Encircling the duodenocystostomy during an enteric conversion of a bladder-drained pancreas allograft.

FIG 7 • A,B. The duodenal and bladder mucosal interface.

FIG 8 • Inspecting the transplant ureter from inside of the bladder. Stent placement should be considered if the bladder repair is close to the ureterocystostomy. Closure of the Bladder Close the bladder using absorbable suture (4-0 polydioxanone [PDS]) (FIG 9). The first layer is a fullthickness running closure with good mucosal approximation. The second layer is performed using a running Lembert technique, fully incorporating the beginning and end of the first layer. If a transplant

ureterocystostomy is located near the planned closure, insertion of a ureteral stent may prevent obstruction from edema. Enteric Anastomosis Lyse small bowel adhesions and confirm the proximal/distal orientation of the bowel. Select a segment of small bowel for anastomosis to the graft duodenum, as described previously. If the mesentery is foreshortened and there is potential for tension, or if the graft duodenum is thin or the duodenotomy large, creation of a Roux-Y limb should be considered. Debride excess/scar tissue/foreign body at the margins of the old duodenal anastomosis. Join the loops of bowel and create the posterior outer layer with interrupted or running suture. Make a corresponding enterotomy in the recipient bowel (FIG 10). Join the posterior inner layer using running absorbable suture, with careful mucosal approximation (FIG 11). Complete the anterior wall outer layer using a running Lembert suture.

FIG 9 • Cystotomy aligned for two-layer closure during the enteric conversion procedure. P.281

FIG 10 • Duodenojejunostomy creation with placement of the back-wall sutures.

FIG 11 • Inner layer posterior wall anastomosis of the duodenojejunostomy during enteric conversion.

PEARLS AND PITFALLS Indications

▪

Delay of conversion will predispose the patient to further morbidities (acute kidney injury, repeated urinary tract infection [UTI], urethral strictures, transfusion, etc.).

▪

The longer posttransplant before enteric conversion, the more likely to encounter a difficult duodenum (thin or with enlarged duodenocystostomy).

Preoperative planning

▪

Ensure absence of UTI prior to transpant or enteric conversion.

Preparation of the duodenal cuff

▪

Shorten the graft duodenum by resecting portions 3 and 4 during the bench preparation.

▪

During conversion: Limit electrocautery dissection near the graft duodenum to avoid thermal injury.

▪

Choose the first loop of bowel that reaches the graft duodenum without tension.

▪

Avoid anastomosis to the distal small bowel—there is an increased incidence of posttransplant diarrhea.

▪

Proximal jejunal anastomosis treats malabsorption if the patient develops native pancreatic exocrine insufficiency.

▪

Avoid spillage of duodenal contents.

▪

Be sure that the posterior wall sutures do not penetrate the lumen.

▪

Avoid tension or create a Roux limb.

Choice of anastomotic location

Anastomotic technique

Biopsy

Leak diagnosis

Leak management

▪

Consider tacking the tail of the allograft to the abdominal wall to facilitate biopsy.

▪

Do not biopsy the head of the gland due to risk of leak or bleed.

▪

Increasing enzymes or pain should prompt diagnostic evaluation.

▪

Computed tomography (CT) with oral contrast (enteric drained)

▪

CT cystogram (bladder drained)

▪

Fluid collections should be drained and sent for analysis (bilirubin or creatinine, amylase and lipase, Gram & KOH stain, culture).

Bladder-drained graft: ▪

Extended Foley decompression

▪

Operative repair/conversion

Enteric-drained graft: Early reoperation offers best salvage. Options include: ▪

Primary repair with wide drainage

▪

Exclusion via Roux limb with wide drainage

▪

Conversion to bladder drainage

▪

Duct injection and other rarer techniques13

▪

Graft removal

P.282

POSTOPERATIVE CARE Bladder management Foley catheter is left in place for 2 weeks after duodenocystostomy. Foley catheter is left in place for 3 to 5 days after conversion, depending on tissue integrity and whether there is any bladder dysfunction or urethral stricture. Bowel decompression Classic: Nasogastric tube is employed until passing flatus or until bowel movement if gastroparesis is significant.

Some groups report success with no postoperative nasogastric tube decompression.14

OUTCOMES The history of pancreas transplantation is rich with surgical innovation. Mastering the heterogeneity of past and present surgical techniques provides a challenge for young surgeons. As a result of these technical refinements, patient survival is no longer negatively affected by enteric drainage.3 Additionally, rejection rates are low enough with modern immunosuppression such that bladder drainage now has a more limited role. An understanding of the potential risks, benefits, and techniques of various methods of exocrine drainage are necessary for optimal patient-specific surgical decision making.

COMPLICATIONS Anastomotic leak Intraabdominal infection Gastrointestinal bleeding Need for reoperation Dehydration and acute kidney injury Metabolic acidosis Urethritis, stricture Hematuria UTI Bladder stone Pain Reflux pancreatitis Mycotic aneurysm

REFERENCES 1. Sollinger HW, Cook K, Kamps D, et al. Clinical and experimental experience with pancreaticocystostomy for exocrine pancreatic drainage in pancreas transplantation. Transplant Proc. 1984;16(3):749-751. 2. Nghiem DD, Corry RJ. Technique of simultaneous renal pancreatoduodenal transplantation with urinary drainage of pancreatic secretion. Am J Surg. 1987;153:405-406. 3. Gruessner AC. 2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR). Rev Diabet Stud. 2011;8(1):6-16. 4. Gruessner AC, Sutherland DE. Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant

Registry (IPTR) as of June 2004. Clin Transplant. 2005;19:433-455. 5. Gruessner R. Recipient procedures. In: Gruessner RWG, Sutherland DER, eds. Transplantation of the Pancreas. New York, NY: Springer-Verlag; 2004:150-179. 6. Krishnamurthi V, Bartlett ST. Surgical techniques of pancreas and transplantation. In: Hakim N, Stratta R, Gray D, eds. Pancreas and Islet Transplantation. New York, NY: Oxford University Press; 2002:115-124. 7. Margreiter C, Pratschke J, Margreiter R. Immunological monitoring after pancreas transplantation. Curr Opin Organ Transplant. 2013;18(1):71-75. 8. Koffron AJ, Kaufman DB. Diagnosis and treatment of pancreatic rejection. In: Hakim N, Stratta R, Gray D, eds. Pancreas and Islet Transplantation. New York, NY: Oxford University Press; 2002:191-203. 9. Troxell ML, Koslin DB, Norman D, et al. Pancreas allograft rejection: analysis of concurrent renal allograft biopsies and posttherapy follow-up biopsies. Transplantation. 2010;90(1):75-84. 10. De Roover A, Coimbra C, Detry O, et al. Pancreas graft drainage in recipient duodenum: preliminary experience. Transplantation. 2007;84(6):795-797. 11. Shokouh-Amiri H, Zakhary JM, Zibari GB. A novel technique of portal-endocrine and gastric-exocrine drainage in pancreatic transplantation. J Am Coll Surg. 2011;212(4):730-738; discussion 738-739. 12. Margreiter C, Aigner F, Resch T, et al. Enteroscopic biopsies in the management of pancreas transplants: a proof of concept study for a novel monitoring tool. Transplantation. 2012;93(2):207-213. 13. Boggi U, Vistoli F, Del Chiaro M, et al. Total duodenectomy with enteric duct drainage: a rescue operation for duodenal complications occurring after pancreas transplantation. Am J Tranpslant. 2010;10(3):692-697. 14. Barth RN, Becker YT, Odorico JS, et al. Nasogastric decompression is not necessary after simultaneous pancreas-kidney transplantation. Ann Surg. 2008;247(2):350-356.

Chapter 43 Transplant Pancreatectomy David Shaffer

DEFINITION Transplant pancreatectomy is defined as excision or removal of previously transplanted pancreatic allograft. The most common indication for transplant pancreatectomy is early pancreas allograft failure with hyperglycemia and return to insulin dependence. The most common cause of early graft failure requiring transplant pancreatectomy is graft thrombosis, either arterial or venous. Thrombosis has been reported to occur in up to 10% of pancreas transplants. Case reports of successful salvage of early thrombosis, usually partial thrombosis, have been published; but usually, by the time the diagnosis is made and patient is reexplored, the pancreas is necrotic and requires complete explantation. Other indications for transplant pancreatectomy include the following: Primary nonfunction Other technical complications, including enteric leak with associated peritonitis and systemic sepsis Acute rejection, cellular or antibody-mediated; unresponsive to antirejection therapy Refractory transplant pancreatitis Late allograft failure (i.e., 1 or more years posttransplant) with hyperglycemia and resumption of insulin dependence, usually due to chronic rejection with graft fibrosis and atrophy, does not require transplant pancreatectomy in the otherwise asymptomatic patient.

DIFFERENTIAL DIAGNOSIS The differential diagnosis of early pancreas allograft dysfunction with hyperglycemia and insulin dependence includes the following: Thrombosis, arterial or venous Delayed graft function Acute pancreatitis Ischemia or reperfusion Reflux, especially for bladder-drained pancreas transplants Viral infection, especially cytomegalovirus (CMV) Acute rejection Enteric leak with sepsis Drug toxicity with glucose intolerance secondary to steroids and/or calcineurin inhibitors

Early allograft failure usually mandates transplant pancreatectomy regardless of etiology in order to Ameliorate systemic toxicity from Necrotic tissue (allograft thrombosis) Acute inflammatory state (refractory rejection, necrotizing graft pancreatitis) Sepsis (leak, abscess) Discontinue immunosuppression

PATIENT HISTORY AND PHYSICAL FINDINGS The typical signs and symptoms of pancreas allograft dysfunction are nonspecific and may include nausea and vomiting, fever, abdominal pain and tenderness, elevated serum glucose, amylase/lipase, and leukocytosis. The time course of signs and symptoms posttransplant are critical in formulating a likely differential diagnosis: Within the first week Thrombosis, arterial or venous Ischemia reperfusion injury Acute pancreatitis One week to 1 month time period Enteric leak Intraabdominal collection or abscess Bladder leak if bladder-drained graft Acute rejection, especially if recipient sensitized or did not receive depleting antibody induction Greater than 1 month from the transplant Acute rejection, especially if recipient received depleting antibody induction Viral infection, particularly CMV Reflux pancreatitis in bladder-drained grafts The most important finding for allograft thrombosis is sudden onset of new hyperglycemia in the early postoperative period. New or sudden onset of hyperglycemia alone within the first week posttransplant may be the only initial clinical sign of arterial or venous thrombosis and mandates immediate further evaluation with diagnostic imaging (pancreas transplant Doppler examination) and usually vascular duplex or CT with IV contrast reexploration. Abdominal signs and symptoms such as nausea, vomiting, abdominal distension, pain, tenderness, or peritoneal signs are early findings in acute transplant pancreatitis, enteric leak, intraabdominal collection or abscess, and acute rejection. These signs and symptoms may be a late finding in vascular thrombosis, particularly arterial thrombosis. Systemic signs of infection with fever, tachycardia, hypotension, and leukocytosis are more consistent with

enteric leak, intraabdominal collection or abscess, acute rejection, and acute pancreatitis. These signs and symptoms may be a relatively late sign of acute thrombosis due to systemic toxicity from necrotic tissue. In cases where a closed suction drain was left intraabdominally adjacent to the pancreas allograft at the time of surgery, high amylase in the fluid may suggest acute pancreatitis or enteric leak. Bilious drain output suggests an enteric leak. In cases of bladder-drained pancreas grafts, an elevated drain fluid creatinine compared to serum creatinine suggests a bladder leak (transplant duodenocystostomy leak). Bladder-drained pancreas grafts may also present with a decrease in urinary amylase. P.284

IMAGING AND OTHER DIAGNOSTIC STUDIES Diagnosis is usually apparent based on time course, history and physical exam, and lab findings, although appropriate radiologic studies may be helpful in confirming the clinical diagnosis. Abdominal computed tomography (CT) scan with contrast, vascular duplex imaging, and CT angiography are the mainstays of imaging with the particular test often dependent on the availability and expertise at one's specific institution. In cases of suspected vascular thrombosis, vascular duplex imaging or abdominal CT scan with intravenous (IV) contrast are the most common and useful tests. Vascular duplex imaging may demonstrate patency or thrombosis of the pancreas allograft arterial inflow or venous outflow; for example, donor iliac artery “Y-graft” interposed between recipient common iliac artery and donor splenic artery and superior mesenteric artery or donor portal vein anastomosed to the recipient inferior vena cava (IVC). Duplex is rapid and noninvasive but operator dependent. Vessels may be obscured by overlying bowel. Patency of the portal venous outflow may be difficult to demonstrate due to its short length. IV contrast-enhanced axial CT can demonstrate perfusion by persistent enhancement of the allograft. CT scan has the advantage of evaluating for extrapancreatic allograft pathology such as abscess or fluid collections, pancreatic edema consistent with pancreatitis or rejection, or bowel complications. Usually, the diagnosis is confirmed by vascular duplex or CT with IV contrast in the typical clinical setting of a sudden rise in blood sugar or other signs of allograft dysfunction leading to reexploration. The surgeon must carefully weigh the risks or benefits of nephropathy following IV contrast administration for the CT scan.

SURGICAL MANAGEMENT Preoperative Planning Adequate fluid resuscitation Prophylactic antibiotics to cover both skin and bowel organisms (e.g., ampicillin/sulbactam or cefazolin and metronidazole) Prophylaxis for deep vein thrombosis Blood product availability (e.g., type and crossmatch 2 units packed cells) Orogastric or nasogastric tube after induction of anesthesia, depending on preference of surgeon and postoperative requirements

Positioning Patient is placed supine on the operating table. Arms can be tucked or out to side, depending on preference of

surgeon and anesthesiologist.

TECHNIQUES SURGICAL EXPOSURE Most centers routinely place the pancreas allograft intraperitoneally on the right side to the right common iliac artery and the distal IVC. If placed simultaneously with a kidney transplant, the kidney will preferentially go on the left side to the left external iliac vessels. The abdomen is reentered via the previous midline incision. Adhesions, usually rare, are taken down with electrocautery. A table-mounted self-retaining retractor is used for exposure. The right colon, which had been mobilized during the initial implantation, and small bowel are packed cephalad and to the left with warm, moist lap pads to expose the pancreas allograft. If a primary venous thrombosis, the pancreas and donor duodenal segment will be edematous and black. Pulsations may still be felt in the donor iliac artery conduit.

TAKE DOWN OF TRANSPLANT DUODENOENTEROSTOMY Pancreatic exocrine secretions are managed by either a duodenoenterostomy or duodenocystostomy, with duodenoenterostomy as the most common technique in the United States today. Duodenoenterostomy can be performed either side-to-side to a loop of mid-small bowel or to a small bowel Roux-en-Y limb. It is the author's preference to perform a side-to-side duodenoenterostomy to a loop of mid-small bowel with the duodenoenterostomy oriented cephalad and tail of the pancreas caudad. To gain adequate mobility of the thrombosed graft to expose the underlying vessels for graft pancreatectomy, particularly in cases with a short portal vein, it is best to first take down the transplant duodenoenterostomy. The thrombosed graft must be handled gently; it is easy to disrupt the vascular anastomoses. The small bowel proximal and distal to the duodenoenterostomy is divided between gastrointestinal anastomosis (GIA) staplers. P.285

LIGATION OF DONOR ILIAC ARTERY CONDUIT The tail of the pancreas is then rotated cephalad to expose the donor iliac artery conduit (“donor iliac artery Ygraft”). The best landmark for this dissection is the proximal iliac artery. The surgeon can follow this inferiorly until the arterial conduit of the allograft is reached. A vascular clamp, for example, Beck clamp or small Satinsky clamp, is placed across the donor iliac artery conduit 1 to 2 cm distal to the anastomosis to the recipient common iliac artery, and the donor iliac artery is divided and doubly ligated with a 0 silk tie and a 2-0 silk suture ligature (FIG 1). Note that a stump of transplant artery is left in place. This avoids the need to patch angioplasty of the recipient iliac artery. The pancreas allograft can be very large and easy to disrupt; clamp placement must be done with exceptional care. Alternatively, a vascular stapler may be used to transect the donor iliac artery.

FIG 1 • Clamping and ligation of the donor iliac conduit (a). Note, the stump of the conduit is left in place. This avoids the need to patch angioplasty of the recipient iliac artery. A vascular stapler can also be used for this. Placement of the clamp can be challenging when the pancreas is engorged. Clamping and ligation of the pancreas transplant portal vein (b). This can be oversewn with a monofilament suture or divided with a vascular stapler. Note, the stump of the vein is left in place.

LIGATION OF DONOR PORTAL VEIN Once the donor artery has been divided, the pancreas allograft can be gently rotated further cephalad to expose the donor portal venous anastomosis to the distal IVC or proximal right common iliac vein. A side-biting vascular clamp, for example, Satinsky, is placed just distal to the venous anastomosis, taking care not to narrow the native vein. The donor portal vein is then divided approximately 5 mm distal to the clamp, leaving a donor venous cuff to oversew with a running 5-0 Prolene suture. Alternatively, the portal vein may be divided with a vascular stapler (FIG 1). The completely transected pancreas allograft is then removed from operative field and sent to pathology.

SIDE-TO-SIDE ENTEROENTEROSTOMY Bowel continuity is then restored with a side-to-side stapled enteroenterostomy. The staple line of the previous divided ends of the small bowel are oversewn with inverting 3-0 silk Lembert sutures. A stapled side-to-side anastomosis with a GIA is performed or a hand-sewn anastomosis. The rent in the mesentery is closed with interrupted 3-0 silk sutures.

ABDOMINAL CLOSURE The abdomen is irrigated with warm saline. The midline fascia is closed with running no.1 polydioxanone (PDS). No drain is used. P.286

PEARLS AND PITFALLS Patient

▪

Sudden rise in blood sugar within first postoperative week after initial normoglycemia

selection

is pancreas graft thrombosis until proven otherwise. ▪

Serum amylase and lipase is not a specific or reliable marker for thrombosis and may be completely normal.

Imaging

▪

Vascular duplex exam is highly operator dependent due to allograft placement deep in the abdomen and overlying bowel and bowel gas may obscure vascular structure.

Procedure

▪

Although scattered reports of graft salvage exist, these are usually cases of partial arterial thromboses. Complete arterial thrombosis and venous thrombosis are not salvageable and requires expeditious transplant pancreatectomy.

POSTOPERATIVE CARE NPO until return of bowel function Postoperative nasogastric tube at discretion of surgeon Resume insulin. If simultaneous kidney and pancreas transplant, maintain usual immunosuppression if kidney is still functioning; otherwise, taper and stop immunosuppression.

OUTCOMES Other than return to insulin, excellent outcomes with return to baseline functional status are anticipated.

COMPLICATIONS Bleeding Enteric leak Intraabdominal abscess Small bowel obstruction Mycotic pseudoaneurysm

SUGGESTED READINGS 1. Humar A, Kandaswamy R, Granger D, et al. Decreased surgical risks of pancreas transplantation in the modern era. Ann Surg. 2000;231:269-275. 2. Troppmann C. Complications after pancreas transplantation. Curr Opin Organ Transpl . 2010;15:112-118.

Chapter 44 Procurement of Lungs for Transplantation Rishindra M. Reddy Philip W. Carrott Jr

DEFINITION The process of procuring lungs for transplant begins with the clinical assessment and management of donor lungs. The surgical procedure involves the visual assessment of the donor lungs and then the dissection, perfusion, removal, and packaging of the lungs for travel to the lung recipient site. The operation requires the close coordination between the abdominal and cardiac transplant surgeons with regard to timing of placing the cross-clamp and the separation of the heart and lungs.

PATIENT HISTORY AND PHYSICAL FINDINGS The first step for lung procurement is the organ offer. The recipient transplant surgeon usually receives the organ offer, but at some centers, it is the pulmonologist or another member of the transplant team. Pertinent donor information includes medical history, history of the acute injury, documentation of brain death, arterial blood gas (ABG) values focusing on the PaO2, bronchoscopy, and review of available imaging. Close monitoring of the ventilator, fluid, and pressor management is essential. A seminal paper from Washington University1 has set donor standards that continue to be used today. A minimum PaO2 of 300 mmHg on ventilator settings of 100% FiO2, positive end-expiratory pressure (PEEP) of 5, and tidal volumes of 10 to 12 mL/kg is needed. A bronchoscopy that is either negative for pneumonia or, if there are secretions, that they clear easily without reaccumulation. A chest x-ray that is clear bilaterally, although atelectasis may be present. If there are concerns about pneumonia or contusion, a chest computed tomography (CT) may be of use to differentiate between these and a pattern of reversible basilar atelectasis. Lungs that are not optimized but have reversible conditions (fluid overload, atelectasis) may be managed by the recipient team in conjunction with the other organ teams. Diuresis and recruitment maneuvers may improve PaO2 levels. Progressive pneumonia or contusions after trauma may be reversible in the long term but often are not reversible or treatable in the window of time needed to preserve the lungs. Contraindications to lung procurement are changing. Programs are procuring more marginal lungs and even lungs from donors following cardiac death (DCD). The advent of ex vivo lung perfusion (EVLP) may allow the procurement and resuscitation of lungs that would not have otherwise been taken, and augment the current 16% lung procurement rate from potential donors. Current contraindications to lung use include donor history of more than 20 pack-year smoking history; age older than 50 years; prior history of lung disease including asthma, pulmonary hypertension, or pulmonary emboli; prior malignancy (except for potential brain tumors); and renal failure. Contraindications found during the donation workup and surgery include lungs with a structural abnormality such as a bleb or nodule of uncertain significance, current pneumonia or aspiration with likely pneumonia, and pulmonary edema that is not felt to be reversible prior to procurement. Coordinating the recipient and donor operating room (OR) teams is vital for successful procurement. There is no standard with regard to coordination of the donor and recipient operations, but our group has the recipient in the OR awake with central intravenous (IV) lines placed at the time the donor OR begins. Minimize the time

that the recipient is intubated. Thus, we do not intubate, prep, and drape the recipient until we know the expected aortic cross-clamp time of the donor. Consideration is also given to the expected time needed to mobilize the recipient's lungs. This careful planning requires that the donor team communicates when they've arrived at the donor site, when the donor OR begins following bronchoscopy and initial intraoperative assessment of the lungs, the expected cross-clamp time (with regular updates as this changes constantly), the cross-clamp time, and an estimated time of arrival at the recipient site. The donor team should also contact the recipient OR 15 to 20 minutes from arrival. This will allow time for cardiopulmonary bypass, if clinically necessary. This close coordination is necessary to minimize the lung cold ischemia time. Generally, the upper limit of an acceptable cold ischemia time is 6 hours.

IMAGING AND OTHER DIAGNOSTIC STUDIES A bronchoscopy should be performed locally, assessing for purulent secretions and sending lavage specimens for culture. A chest x-ray is also needed to rule out obvious structural concerns or trauma. Chest CT scans are helpful when assessing marginal lungs or a possible pneumonia.

SURGICAL MANAGEMENT Preoperative Planning Upon arrival at the donor site, the lung procuring surgeon must review a few key elements. The first step is to review the brain death evaluation and the consent to donate. Next, a thorough review of the donor's history and hospital course is needed, including re-review of the acute injury that led to the donor's status. Specific attention should be paid to the ventilator management and peak airway pressures of the donor, as high pressures may result in irreversible injury during the organ preservation process. Often, details of the donor's history may not be communicated by the organ donation team to the recipient surgeon, and it is incumbent on the donor surgeon to ensure that the lungs are safe. Within this context, most lung transplant centers send out their own procurement team, as opposed to working with a local thoracic surgeon at the donor site. The donor team must review the ABG results, focusing not only on the actual values but also on the trends. P.288

Positioning Position the donor in a supine fashion, with both arms tucked at the sides. Skin prep the donor from the chin to the pubis to allow both the chest and abdominal teams to work concurrently. Central lines in the chest and neck may be prepped and will be excluded in the draping process.

TECHNIQUES LUNG ASSESSMENT The lung procurement begins with a bronchoscopy in the OR, either before or during the prepping and draping of the patient. Verify the endotracheal tube size; a tube less than 7 Fr will not accept a regular-sized bronchoscope. Attach the bronchoscope to suction and evaluate the bronchial anatomy and remove all secretions. Remove purulent secretions and determine whether mucopurulent secretions are limited to the central airways, or if they are coming from a peripheral source indicating pneumonia. If there is concern about pneumonia, repeat the bronchoscopy in 30 to 60 minutes looking for evidence of recurrent purulence. Note that the bronchoscope used for airway management by the anesthesia team is not adequate to remove secretions. Verify that ventilation settings include an FiO2 of 100% and a PEEP of 5 throughout the procurement process, as repeat ABGs may be needed to reassess suitability of the lungs.

After the bronchoscopy, perform a median sternotomy. Make a skin incision from the sternal notch to the xiphoid process, connecting to the laparotomy incision of the abdominal team. Dissect with electrocautery through the subcutaneous fat, through the midline fascia, between the pectoralis major muscles, and onto the anterior table of the manubrium and sternum. Carry the dissection to the side of the xiphoid process. Place a finger under the xiphoid and lower sternum, freeing the pericardium and anterior mediastinal fat from the posterior table of the sternum. Dissect the sternal notch; first between the strap muscles and then through the ligamentous tissue at the base of the sternal notch. Place a finger behind the manubrium to free the mediastinal fat on the superior aspect of the sternum. Ask the anesthesiologist to hold lung ventilation to minimize the risk of injury to the lungs. Use a reciprocating blade saw and proceed either at the top or bottom of the sternum. Saw through the midline to the other end, taking care to lift the posterior table with the blunt edge of the saw to elevate the sternum from the structures beneath it. Ventilate the lungs and spread the sternum. Cauterize bleeding from the anterior and posterior table. Bone wax can be used to minimize bleeding from the sternum. Place a laparotomy pad in the midline to tamponade sternal bleeding from the bone. Place the sternal retractor. Carry the dissection through the thymus gland/fat and identify the innominate vein in the superior aspect of the chest. Incise the pericardium with the use of a plastic Yankauer suction placed under the pericardium on top of the heart. Carry the pericardial incision to the diaphragm and “T” off either side. Make the superior aspect of the pericardial incision to the lower border of the innominate vein (FIG 1). If the heart is being procured, a quick assessment can be made at this time. Assess the lungs. Open the pleural spaces on either side from the diaphragm to the level of the innominate. Take care to not go too high on the pleural exposure, as the internal mammary vein may be damaged. Inspect the lungs one at a time. Ask the anesthesia provider to give a Valsalva maneuver after the entire lung, especially the lower lobe, is rotated out of the pleural space (FIG 2, right middle and lower lobes rotated out). This rotation may reduce preload and cause the donor to become transiently hypotensive. The donor surgeon must make the anesthesiologist aware of this possibility to prevent a clinical overreaction. Push all of the atelectasis out of the lower lobes to complete the recruitment process of the lungs. This may require milking air into the posterobasilar segments of the lower lobes. Make a full evaluation of the lung, including palpation, to identify possible nodules or structural abnormalities. If the atelectatic lung does not fully expand, then consider either a contusion and/or pneumonia. Once the recruitment and evaluation is completed, place the lungs back in the normal position and place pericardial stay sutures. Clamp them to the drapes or suture them to the skin.

FIG 1 • The sternal retractor is placed with the “L”-shaped portion placed superiorly as to not interfere with the abdominal team's work. The innominate vein is identified, and the pericardial incision carried to the diaphragm. Here, the pericardial stay sutures (red arrows) have been placed bilaterally after the lungs have already been inspected. P.289

FIG 2 • The right lung rotated out of the chest, with the middle lobe inflated while the right lower lobe (red arrow) is atelectatic. If there were any concerns about the PaO2 levels, check a repeat ABG 15 to 20 minutes after the recruitment maneuvers are completed. If there is any question on either lung, each lung can be assessed individually by drawing ABG blood samples directly from the pulmonary veins within the pericardium. This can give valuable information if the overall PaO2 is marginal, and there are concerns about one lung. One lung might not be

usable while the other may still be procured for the recipient. If one lung has a devastating injury, either from trauma or pneumonia, and the other lung is spared, confirmation of normal function may be obtained by clamping the pulmonary artery of the injured side and taking a blood gas from the pulmonary veins of the uninjured lung.

CANNULATION AND PERFUSION The lungs may be left alone during the remaining procurement procedure until the donor is heparinized. The heart donor team will mobilize the aorta, freeing it somewhat from the main pulmonary artery (PA) and the right pulmonary artery. Mobilize the superior vena cava (SVC), both above and below the azygous vein, and the inferior vena cava (IVC) within the pericardium. The chest and abdominal teams must agree on where to drain the IVC, either into the chest or into the abdomen (most often done in the chest). Also, the heart and lung teams must agree on where to drain the left side of the heart. This is usually accomplished by making an incision at the junction of the left atrium and the left superior pulmonary vein (PV) or by transecting the left atrial appendage. Make sure that prostaglandin is on the field and ready to be administered. When all teams are ready, administer a large dose of IV heparin (typically 30,000 units). While the teams are waiting 3 minutes to allow the heparin to perfuse systemically, bring the heart and lung perfusion lines onto the field and de-air them. Then, purse-string sutures are placed on the aorta by the heart team if present. Place purse-string sutures on the distal main pulmonary artery. The PA purse string is usually a triangle or diamond shape, nonpledgeted, 4-0 Prolene with a 1-cm center to allow for the placement of the PA cannula. Make a hole in the center of the purse string with a no. 11 blade scalpel. Dilate the hole with a tonsil clamp. Place an L-shaped cannula. This is the same cannula usually used for single-stage caval perfusion. Place the cannula in a reverse fashion to face the pulmonary valve, minimizing the risk of the perfusate going preferentially to a single lung. Secure the purse-string suture in a standard fashion with a Rommel, which is then tied to the PA cannula with a 2-0 silk suture 2 to 3 cm above the PA. Attach the PA cannula to the deaired lung tubing. Once all the cannulas are attached by the chest and abdominal teams, administer the ice-cold prostaglandin, with the needle placed next to the cannula within the center of the purse string. Give the prostaglandin slowly (1,000 mcg over 1 minute). Make the anesthesiologist and other team members aware of the timing, as the donor will become hypotensive. Once the prostaglandin is completely administered, begin the sequence of perfusing the organs. Step 1: Clamp in a counterclockwise manner, beginning with the SVC and ending with the aorta (FIG 3). First, ligate the SVC, making sure that the azygous is either ligated or the clamp is below the azygous vein. P.290

FIG 3 • View of the heart with the counter-clockwise steps culminating in the cross-clamping of the aorta. The azygous vein is tied in advance in two places to allow the transection later without back-bleeding. The SVC is either tied down (shown) or clamped (1). Then, the IVC is incised at the pericardial reflection with a sucker placed to vent the right heart and liver (2). The left atrial appendage is transected to vent the left heart (3). Lastly, the cross-clamp is applied to the aorta, distal to the cardioplegia cannula site (4). Step 2: Cut the IVC at the pericardial reflection within the chest for at least one-third to one-half of its circumference to drain the right heart adequately. The specific location of this transection should be agreed upon by the liver surgeon. Place sump sucker here immediately or blood from the IVC will fill the pericardium and obliterate one's view. Step 3: Make an incision to vent the left heart. Ideally, this should be done by cutting across the base of the left atrial appendage. This allows the pulmonary artery perfusate to drain from the left atrium without filling and dilating the left ventricle, which can damage the donor heart. An alternate approach to drain the left heart is to incise halfway between the coronary sinus and left inferior pulmonary vein. This incision will later be used to separate the heart from the lungs in the left atrium. Step 4: Place an aortic cross-clamp distal to the coronary perfusion cannula. Step 5: Begin the lung and heart perfusate and place slush on the heart and over the lungs. Divide the pericardial sutures to allow access to the bilateral pleural spaces. It is important that the anesthesiologist continues to ventilate the lungs during this period. During the perfusion process, assure that blood is adequately being vented from the IVC and the left atrial appendage.

REMOVAL OF THE LUNG (AND HEART) Once the perfusate is completely given to the heart and the lungs, the anesthesiologist should stop ventilating but not leave the room. Remove the slush and the heart and liver; surgeons must complete the division of the IVC at an agreed spot. The pulmonary vein cuffs: Once this is completed, the surgeon on the left should place a left index finger into the right atrium, retracting the heart to the left. The heart and lung surgeons must decide where to divide the

left atrium, leaving an oval cuff of atrial tissue for the pulmonary veins on each lung. Step 1: Begin in Sondergaard's groove, incising the fat and entering the left atrium near where the right inferior pulmonary vein joins the left atrium. Step 2: Continue the atriotomy along the inferior border toward the left inferior pulmonary vein. Step 3: Now both the heart and lung surgeons can see into the left atrium and agree upon where to take the lateral incisions. Make these incisions anterior to the entrance of the pulmonary veins, leaving a straight or oval-shaped cuff. If the atriotomy is taken too close to the pulmonary veins, the final cuff may take a “Figure 8”-type appearance on the anterior borders (FIG 4), which does not allow enough tissue for the lung recipient surgeon.

FIG 4 • Two views of the posterior wall of the left atrium with a safe anterior cuff border bilaterally (superior picture) and a suboptimal division of the left atrium, leaving a limited pulmonary vein cuff (inferior picture). P.291 Step 4: Divide the superior border of the atrium or pulmonary veins. Leave the posterior wall of the left atrium in the donor. Transect the SVC above the level of the azygous vein. This is usually done by the heart surgeon. The pulmonary artery: The heart and lung surgeons must decide where to divide the pulmonary artery. Step 1: Remove the pulmonary artery cannula. Step 2: Open the cannula site distally, aiming toward the inner “cuff” of the main PA that reflects the split toward the right and left branches. If care is not taken here, the natural elevation of the heart may bring the left pulmonary artery into the field, and the donor team can accidentally cut across the left main PA. Step 3: Once the incision is made to the midline, the PA can be transected circumferentially while viewed from within the main PA (FIG 5).

Step 4: Divide the remaining tissue between the right main PA and the aorta. The heart donor surgeon can cut across the aorta, usually within or distal to the arch. The heart can be removed off the field and then the lung removal can be performed. Lung removal: The second retrograde perfusion of the lungs can be performed at this point if desired. Alternatively, the retrograde perfusion can be performed on the back table. Step 1: Divide the lateral borders of the pericardium at the level of the diaphragm bilaterally. Carry the dissection to the level of the esophagus.

FIG 5 • Sequence of dividing the pulmonary artery. Begin at the cannulation site and extend the incision toward the interior “cuff” (1). Once the hole is large enough to assess where the middle of the PA is, lateral incisions should be made (2) to maximize the length of the main PA but to not shorten the left PA. The last cut should be made to divide the left and right PAs (3). Step 2: Divide the posterior pericardium in the middle, including the division of the posterior wall of the left atrium. Step 3: Continue the dissection bilaterally along the esophagus, keeping the esophagus in the chest, and taking all tissue anterior to it. This will allow the surgeon to elevate both hila and protect the posterior aspect of the carina and trachea. Step 4: Dissect the areas above the hila and lateral to the trachea, dissecting the pleura in the area of the internal mammary vein origins. This portion of the dissection is the most difficult; the hilar tissues are bloodless and the tissue planes are obscured by lymphatic tissues. Keep track of your landmarks to avoid injury to the pulmonary vasculature or membranous trachea. Some authors advocate removing the esophagus with the lung block to avoid tracheal injury. This does expose the lung block to gastrointestinal contamination and is not recommended. Keep a healthy swath of pericardium with each lung. It is used to wrap the bronchial anastomosis or repair surgical damage to pulmonary arteries or veins.

Step 5: Divide the innominate vein and identify the anterior trachea. Encircle the trachea as high in the chest as possible. Step 6: Ask the anesthesiologist to pull the endotracheal tube above the level of the circumferential tracheal dissection. Feel the endotracheal tube and place a thoracoabdominal (TA) stapler below it. Step 7: Ask the anesthesiologist to administer a Valsalva to a peak pressure of 20 mmHg. Ensure that both lungs are inflated. This is facilitated by delivering both lungs out of the chest. Step 8: Drop the peak pressure to 12 to 15 mmHg, so the lungs are inflated 60% to 70% of maximum inflation but all of the atelectasis is removed. Clamp the TA stapler. Transect the trachea proximal to the stapler and remove both lungs en bloc (FIG 6). Back-table lung dissection: Bring the lungs to a separate table, with retrograde perfusate and tubing set up. The lungs should be divided: Step 1: Begin with the pulmonary artery, which may or may not still be attached at the superior cuff of the main pulmonary artery. Step 2: Once the PA is divided, the carina is identified with the left main bronchus dissected free, distal to the carina. Fire the TA stapler twice across the left mainstem bronchus about 1 cm from the carina, making sure not to take the stapler across the carina onto the right mainstem bronchus (FIG 7). Only a few millimeters are needed to separate the staple lines, enough distance to allow a scalpel to divide the lungs. The carina and trachea go with the right lung. Step 3: Further dissection can be performed to dissect the pulmonary artery and vein cuffs. This can also be done during the backbench preparation performed in the recipient OR. As more programs use EVLP, or if both lungs will be transplanted into the P.292 same patient, the lungs may be packaged together, with division to be performed on the back table in the recipient OR. This will save a few minutes of separate packaging and stapling. Ex vivo perfusion is facilitated by ventilating the trachea of a double lung block rather than separate bronchi.

FIG 6 • Diagram of the trachea and where to place the stapler and cut across the trachea (Staple 1) and across the left mainstem bronchus (Staples 1-2). The tracheal transection occurs while the lungs are still in the donor, and the bronchial resection can occur after the lungs have been removed to a back table. Step 4: Apply retrograde perfusion to lungs individually, making sure to flush the superior and inferior pulmonary veins. The perfusate coming out of the pulmonary artery will likely appear bloody, with clots, but should clear quickly. If the tubing is placed too deep into a pulmonary vein, only a branch of the PV may be perfused. If there is a proximal branching, as commonly occurs on the right superior pulmonary vein, focus the perfusate into the branch vessels. Step 5: Once the first lung is perfused, package it while the second lung is perfused. Place the lung in a bag containing ice-cold perfusate with no ice. The lung should be fully inflated. The bag is tied and then placed in a second bag where slush can be placed. The second bag is tied and placed in a container, verifying right or left. Fill the container with slush and tightly seal it. Pass the container off on the sterile field. The same process occurs with the contralateral lung.

FIG 7 • Picture of the lungs en bloc after the posterior wall of the left atrium has been divided and the stapler applied to the left mainstem bronchus but prior to division of the left bronchus. The lungs are inflated, and little to no dissection has been completed on the hilum, as that can be done during the backbench preparation at the recipient site. Step 6: Once the lungs arrive at the recipient OR, either the donor or recipient surgeon may perform the backbench preparation. Repeat the retrograde perfusion. Mobilize the pulmonary artery circumferentially. Clean the pulmonary vein, maintaining as large and oval cuff as possible. Remove excess pericardial tissue at this time. Transect the left bronchus near the staple line. Two rings from the first bronchial carina is usually enough length on the donor bronchus. Transect the right lung bronchus at the carina. P.293

PEARLS AND PITFALLS

Donor management (changes)

Procurement (injury to vascular)

Procurement (injury to airway)

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Donor lungs may need recruitment and diuresis prior to the arrival of the donor team.

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ABGs should be performed on ventilation settings of an FiO2 of 100% and a PEEP of 5.

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Lungs are dynamic organs that may change even within 12 hours. Watching for trends is important.

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Injuries can occur to the pulmonary vein cuff or to the pulmonary artery during the process of removing the heart.

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Plans to repair an injury may be done at the donor site but could also be done at the recipient site with the recipient surgeon who may not need the vascular structure repaired.

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Early communication to the recipient team of a perceived vascular injury is essential, as it could affect the method of recipient dissection.

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Do not spend more than a few minutes of ischemic time trying to repair an injury.

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Injuries to the airway need to be addressed prior to lung packaging for travel. If a lung is not maintaining its aerated state, it may have a higher rate of injury upon implantation, reperfusion, and reexpansion.

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A peripheral leak or parenchymal lung injury may be sutured or even stapled across. A central airway (tracheal or bronchial) injury should be identified by submerging the lung in perfusate. The injury can be repaired primarily.

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Leave as much tissue as possible on donor bronchi to avoid tissue loss from ischemia postimplantation.

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If the lung is collapsed and all leaks have been addressed, a small 4-0 Prolene suture can be placed in a purse string. A 14- or 16-gauge angiocatheter can be placed through the center. The needle is removed, and sterile tubing from anesthesia connecting to an oxygen source can be directly connected to the catheter. The lung can be reinflated, although there is no way to measure the pressure until it feels adequately aerated. The angiocatheter can be removed and the purse string tied immediately. The lung can then be safely packaged for travel.

OUTCOMES Lung transplant outcomes are closely tied to the quality of the donor lungs, the donor procurement, and the implantation. The donor procurement process is only one part of many factors that contribute to long-

term outcomes.

COMPLICATIONS There are numerous potential complications that occur with the donor procurement process, but often they may not become apparent until transplant. Lungs that are too edematous, have contusions, active pneumonia, or were transported for a long time in a deflated state may not reinflate when transplanted. These patients may require venovenous or venoarterial extracorporeal membrane oxygenation (VV or VA ECMO). Vascular injuries during procurement or dissection of the heart can be repaired but should be repaired as quickly as possible, either primarily with a pericardial patch.

REFERENCES 1. Sundaresan S, Trachiotis GD, Aoe M, et al. Donor lung procurement: assessment and operative technique. Ann Thorac Surg. 1993;56(6): 1409-1413.

Chapter 45 Single Lung Transplantation Andrew C. Chang Tyler R. Grenda

DEFINITION Single lung transplantation is defined as the removal of either the right or left lung and orthotopic implantation of a same side donor lung. Lung transplantation can only be performed at certified transplant centers. The mechanism of certification varies by country.

PATIENT HISTORY AND PHYSICAL FINDINGS A thorough history should be performed. In particular, any history of prior chest operation, hypercoagulability, malignancy, frequent respiratory tract infections, or cardiovascular disease should be explored. A list of absolute and relative contraindications is detailed in Chapter 46. The patient's family history for these risk factors should also be obtained. Both obesity and sarcopenia are risk factors for worse survival. Although exact body mass index (BMI) criteria vary by transplant center, typically, a BMI less than 32 is preferred, depending on the patient's functional status and comorbid conditions. Patients who have significant weight loss and deterioration of functional status, such as indicated by worsening 6-minute hall walk testing, may not have adequate reserves to undergo transplantation. A full physical should be performed, with particular attention for peripheral vascular disease, cardiovascular disease, and prior chest interventions. Laboratory examination, including a comprehensive metabolic panel; electrolytes; pregnancy testing (in women); prostate specific antigen (in men); and serology testing for hepatitis B and C, HIV, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and syphilis. Testing for thiopurine S-methyltransferase (TPMT) deficiency/polymorphism is recommended as defects in TPMT activity can lead to azathioprine-related toxicity, particularly myelosuppression. In addition, tuberculosis testing should be performed, along with an electrocardiogram and chest x-ray. Drug testing is usually performed. During evaluation for transplantation, radiographic evaluation can include chest computed tomography (CT) scan, chest radiography, quantitative radionuclide ventilation/perfusion scan, and appropriate cardiac function testing such as stress echocardiography and cardiac catheterization (right heart, left heart, or both as indicated). If there is a concern for gastroesophageal reflux disease, then contrast esophagogram and functional testing, including esophageal manometry and esophageal pH/impedance probe testing, can be considered.

DONOR ORGAN MANAGEMENT Potential donors (deceased) should have a meticulous history obtained, with attention to any malignancy, systemic infection, prior chest operation, cardiovascular disease, pulmonary hypertension, tobacco use, asthma, and substance abuse. The donor must be ABO compatible with the recipient. Donor evaluation can include right heart catheterization to evaluate for evidence of pulmonary hypertension, or fluid overload, as well as chest CT if there is concern for parenchymal disease, such as in potential donors with a history of extensive tobacco use (>20 packyears) or asthma.

Donor organ management should include frequent assessment of arterial Po2, with ideal ranges greater than 300 during 100% FiO2 “challenges.” For donors who have lower or deteriorating arterial oxygen concentration, alveolar recruitment measures can include increasing positive end-expiratory pressure (PEEP) or using ventilator strategies such as inverse ratio or airway pressure release ventilation (APRV) modes. Prone positioning also can be considered. Use of an opioid inverse agonist, for example, naloxone, can be considered to ameliorate neurogenic pulmonary edema. After successful recruitment with such measures, reassessment of arterial Po2 should be considered to determine whether acceptable oxygenation can be maintained.

SURGICAL MANAGEMENT Preoperative Planning The side for transplantation is typically determined at the time of transplant evaluation, taking into consideration the differential perfusion, prior operations, or evidence of diaphragmatic palsy. Consent of the recipient should include operative risks (e.g., infection, bleeding, pain, organ failure, stroke, major adverse cardiac event, need for chronic immunosuppression therapy, need for reoperation, and death). In addition, recipients should be advised regarding the center's practice regarding use of “marginal” donors, for example, those with significant smoking history, advanced age, organs obtained by “donation after cardiac death,” or donors considered Centers of Disease Control and Prevention (CDC) high-risk for transmission of bloodborne diseases such as hepatitis B, hepatitis C, or HIV.

Positioning Single lung transplantation can be performed with the patient supine, via anterolateral thoracotomy, our preferred approach, or in the lateral decubitus position using a posterolateral or even axillary thoracotomy. The axillary approach should be considered mostly for patients with obstructive lung disease, such as emphysema, and not for those with restrictive lung disease. P.295 Care should be taken to place a shoulder roll, to position the arms appropriately, and to pad the legs. In the thoracotomy position, an axillary roll is placed to cushion the brachial plexus. Sequential compression devices (SCDs) and subcutaneous heparin should be used, and the patient should be firmly affixed in place. Preoperative antibiotics are administered as per institutional or center protocol. Induction therapy includes a purine synthesis inhibitor, and some centers also administer anti-T lymphocyte therapy. Standard skin preparation should be used.

TECHNIQUES PLACEMENT OF INCISION Right single lung transplantation is described. The approach to left lung transplantation is similar, although exposure of the hilum can be more difficult for patients with cardiac enlargement. With the anterolateral approach, enter the chest through the 4th intercostal space and divide the ipsilateral internal thoracic vascular pedicle (FIG 1). Resect the anterior costochondral cartilage of the 4th rib and divide the posterior intercostal muscle in order to maximize hilar exposure. Such an approach affords rapid exposure to the pericardium, by dividing the sternum transversely, if cardiopulmonary bypass is required. If the patient has an elevated hemidiaphragm, a heavy silk retraction suture can be placed into the dome of the hemidiaphragm and passed through a separate stab incision for improved exposure.

FIG 1 • Anterolateral thoracotomy approach.

PREPARING THE DONOR LUNG Trim the donor left atrial cuff and pulmonary artery to appropriate length. Flush the donor lung retrograde using the pulmoplegia in order to clear any residual debris or occult pulmonary emboli and to maintain cooling of the lung parenchyma during implantation. Trim the donor bronchus to within 1 to 2 cartilaginous rings from the upper lobe orifice, with minimal dissection of the surrounding soft tissue, in order to preserve the bronchial blood supply and limit local airway ischemia. Submit airway specimens for microbiology to aid in postoperative antimicrobial therapy.

MOBILIZATION OF THE PULMONARY HILUM Although much of the hilar dissection can be completed before arrival of the donor organ, defer the recipient pneumonectomy until the donor lung has been visualized and deemed suitable for use. Mobilize the inferior pulmonary ligament and complete an extrapericardial exposure of the hilar vessels. Take care to avoid traction or electrocautery injury to the phrenic nerve. Isolate the branch pulmonary veins in order to have adequate recipient left atrial cuff for the venous anastomosis. Divide the pulmonary artery distal from the previously divided apical branch to the upper lobe in order to assure an unrestricted arterial anastomosis. Typically, surgical staplers are used to divide the pulmonary artery and vein branches, although silk ligatures particularly for the vein branches are suitable. Divide the bronchus and trim it back to the mainstem as far into the hilum as technically feasible. Minimize dissection of the surrounding lymphatic and adipose tissue in order to maintain perfusion to the recipient airway. Place a 2-0 silk retraction suture in the cartilaginous portion of the proximal airway to facilitate exposure during the airway anastomosis. Divide the remaining parenchymal and pleural attachments; take care to avoid injury to adjacent posterior structures, particularly the esophagus, completing the recipient pneumonectomy. Assure meticulous hemostasis, particularly of the lymphatic tissue and bronchial vessels at the divided mainstem bronchus, as there is limited exposure of this region following implantation. Open the pericardium in order to expose the left atrium and intrapericardial branch pulmonary artery. P.296

AIRWAY ANASTOMOSIS

Complete an end-to-end anastomosis without “telescoping” in order to limit subsequent airway stenosis. The membranous airway anastomosis is accomplished with running 4-0 absorbable monofilament suture (FIG 2). The cartilaginous airway is approximated with interrupted 4-0 absorbable monofilament sutures, in a figure-ofeight fashion, which allows for adjustment in airway size mismatch (FIG 3). For smaller airways, simple interrupted sutures can be placed.1,2

FIG 2 • Anastomosis of the posterior membranous airway.

FIG 3 • Completion of the airway anastomosis (cartilaginous airway).

P.297

PULMONARY ARTERY ANASTOMOSIS Place a vascular clamp proximally on the right main pulmonary artery and secure to prevent inadvertent dislodgment. Remove the recipient pulmonary artery. Remove and open the apical branch suture lines to provide a continuous arterial cuff for anastomosis. Complete the anastomosis using a running 5-0 nonabsorbable monofilament suture (FIG 4). A stay suture can be placed for orientation and to prevent “pursestring” narrowing of the completed anastomosis. The completed anastomosis is secured with the arterial anastomosis distended with saline or at the time of reperfusion in order to limit inadvertent narrowing of the arterial anastomosis.

FIG 4 • Pulmonary artery anastomosis.

PULMONARY VEIN (LEFT ATRIAL) ANASTOMOSIS For right lung transplantation, develop the interatrial groove sharply in order to allow placement of a vascular clamp across the recipient left atrium. A Semb vascular clamp passed between the opened superior and inferior vein branches helps guide the atrial incision to maintain equal length of the posterior and anterior walls. Remove the recipient pulmonary vein staple lines or sutures and open the orifice to provide a continuous left atrial cuff for anastomosis (FIG 5). Complete the anastomosis using a running 4-0 nonabsorbable monofilament suture (FIG 6). A stay suture can be placed for orientation and to prevent pursestring narrowing of the completed anastomosis. If there is adequate atrial cuff, the “back wall” of the anastomosis is imbricated to avoid exposure of nonendothelialized tissue, which has the potential for developing left atrial thrombus. Leave the completed anastomosis untied for subsequent de-airing at the time of lung reperfusion. P.298

FIG 5 • Preparation of the recipient pulmonary vein.

FIG 6 • Pulmonary vein (left atrial) anastomosis.

REPERFUSION AND CLOSURE Prior to reperfusion, administer systemic methylprednisolone. Remove any topical cooling from the chest. Partially release the pulmonary arterial clamp to flush the preservative solution and ventilate the implanted lung to de-air the pulmonary vascular bed. Remove the pulmonary vein clamp gradually in order to maintain adequate systemic perfusion and secure the venous suture line. Place chest drains for apical and posterior pleural drainage. Our preference is to use a 28-Fr tube thoracostomy for anterior apical drainage and a posterior channeled silicone drain. Reapproximate the ribs with no. 2 braided polyglactin sutures passed through pilot holes drilled into the lower rib in order to reduce intercostal neuralgia. Close the remaining muscular and soft tissue in layers with running absorbable suture

and close the skin. P.299

POSTOPERATIVE CARE Immunosuppression regimen typically includes a calcineurin inhibitor, purine synthesis inhibitor, and systemic corticosteroid therapy. Antibiotic therapy is adjusted as determined by results of bronchial airway cultures. Postoperatively, patients remain supported with mechanical ventilation until criteria for adequate oxygenation and ventilation are achieved.

OUTCOMES Although the number of lung transplant recipients has increased annually, with more than 3,500 recipients reported in 2010, the number of single lung transplant recipients has remained stable at approximately 900 operations per year. Overall, median survival for single lung transplant recipients is 4.6 years. Among patients who survive the first year following transplantation, median survival is 6.5 years, as noted in recent international registry reports.3

COMPLICATIONS Acute rejection Atrial arrhythmia Bronchial anastomotic dehiscence or malacia Deep vein thrombosis Ileus/gastrointestinal Native lung hyperinflation Persistent air leak or pneumothorax Pleural effusion Primary allograft dysfunction Pulmonary reperfusion edema

REFERENCES 1. van Berkel V, Guthrie TJ, Puri V, et al. Impact of anastomotic techniques on airway complications after lung transplant. Ann Thorac Surg. 2011;92(1):316-321. 2. FitzSullivan E, Gries CJ, Phelan P, et al. Reduction in airway complications after lung transplantation with novel anastomotic technique. Ann Thorac Surg. 2011;92(1):309-315. 3. Christie JD, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: 29th Adult Lung and Heart-Lung Transplant Report—2012. J Heart Lung Transplant. 2012;31(10):1073-1086.

Chapter 46 Bilateral Sequential Lung Transplantation Bassem N. Mora David P. Mason

DEFINITION Bilateral sequential lung transplantation involves the sequential removal of both recipient lungs with subsequent orthotopic implantation of donor lung allografts. This typically involves bilateral mobilization of the diseased lungs prior to arrival of the donor organs, followed by sequential recipient pneumonectomy and implantation of the donor lung allografts. Donor lungs are most commonly procured following clinical brain death. In select cases, lung allografts can also be procured following donation after cardiac death (DCD). Living related lung transplantation has also been described, although its use in clinical practice is limited due to the need for two donors, a very small recipient, and potential for significant morbidity to the donors. It is rarely practiced in the United States due to recent changes to the lung allocation system.

PATIENT HISTORY AND PHYSICAL FINDINGS In the United States, lung transplantation can only be performed at accredited transplant centers under the guidance of the United Network of Organ Sharing (UNOS). Posttransplant outcomes are reported annually to UNOS. Each lung transplant candidate, following a thorough preoperative evaluation, is discussed in a multidisciplinary transplant meeting, reviewing indications for lung transplantation, contraindications, and alternative treatments. Prior to the acceptance of donor lungs for transplantation, a thorough assessment of the brain-dead donor is carried out by the accepting transplant center. Multiple variables are reviewed, including the circumstances of brain death, potential contraindications to organ donation, cigarette use history, high-risk behavior history, age, ABO blood group compatibility, radiologic studies, and findings on bronchoscopy and the arterial blood gases. Typical contraindications to organ donation include active malignancy, active cigarette use, advanced age, pulmonary infiltrates or pneumonia, pulmonary contusions compromising graft function, significant purulent secretions on direct bronchoscopic examination of the airways, and a PaO2 less than 300 mmHg on 100% FiO2.

IMAGING AND OTHER DIAGNOSTIC STUDIES ABO compatibility is routine in lung transplantation. Tissue human leukocyte antigen (HLA) typing and crossmatching are considered with a “virtual” cross-match as well as with retrospective cross-matching. For patients who are immunologically incompatible, plasma-pheresis with various desensitization protocols is an option. A detailed pretransplant evaluation of the recipient is beyond the scope of this chapter. A number of laboratory

tests are routinely ordered, including various hematology, coagulation, and chemistry blood tests; nicotine and cotinine levels; viral and fungal serologies; tumor markers; blood typing; and immune panels. Sputum is sent for routine culture and sensitivity for acid-fast bacilli and fungus. Procedural studies include an electrocardiogram, echocardiogram, bone densitometry, bronchoscopy, left and right heart catheterization, esophagogastroduodenoscopy, colonoscopy, esophageal manometry, dobutamine stress testing, gastric emptying studies, and a barium swallow. Pulmonary laboratory studies include pulmonary function testing, an arterial blood gas, spirometry, and a 6minute walk test. Radiologic studies include a two-view chest radiograph, quantitative lung ventilation-perfusion scan, highresolution chest computed tomography (CT) scan with contrast, and a nasal sinus CT scan or abdomen and pelvis CT scan as indicated. Note the extensive reticular interstitial lung disease along with associated architectural distortion with fibrosis, traction bronchiectasis, and honeycombing. A number of consults are arranged to determine fitness for transplantation including various medical specialties such as pulmonary medicine, thoracic surgery, gastroenterology, cardiology, otolaryngology, immunology, infectious disease, chemical dependency, psychiatry, and social work.

SURGICAL MANAGEMENT Either single or bilateral lung transplantation can be performed depending on institutional preference and patient diagnosis. Some centers routinely perform bilateral lung transplantation in all patients due to the associated 25% increase in overall survival compared to unilateral lung transplantation seen in some patient populations. Other centers, including ours, are more selective, given the scarcity of donor organs. Older patients with idiopathic pulmonary fibrosis and chronic obstructive lung disease are selectively offered single lung transplantation. Patients with pulmonary hypertension and infectious lung diseases typically undergo bilateral sequential lung transplantation.

Preoperative Planning Routine preoperative laboratory studies and a chest radiograph are ordered on the day of the transplant procedure. Blood pressure monitoring is achieved by an arterial line placed prior to induction of anesthesia. Operative informed consent should include a clear statement regarding the possibility of transmission of infectious disease or malignancy from the donor as well as whether the donor is considered a Centers for Disease Control and Prevention (CDC) high-risk donor. Standard operative risks should be discussed, including but not limited to bleeding, infection, immunosuppression P.301 complications, allograft dysfunction, airway or vascular anastomotic complications, need for prolonged mechanical ventilation and tracheostomy, acute and chronic rejection, need for mechanical circulatory support such as extracorporeal membrane oxygenation (ECMO), and death. In patients who are certain to require cardiopulmonary bypass (CPB) during the operation, a single lumen endotracheal tube can be used. Patients undergoing lung transplantation without CPB are typically intubated with a left-sided, double lumen endotracheal tube to allow for selective lung ventilation during the procedure. A Swan-Ganz pulmonary artery (PA) catheter with an introducer sheath for large-volume resuscitation is placed following induction of anesthesia, usually via the right internal jugular vein. The tip of the PA catheter is

advanced just beyond the pulmonary valve, so as not to interfere with stapling of the PA at the time of recipient pneumonectomy. The presence of pulmonary hypertension may warrant CPB for the operation's safe conduct. The perfusion team should be present in the operative suite throughout the procedure, as CPB may be needed emergently at any time. A transesophageal echocardiogram is performed routinely in all patients to assess ventricular function, rule out associated cardiac anomalies, assist in de-airing at the end of the procedure, and assessing the vascular anastomoses. A Foley urinary catheter is placed. Perioperative antibiotics are center-specific. We typically employ cefuroxime for perioperative coverage in addition to vancomycin on a selective basis. Postoperative antibiotics are chosen based on donor and recipient airway cultures. One gram of methylprednisolone is administered prior to reperfusion of the right lung allograft.

Positioning Position the patient with both arms tucked. In the case of the clamshell incision, a vertical back roll is placed in order to further elevate the lateral chest off the operative table. Mark the proposed incision on the patient. In the case of the clamshell approach, the 4th intercostal space is marked as well as the inframammary crease, particularly in women. In the case of a median sternotomy approach, the central part of the sternum is marked. Both femoral arteries are marked in case the patient requires postoperative ECMO support. Widely prep and drape the chest, abdomen, pelvis, groins, and legs. The prep should extend laterally to the midaxillary line for the clamshell approach. An iodine-impregnated drape is placed over the skin. A cell saver is used in all cases. This is helpful in blood salvage prior to and following CPB. A separate “dirty” suction catheter is used to suction the bronchus of airway secretions. Especially in the case of inflammatory lung disease such as cystic fibrosis or bronchiectasis, frequent bronchoscopic suctioning of the airways by the anesthesia team is necessary.

TECHNIQUES INCISION Our institutional preference is to perform bilateral sequential lung transplantation through either a trans-sternal bilateral anterolateral thoracotomy “clamshell” incision (FIG 1) or a median sternotomy, depending on surgeon preference. Alternatively, bilateral anterolateral thoracotomy incisions through the 4th intercostal space can be made, avoiding the need for sternal division (FIG 2). This limits surgical exposure but results in superior sternal stability. Two perpendicular retractors are used per side to expose the hilar structures. In the absence of sternal division, if CPB is needed, then either peripheral groin cannulation can be used or central cannulation of the right atrium and ascending aorta through the right thoracotomy.

FIG 1 • Clamshell trans-sternal bilateral anterolateral thoracotomy incision. In women, the anterolateral thoracotomy incision should be in the inframammary crease. Flaps should be elevated to allow entry into the 4th intercostal space. In large P.302 breasted women, a retraction stitch is sometimes placed through the breast tissue and secured superiorly to the drape to allow better exposure.

FIG 2 • Bilateral anterolateral thoracotomy incisions without sternal division. In the setting of single lung transplantation, the 4th intercostal space is typically used. Due to anatomic differences between the right and left hilum, a posterolateral approach offers some advantage on the left side, whereas an anterior thoracotomy is almost always preferable on the right side. In the case of a clamshell incision, following entry into the pleural space, the intercostal muscles are incised laterally with electrocautery to the paraspinal ligaments to allow less traumatic opening of the thoracotomy retractor. Both internal mammary artery pedicles are clipped, divided, and oversewn. Both pleural spaces are entered and bilateral thoracotomy retractors are placed. Mediastinal structures should be mobilized prior to heparinization and CPB. Pericardial stay sutures are

placed and the right and left pulmonary arteries and the right-sided pulmonary veins are mobilized.

CARDIOPULMONARY BYPASS The routine use of CPB in bilateral lung transplantation is controversial. Most centers rarely use it for single lung transplantation unless there is intraoperative hemodynamic instability. In the setting of bilateral lung transplantation, some centers use CPB selectively and others routinely. We prefer to use CPB for the majority of bilateral lung transplants. We believe this results in more stable hemodynamics, faster recipient pneumonectomy and implantation, quicker blood salvage through cardiotomy suckers, and avoidance of exposure of the ischemic first lung allograft to the entire cardiac output while the second lung allograft is implanted. Disadvantages include the potential for systemic inflammatory response, the need for arterial and venous cannulation, and the potential for increased postoperative bleeding from acquired coagulopathy and increased transfusion requirement. The use of a median sternotomy incision, in contradistinction to a clamshell incision, requires CPB in all cases because exposure of the left hilum is otherwise impossible without decompression of the heart. Likewise, if concomitant cardiac surgical procedures are to be performed, then CPB is necessary. The institution of CPB should be done when the procurement team is en route to the operative suite. After full heparinization, arterial cannulation is accomplished through the ascending aorta. Venous cannulation is via a two-stage cannula in the right atrial appendage or via bicaval cannulae in the superior and inferior vena cava, depending on surgeon preference. Right Hilar Mobilization A suture can be placed on the diaphragm to retract it caudally and further expose the right hilar structures. Release the inferior pulmonary ligament up to the inferior pulmonary vein. Care should be taken to avoid bleeding at the most caudal aspect of the ligament where a small arterial blood vessel is invariably present. Use scissors to mobilize the hilum, with occasional electrocautery. Clips are applied generously on small bronchial and lymphatic vessels to avoid postoperative bleeding and lymphatic leak. Mobilization of the recipient lungs is more difficult in the setting of prior surgery or adhesions, and appropriate coordination with the donor team is of paramount importance to avoid unnecessary delays in allograft implantation. The right inferior pulmonary vein (RIPV) is mobilized and so is the right superior pulmonary vein (RSPV) and right main pulmonary artery (RMPA). The RMPA is superior to the RSPV as well as anterior to the right mainstem bronchus. It is difficult to mobilize the right mainstem bronchus prior to division of the RMPA and pulmonary veins. Adhesions of the lung to the chest wall can be mobilized using electrocautery. We believe that this is easier to perform using the clamshell incision compared to the sternotomy incision. Take care to avoid injury to the right phrenic nerve. This is of paramount importance postoperatively with respect to graft function, pulmonary toilet, and chest wall mechanics.

RIGHT HILAR DIVISION Once the donor team is en route, CPB is established. It should be reemphasized that bilateral sequential lung transplantation can be done without the use of CPB, although it is our preference to employ CPB in most bilateral lung transplants. The hilar structures are not divided prior to the arrival of the donor team in the operating room and prior to inspection of the lung allograft to assure the donor lungs are usable.

The RSPV is the most anterior structure in the right hilum. It is divided first. The Endo GIA stapler with a vascular load is used to divide the upper lobe branch of the vein after appropriate intrapericardial mobilization (FIG 3). The middle lobe branch of the RSPV is divided next (FIG 4). The branches of the RSPV are grasped with an atraumatic grasper and are retracted anteriorly to expose the right PA superiorly and RIPV inferiorly and posteriorly. Both structures are further mobilized prior to their division. Divide the truncus anterior branch of the right PA with a vascular load (FIG 5). Dividing the right PA beyond its first bifurcation allows for more length to perform the right PA anastomosis later. P.303

FIG 3 • Division of the upper lobe branch of the RSPV.

FIG 4 • Division of the right middle lobe vein.

FIG 5 • Division of the truncus anterior of the right PA.

FIG 6 • Division of the ongoing portion of the right PA. Divide the ongoing portion of the right PA with a vascular stapler (FIG 6). The right PA is mobilized posteriorly off of the right mainstem bronchus. It is also mobilized superiorly and inferiorly into the mediastinum, working through the lateral pericardium. It is retracted anteriorly with an atraumatic grasper as needed to expose the RIPV. Divide the RIPV with the vascular stapler to complete the division of the hilar vessels (FIG 7). Clip and divide the bronchial arteries. Invariably, there are a number of lymph nodes that are in close juxtaposition to the right bronchus. Some of these lymph nodes may need to be resected to allow for the bronchial anastomosis. The right mainstem bronchus is transected with a knife at the junction of the right upper lobe and the bronchus

intermedius (FIG 8). A dirty suction tip is used to aspirate airway secretions until the bronchial anastomosis is completed.

FIG 7 • Division of the RIPV. P.304

FIG 8 • Sharp division of the right bronchus. Do not denude the airway at the proposed bronchial anastomotic site because it serves as an important source of blood supply to the donor airway. Devascularization of the recipient or donor airway is associated with an increased incidence of airway complications such as bronchial stricture and dehiscence. Remove the right lung. An atraumatic clamp is placed on the right hilar vessels (RPA, RSPV, RIPV), and gentle traction is applied in order to mobilize them further medially. The posterior pericardial attachments are mobilized at this point. The fibrous attachments of the RPA to the RSPV and the pericardium are divided (FIG 9). This allows for a tension-free anastomosis.

FIG 9 • Mobilization of the posterior mediastinum between the RSPV and the right PA.

DONOR RIGHT LUNG PREPARATION Although the recipient right hilar structures are mobilized, the donor lung allograft is prepared on the back table. The double-lung block is placed on ice and separated into right and left specimens. This is accomplished by dividing the main PA in the midline and dividing the left atrium vertically into right and left sections. A knife is used to transect the right and left bronchus. Cultures are obtained from the donor right and left bronchus to aid in perioperative antibiotic therapy. The lung is placed in an iced towel and stored deflated on ice.

RIGHT BRONCHIAL ANASTOMOSIS Place the right lung in the right chest over iced sponges and oriented anatomically. The bronchial anastomosis is performed first followed by the PA anastomosis then the atrial anastomosis. Using a sharp knife, shorten the length of the donor airway. This minimizes ischemia of the donor airway and potentially decreases the incidence of airway complications. A traction suture may be placed through the middle of the anterior aspect of the recipient right bronchus to retract it anteriorly and provide better exposure. The membranous donor-to-recipient bronchus is sutured using a double-loaded running monofilament 4-0 suture (FIG 10). The same suture is continued circumferentially to approximate the cartilaginous airway then tied anteriorly (FIG 11). A number of suture techniques are in use for the airway anastomosis, depending on surgeon preference. These include running versus interrupted techniques. We P.305 prefer to use a single 4-0 nonabsorbable polypropylene suture.

FIG 10 • Anastomosis of the right membranous bronchus.

FIG 11 • Completion of the right bronchus anastomosis. If the airway is particularly small, we run the membranous airway and place simple interrupted sutures in the cartilaginous airway. If there is a large size discrepancy between the donor and recipient airways, one airway can be telescoped into the other although this is not preferable. Test the airway anastomosis by checking for air leaks under saline by manually inflating the lung allograft. If present, those should be repaired. Fashion the peribronchial adventitial tissue over the anterior aspect of the bronchial anastomosis to separate the airway from the vascular hilar structures in the event of an airway complication. Thymic fat pad, pericardium, or intercostal muscle can be used to cover the airway anastomosis. Following completion of this anastomosis, the anesthesiologist performs bronchoscopic suctioning of the airway to remove any additional blood or inspissated mucus.

RIGHT PULMONARY ARTERY ANASTOMOSIS Apply a right-angled vascular clamp medially to the recipient right PA. The stapled tip of the right PA is cut off. The donor right PA is shortened to avoid redundancy of the PA and kinking.

FIG 12 • Anastomosis of the right PA. The donor and recipient right pulmonary arteries are anastomosed in an end-to-end fashion using a 5-0 polypropylene suture. The back wall of the donor and recipient right PA is sutured first (FIG 12). The front wall of the anastomosis is completed next, suturing from the outside. The suture is tied but the clamp is kept on the PA until the pulmonary venous anastomosis is completed (FIG 13).

FIG 13 • Completion of the right PA anastomosis. P.306

RIGHT PULMONARY VENOUS ANASTOMOSIS Apply a Satinsky angled vascular clamp to the body of the left atrium in the hilum. The stapled tips of the RSPV and RIPV are excised with scissors, and the two open ends are connected to result in a large left atrial recipient cuff (FIG 14).

The left atrial donor and recipient cuffs are anastomosed with a running 4-0 polypropylene suture (FIG 15). In a manner similar to the PA anastomosis, the back wall is completed first followed by the front wall.

FIG 14 • Preparation of the recipient left atrial cuff. Care should be taken to avoid the presence of left atrial muscle within the anastomosis. Rather, intima to intima should be approximated. This decreases the potential for thrombus formation at the anastomosis. Prior to tying this suture line, the right PA clamp is released slowly while venous return is retarded by the perfusionist to allow “de-airing” through the pulmonary venous anastomosis. The suture is tied after appropriate de-airing maneuvers (FIG 15, inset) with the patient in steep Trendelenburg. Both clamps are released. Transesophageal echocardiography is used to inspect for any air within the left atrium and evaluate the anastomoses.

FIG 15 • Anastomosis of the left atrial cuff. Completed right lung transplantation procedure is shown in the inset.

LEFT PNEUMONECTOMY The left lung transplant procedure is performed in a similar manner to the right. Circumferentially mobilize the hilar left main pulmonary artery (LMPA) and pulmonary veins. An opening is

made in the left pericardium anterior to the left hilum to further mobilize the hilar vessels.

FIG 16 • Division of the left PA. It is easier to first divide the LMPA using a vascular stapler (FIG 16). The intrapericardial aspect of the LMPA is mobilized further. Retract the LMPA anteriorly and divide the left pulmonary veins (FIG 17). The left superior pulmonary vein (LSPV) is divided first because it is more anterior and P.307 superior, thus easier to divide. The left inferior pulmonary vein (LIPV) is mobilized circumferentially then divided (FIG 18).

FIG 17 • Division of the LSPV.

FIG 18 • Division of the LIPV. The peribronchial tissue is divided and clipped. Lymph nodes are often present close to the left mainstem bronchus and are mobilized with the specimen. Divide the left mainstem bronchus, avoiding spillage of airway secretions (FIG 19). The plane in the posterior mediastinum between the LMPA and left upper pulmonary vein (LUPV) is mobilized to allow for tension-free vascular anastomoses (FIG 20). Remove the left lung. Hemostasis is achieved at this juncture, as it will be difficult to visualize this area following lung implantation.

FIG 19 • Division of the left mainstem bronchus.

FIG 20 • Mobilization of the posterior mediastinum between the LSPV and the left PA.

LEFT LUNG IMPLANTATION As for the right side, the left lung is implanted by first suturing the left bronchus (FIG 21). A vascular clamp is applied to the LMPA proximally and the anastomosis completed next. Care should be taken to avoid kinking or twisting of the left PA (FIG 22). This suture is tied. A vascular clamp is applied to the left atrium proximally and the recipient left atrial cuff is prepared in similar fashion to the right (FIG 22). The left pulmonary venous anastomosis is completed in a similar manner to the right (FIG 23). Following deairing, the suture line is tied and the vascular clamps are removed (FIG 23, inset).

FIG 21 • Anastomosis of the left bronchus. P.308

FIG 22 • Anastomosis of the left PA.

FIG 23 • Anastomosis of the left atrial cuff. Completed bilateral sequential lung transplantation procedure is shown in the inset.

COMPLETION Ventilate both lungs and inspect for atelectasis. Any bleeding, particularly from the anastomoses, should be addressed at the present time. The patient is slowly separated from CPB to allow for controlled reperfusion. Echocardiography should guide appropriate de-airing of the left atrium. Pleural drains are placed. We prefer two large-bore 32-Fr chest tubes, one posterior and one inferior to the lung placed over the diaphragm. We also routinely place a 19-Fr Blake drain supradiaphragmatically to facilitate rapid chest tube removal. The wound is closed in layers. In the case of the clamshell incision, we use at least four nonabsorbable pericostal sutures on each side. The divided sternum is reapproximated with no. 6 sternal wire. The tissues

are closed in layers.

PEARLS AND PITFALLS Donor selection

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Contraindications to organ donation include active malignancy, active cigarette use, advanced age, pulmonary infiltrates or pneumonia, pulmonary contusions compromising graft function, significant purulent secretions on direct bronchoscopic examination of the airways, and a PaO2