Successful isolated small bowel transplantation in short bowel syndrome: Anaesthetic considerations

Sir,

A 34-year-old lady, a known case of lupus anticoagulant, underwent extensive small bowel resection for a superior mesenteric artery (SMA) thrombosis. Owing to short bowel syndrome, she was maintained on total parenteral nutrition (TPN) and listed for an isolated small bowel transplant (SBT) in view of catheter-related sepsis.[1]

At the time of her allotment to a group-matched donor one and half years later, she weighed 29 kg, haemoglobin 12.2 g/dL, platelets 267 × 10³/mcL, fibrinogen 363 mg/dL, INR 0.97, and glycosylated haemoglobin of 5.1 while on enoxaparin 0.6 ml subcutaneous (s.c) and insulin on account of lupus anticoagulant and coexisting diabetes mellitus.

Sub-cutaneous dose of 15 mg alemtuzumab (Campath-1H) was administered 1 h prior to surgery Modified rapid sequence induction with intravenous (IV) midazolam 2 mg, fentanyl 100 μg, lidocaine 40 mg and propofol 60 mg, intubation at 1 min after 30 mg rocuronium with application of cricoid pressure was performed and maintenance with isoflurane at 0.7-1.0 minimum alveolar concentration (MAC) in a 50% air oxygen mixture. Cis-atracurium was used for neuromuscular blockade subsequently. Femoral arterial and right internal jugular accesses were obtained with ultrasound guidance. Antibiotic prophylaxis of injection doripenem 500mg, teicoplanin 400mg and fluconazole 400 mg were provided. The graft SMA was anastomosed to the recipient infrarenal aorta and SMV (vein) to the inferior vena cava. The patient received 3.0 L crystalloid (Kabilyte, Fresenius-Kabi), 1 unit packed red cells (PRBC) and 25% albumin (100 ml) during the 5 h surgery with unfractionated heparin (UFH) 2500 IU, methylprednisolone 500 mg IV and 75 mg of aspirin through the Ryle's tube at arterial anastomosis. Noradrenaline at 0.04 μg/kg/min and prostaglandin E1 at 0.25 μg/kg/h was initiated and the patient shifted to the ICU with lactates of 3.9 mmol/L. Although she was extubated shortly after, persistent abdominal pain warranted a re-look 24 h later that revealed a patchy gangrenous small bowel graft that needed explant. After super urgent listing, she was taken for re-transplant 24 h later (pH 7.34, HCO³ 22 mEq/L lactate of 1.6 mmol/L). Anaesthesia induction was similar to the earlier management. Two units of PRBC, 400 ml of 20% albumin, 3.5 L crystalloid (Kabilyte) were transfused and 200 μg phenylephrine as intermittent boluses and infusion of noradrenaline at 0.04 μg/kg/min and prostaglandin E1 at 0.25 μg/kg/h started at reperfusion. Infusion of 20% albumin was started to avoid bowel oedema following reperfusion. Additional methylprednisolone 500 mg and UFH 2500 units were administered at vascular anastomosis of the new graft [Figure 1]. The surgery was completed with jejuno-jejunal anastomosis, end ascending graft colostomy and venting gastrostomy. She was extubated 12 h later after confirmation of normal Doppler parameters.

Figure 1.

(a) Small bowel graft on ice. SMA: Superior mesenteric artery. SMV: Superior mesenteric vein. (b) Graft after reperfusion

Her postoperative course was complicated by gram negative sepsis, intermittent stomal dysfunction, a chyle leak and peripancreatic collection that were managed per guidelines. She had gained weight (42 kg) and was on supervised oral nutrition at the time of her discharge 48 days later.

Short bowel syndrome following massive surgical resection is the commonest indication for SBT and is emerging as a viable option in adults.[2] The anaesthetic concerns for the recipient were background prothrombotic state, scarcity of peripheral and central venous access sites following repeated cannulation, the risk for aspiration and nutritional deficiencies [Table 1]. Ultrasound-guided vascular access and modified rapid sequence induction was performed in this patient. Acetated crystalloid solution was used to avoid confounding effects on serum lactate.[3] Our patient was haemodynamically stable and did not require advanced cardiac monitoring[4] but transoesophageal echocardiography (TEE) may be useful if haemodynamic instability occurs during surgery.[5] Two arterial lines, one in the radial and the other femoral should be available if a complete aortic cross clamp is needed, however we experienced technical difficulty and had femoral access only. An infusion of prostaglandin E1 at 0.25 μg/kg/h was started as it can improve microcirculation and enhance immunosuppression. The postoperative management centred on scrupulous asepsis in care, maintenance of haemodynamics, nutritional replacement and management of infections. Parenteral nutrition was continued postoperatively until the chyle leak had settled and the patient able to tolerate oral feeds.

Table 1.

Anaesthetic considerations in small bowel transplant

Stage of surgery	Concerns	Implications and tests
Donor evaluation	Ideal donor[6] (Deceased brain-dead donor)	HLA matched,
		No abdominal trauma
		Age<50 years and size matched to recipient (75% of recipient weight)
		Na<155 mmol/L,
		ICU stay<1 week,
		No ongoing transfusion
		Initiation of early enteral nutrition
Preoperative evaluation	Indication for SBT	Prior surgery-adhesions
	Hypercoagulable states.	Anticoagulation
	Central and peripheral access evaluation.	Doppler/venography assessment
	Cardiovascular evaluation	Noninvasive stress testing/Invasive if indicated.
	Standard tests	CBC, metabolic panel
	Micronutrient deficiencies	Mg, Zn, Cu, Se, vitamins,
		Albumin, transferrin
Prior to shifting to OR	Immunosuppression	OT asepsis. Limited personnel.
	Anticoagulation	Gowns/gloves
During surgery	Dissection phase	Blood losses. Non-lactate containing crystalloid.
	Anastomotic phase	Immunosuppression
		Reperfusion syndrome
		Anticoagulation added
	Bowel reconstruction	Maintenance of blood pressures
		Albumin for bowel oedema
		Avoidance of excessive vasopressors to avoid vasospasm
Postoperative	Extubation when stable
	Vascular integrity	Lactate levels
		Enteroscopy
	Infections	Meticulous asepsis
	Chyle leak	TPN, low fat diet
	Nutrition	TPN until tolerating orally (2-6 weeks)
	Rejection	Immunosuppression

SBT=Small bowel transplant, CBC=Complete blood count, Mg=Magnesium, Zn=Zinc, Cu=Copper, Se=Selenium, TPN=Total parenteral nutrition, OT=Operation theatre, ICU=Intensive care unit, HLA=Human leukocyte antigens, 6: reference 6

We believe that this is the first recount of anaesthesia for SBT in India and wish to highlight the anaesthetic implications for the management of isolated small bowel transplantation in this patient. [6]

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Conflicts of interest

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