P. Farinelli

Intrapancreatic Common Hepatic Artery Arising From the Superior Mesenteric Artery, a Challenging Anatomic Variation in a Multiorgan Harvesting

INTRODUCTION Understanding abdominal vascular anatomy is crucial for multiorgan recovery. In this case report, we have described a common hepatic artery that arises from the superior mesenteric artery but follows an intrapancreatic course. METHODS The donor was ideal for multiorgan recovery and the recipient was a 29-year-old woman awaiting a second transplant owing to primary nonfunction of her first engrafted organ. The indication for transplantation was secondary biliary cirrhosis. A type I diabetic recipient on dialysis therapy was awaiting the kidney and pancreas. RESULTS The urgent condition of our liver recipient combined with the anatomical finding prioritized liver procurement, therefore the pancreas was discarded. CONCLUSIONS The recognition of all anatomic variations will allow us to improve the use of the scarce resource of deceased donor organs.

Long Term Outcomes after Intestinal Transplantation from a Single South-American Center, Lessons Learned

Introduction In many countries, intestinal failure patients (IF pts) had the only option of parenteral nutrition (PN) as available treatment until intestinal transplantation (ITx) evolves as part of a multidisciplinary team. We would like to report the long-term outcomes of a series of ITx performed in children and adults at a single center, 9 years after its creation. Material and Methods retrospective analysis of all consecutive ITx performed between May 2006 and Oct 2017. Diagnoses, pre ITx mean time on PN, indication for ITx, time on the waiting list (WL), type of ITx, mean total ischemia time (TIT), and warm ischemia time (WIT), time for PN discontinuation, 5-year actuarial patient survival are reported. Results 44 patients received 47 ITx. The mean time on PN for the Tx group was 1604 days*. The main indication for ITx was: lack of central venous accesses followed by PN associated liver disease, and catheter related infectious complications. The mean time on the WL was 222 days (SD: 195 days). ITx were performed in 28 children and 16 adults. Thirty-seven procedures were isolated ITx; 10 multiorgan (MTO) (4 combined, 7 multivisceral - 2 with kidney); 4 (8,5%) were re-transplants: 3 isolated, 1 multivisceral; 8 included right colon. Sixteen pts (36%) received the abdominal rectus fascia. All procedures were performed by the same team; TIT was 7:36±2:10 hs, WIT was 39.1±10.5 min. Mean length of implanted intestine: 325 ± 59.5 cm, BC ileostomy were performed in 59.5% of the cases. 18/47 Tx required early re-operations. The overall mean follow up time is 49±45.2 months; the mean time to be off PN was 68 days (* p: 0,001); the overall 5 year pt survival is 55.1%; 60.5% for Isolated ITx vs 35% for MTO (p=0,01); 60.3% for ped recipient’s vs 44.9% for adults (p=NS). Conclusions After 11 years of establishing a dedicated adult and ped IF program, we proved that ITX is a valid therapeutic alternative for pediatric and adult candidates. Long term results are comparable to a large series reported from centers of develop countries or the ITR.

Unusual spontaneous porto-systemic shunt: The importance of diagnosing non-anatomical porto-systemic shunts to improve portal flow in pediatric living-related liver transplantation. Case report

Collateral circulation secondary to liver cirrhosis may cause the development of large PSSs that may steal flow from the main portal circulation. It is important to identify these shunts prior to, or during the transplant surgery because they might cause an insufficient portal flow to the implanted graft. There are few reports of “steal flow syndrome” cases in pediatrics, even in biliary atresia patients that may have portal hypoplasia as an associated malformation. We present a 12‐month‐old female who received an uneventful LDLT from her mother, and the GRWR was 4.8. During the early post‐operative period, she became hemodynamically unstable, developed ascites, and altered LFT. The post‐operative ultrasound identified reversed portal flow, finding a non‐anatomical PSS. A 3D CT scan confirmed the presence of a mesocaval shunt through the territory of the right gonadal vein, draining into the right iliac vein, with no portal inflow into the liver. The patient was re‐operated, and the shunt was ligated. An intraoperative Doppler ultrasound showed adequate portal inflow after the procedure; the patient evolved satisfactorily and was discharged home on day number 49. The aim was to report a case of post‐operative steal syndrome in a pediatric recipient due to a mesocaval shunt not diagnosed during the pretransplant evaluation.