The patient is a 56-year-old woman with a history of chronic pancreatitis. She developed hepatic artery aneurysm and underwent repair of the aneurysm with subsequent thrombosis of the artery. Then she developed intrahepatic bilomas and repeated bouts of cholangitis and sepsis requiring hospitalization and chronic antibiotherapy. She underwent a left hepatectmy (the predominantly diseased lobe) with Roux-en-Y biliary reconstruction to fix her biliary stricture problem. Over the next one year she developed secondary biliary cirrhosis, and in addition to insulin dependent diabetes she developed exocrine pancreatic insufficiency secondary to repeated attacks of pancreatitis. She was placed on the waiting list for en-bloc liver and pancreas transplantation.

A suitable donor (45-year-old) became available and en-bloc liver duodenum and pancreas with intact portal vein, splenic vein, superior mesenteric vein and artery, bile duct and celiac axis were recovered. The abdominal organs were flushed with eight liters of Custodiol® HTK solution in situ and 2 liters on the back-table through the portal vein via the superior mesenteric vein.

The recipient operation was completion hepatectomy without bypass, with piggyback implantation of the enblock liver/duodenum/ pancreas. Hepatic venous outflow was through the anastomosis between suprahepatic inferior vena cava of the graft and confluence of hepatic veins of the recipient. Portal vein of the recipient was anastomosed to the stump of the superior mesenteric vein of the en-bloc organs. The organs were reperfused through the portal vein with cold ischemia time of seven hours and thirty-five minutes. For arterialization of the grafts we anastomosed common patch of the celiac and superior mesenteric arteries of the donor to the pre-place donor aortic conduit on the infrerenal aorta of the recipient. This conduit was passed through the meso-transverse colon to the en-bloc graft. After successful arterialization of the graft we focused on biliary reconstruction. Since the bile duct was intact in the en-bloc graft we just needed to make an anastomosis between the duodenal patch of the donor to the previously made Roux limb of the recipient. After completion of this anastomosis, thorough irrigation of the operative field, and placement of appropriate drains, abdominal cavity was closed.

Postoperatively, the liver enzymes peaked at AST 6200, and ALT 2700, which rapidly came down and by day 4 they were 166 and 430 respectively. Blood sugar stayed in mid 100’s for the next several days requiring insulin supplements. On day 2 after transplantation, because of the presence of bile in the drain we decided to re-explore the patient. The bile leak was from the duodeno-jejunal anastomosis which the anastomosis was revised. An intraoperative cholangiogram through the cystic duct stump of the donor bile duct showed no leak. A laceration in the body of the pancreas was found which was concerning for possible future leak. Because of the plan to re-explore the patient after 3 days for further evaluation of organs abdominal cavity was irrigated but not closed.

After three more interval explorations abdominal cavity was closed and the patient was transferred to regular floor and from there to rehabilitation program. During this period we noticed a low-volume pancreatic fistula which closed spontaneously. The patient required no more pancreatic exocrine supplements and no more insulin. Her liver function tests remained normal except some elevation of canalicular enzymes which eventually returned to normal (Alkaline phosphatase 74) three month after transplantation. Her abdominal wound healed completely.

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