Real-Time Intraoperative Assessment of Microcirculation in Living-Donor Small Bowel Transplant: A Case Report

Living-donor small bowel transplant has emerged as a modality to transplant patients with short bowel syndrome without prolonged wait time, albeit at the cost of technical challenges associated with vascular anastomosis due to the small size of vessels. Suboptimal perfusion in a transplanted bowel can lead to a devastating outcome, and clinical judgment alone is not completely reliable for assessment of bowel microcirculation. Here, we report a 55-year-old female patient who underwent flow cytometric cross-match-positive living-donor bowel transplant from her daughter. Initial suboptimal perfusion prompted a revision of the arterial anastomoses. Despite normal Doppler signals over the mesenteric vessels, the bowel had a variegated appearance. The microcirculation of the bowel wall was subsequently assessed in a real-time fashion by indocyanine green fluorescence angiography, which showed improved perfusion indices with time. Hence, this simple test helped us to avoid another unnecessary exploration and revision of the anastomoses. At present, the patient is thriving on an enteral diet. This case underpins the importance of real-time intraoperative assessment of bowel per-fusion and microcirculation in difficult cases. These assessments are needed to help surgeons identify tissues at risk for ischemia and necrosis, thereby allowing for maneuvers to improve intestinal viability.