University of Nice, France
Dr. Thierry Yandza has completed his MD and Ph.D from Paris University. He is the director of the Intestinal Transplant Program at the University of Nice, France. He has published more than 50 papers in reputed journals and he serves as a reviewer of reputed scientific journals such as The American Journal of Transplantation.
In small bowel transplantation, the current consensus is to avoid transplanting patients with insufficient vascular patency to guarantee easy central venous access. Here we present the case of a patient who received an intestinal transplant despite obstruction of the superior vena cava (SVC). A 60-year-old woman with chronic intestinal pseudo-obstruction received an isolated small bowel transplantation in October 26th, 2011. The pretransplant work-up revealed extensive veno-occlusive disease involving the SVC above the azygos vein. During transplantation, a 12-French double-lumen Hickman catheter was placed in the left femoral vein. The total volume infused was 20000 mL. Eighteen hours after surgery, the patient presented with sudden cardiopulmonary arrest. She had a large facial and neck edema that did not allow visualization of the larynx with a laryngoscope. Reintubation was rendered possible through the oral route with the use a pediatric fibreoptic bronchoscope. She recovered after active resuscitation and mechanical ventilation. The diagnostic of acute superior vena cava syndrome (SVCS) was made. SVCS was treated with drastic reduction of intravenous perfusion, changing of bed position with head elevation, diuretics, and intravenous heparin. In order to avoid recurrence of SVCS with airway obstruction, a preventive tracheotomy was performed on postoperative day 14. Ten months after transplantation, the patient is well with a normal oral diet. In conclusion, our case emphasizes that small bowel transplantation should be avoided in patients with SVC thrombosis. If small bowel transplantation is done however, tracheotomy performed before transplantation may be discussed in order to avoid a post-transplant SVCS.