A novel technique for reconstruction of the proximal alimentary tract after bowel transplantation for intestinal pseudo-obstruction

Sir: Chronic intestinal pseudo-obstruction is a term used for a syndrome in which there are symptoms and signs of bowel obstruction without evidence of a structural obstructing lesion. Idiopathic pseudoobstruction results from impaired gut motility [1, 31. The two pathophysiologic types of this motility disorder are myopathic and neuropathic. The latter may affect extrinsic or intrinsic neural control of gut motility [1, 31. Long-term survival is possible with careful attention to modern methods of nutrition, be they enteral or parenteral [2]. However, liver failure or a lack of vascular access may limit the possibilities of total parenteral nutrition. In such cases, an intestinal transplant may be indicated. This has, in fact, already been carried out in several cases [4]. In addition to the enormous immunological problems invariably associated with bowel transplantation, this procedure is rendered even more complex by the fact that the underlying motility disorder may affect all parts of the gastrointestinal tract, i. e., the esophagus, the stomach, and the colon [l]. After revascularization of an intestinal allograft, the proximal end of the grafted gut is usually anastomosed to the first loop of the recipient jejunum and the distal end exteriorized for biopsy monitoring [5] . For restoration of the alimentary tract, sufficient gastric emptying must be achieved. For patients in whom the disease directly affects the gastric motor activity, total gastrectomy with anastomosis of the esophagus to the proximal end of the transplant could solve the problem. In such a situation, however, major problems may arise when the graft is irreversibly rejected and must therefore be removed. We thus searched for a technique that would enable us to overcome the problem of insufficient gastric emptying and permit us to restore the upper alimentary tract in such a way that distal exteriorization of the esophagus could be avoided in case of graft loss.