Native Jejunal Conduit for Urinary Diversion in Enbloc Liver-Intestine-Kidney Transplantation for a Patient with Irradiation Enteritis and Cystitis

Background: Recipients requiring kidney-enbloc visceral allograft often face challenges during transplantation. We report a case with a unique technique of urinary diversion in enbloc liver-intestine-kidney transplantation for irradiation enteritis and cystitis. Methods: The patient is a 65 year-old man with Crohn’s disease and history of anal adenocarcinoma treated with abdominoperineal resection and adjuvant chemo- and radiotherapy. Case will be presented with pictures and/or video. Results: The patient developed gut failure due to short gut and multiple bowel obstructions secondary to radiation enteritis. Urinary incontinence developed after irradiation caused frequent urinary tract infection leading to kidney failure. He was listed for combined liver-intestine-kidney transplantation and received en-bloc allograft from a 35 year-old male brain-dead donor. During evisceration of native organs, frozen abdomen was encountered and subtotal enterectomy leaving 30 cm of jejunum was performed. Urinary bladder was rock hard with no augmentation, unacceptable to implant the allograft ureter. Arterial inflow was established with an aortic conduit between the native and allograft infra-renal aorta. The native jejunum was transected at 10 cm and the proximal segment was connected to allograft jejunum to establish the continuity of alimentary tracts. The distal 20 cm of native jejunum was anastomosed to allograft ureter for urinary diversion.Postoperative course was unremarkable with adequate urinary output and allograft functions. The patient was well rehabilitated in hospital due to lack of safe rehabilitative facilities during COVID pandemic and discharged home on post-operative day 47. Conclusion: Combined kidney and visceral transplantation in the setting of irradiated bladder requires pre-operative planning of urinary reconstruction with several options. When native intestine is available and not damaged from original disease, urinary diversion using the native jejunum is the safest option amongst others including cystoplasty and urinary diversion using allograft ileum.