CPT® Code 44136

1. Indications

The procedure of intestinal allotransplantation from a living donor, as described by CPT® Code 44136, is indicated for patients who suffer from severe intestinal dysfunction or failure. This may include conditions such as:

• Short bowel syndrome - A condition where a significant portion of the small intestine is missing or has been removed, leading to malabsorption and nutritional deficiencies.
• Intestinal ischemia - A condition characterized by reduced blood flow to the intestines, which can result in tissue damage and loss of function.
• Congenital intestinal defects - Birth defects that affect the structure and function of the intestines, necessitating surgical intervention.
• Severe inflammatory bowel disease - Conditions such as Crohn's disease or ulcerative colitis that may lead to irreversible damage to the intestines.

2. Procedure

The procedure for intestinal allotransplantation from a living donor involves several critical steps, each designed to ensure the successful transplantation of the donor intestine into the recipient. The first step involves the entry into the abdominal cavity, where the surgeon inspects the area for any adhesions that may need to be lysed. This is crucial for providing a clear surgical field. Following this, the falciform ligament is taken down, allowing for better access to the liver, which is inspected for any abnormalities. The incision is then extended subcostally to the right to facilitate further exploration of the abdominal organs.

• Step 1: The gallbladder is exposed and resected as needed, which may be necessary to provide adequate space for the transplantation.
• Step 2: The cecum is mobilized, and the mesentery is dissected from the retroperitoneal structures to expose the vascular structures that will be involved in the transplantation.
• Step 3: The inferior vena cava is identified and dissected to the level of the renal vein, followed by the dissection of the superior mesenteric and renal veins, and the infrarenal aorta. This meticulous dissection is essential for the placement of grafts.
• Step 4: Arterial and venous grafts are placed on the aorta and inferior vena cava, respectively, to facilitate blood flow to the transplanted intestine.
• Step 5: The donor intestine is then brought into the operative field, where it is anastomosed to the aortic and inferior vena cava grafts, ensuring proper perfusion.
• Step 6: The recipient's native jejunum is resected, and the donor intestine is anastomosed proximally and distally to complete the connection.
• Step 7: Throughout the procedure, any bleeding is controlled to maintain hemostasis.
• Step 8: A gastrostomy tube is placed to provide nutritional support, and the stomach is anchored to the abdominal wall to prevent displacement.
• Step 9: A jejunostomy tube is inserted to facilitate further nutritional intake from the newly transplanted intestine.
• Step 10: The donor intestine is exteriorized in the right lower quadrant through a chimney ileostomy, allowing for the management of intestinal output.
• Step 11: Drains are placed as needed to prevent fluid accumulation, and the incisions are closed securely.
• Step 12: Finally, the gastrostomy and jejunostomy tubes are secured with sutures to ensure stability and proper healing.

3. Post-Procedure

After the intestinal allotransplantation procedure, patients typically require close monitoring in a postoperative setting to assess for any complications, such as infection or rejection of the transplanted intestine. Recovery may involve a gradual reintroduction of nutrition, starting with intravenous fluids and progressing to enteral feeding through the gastrostomy and jejunostomy tubes. Patients will also need to be monitored for signs of graft function and may require immunosuppressive therapy to prevent rejection of the transplanted organ. Follow-up care is essential to ensure proper healing and to manage any potential complications that may arise during the recovery period.