Operating on immunosuppressed transplantation patient

Section: Surgical Oncology Curriculum: Curriculum, page 73

Issues

• Altered anatomy
• Altered physiology
• Increased risk of infection
• Diagnosis difficult and delayed
• Antimicrobial resistance
• Impaired wound healing
• Suppressed symptoms and signs of post-op complications
• Associated co-morbidities
• Graft function and presence or potential for rejection

Pre-operative

• Multidisciplinary approach
  • Transplant team
  • ICU
  • Anesthetics
  • Infectious diseases
  • Pharmacist
• Preoperative evaluation (thorough review)
  • Original disease
  • Comorbidities
  • Review of previous op note
    • Have all the details of kidney transplant: review their approach, placement of the kidney and any complications that required further treatment (IR drainage, endovascular stenting re-do surgery)
  • Cardiovascular evaluation (can the patient be optimized)
    • Patients history, previous investigations
    • ECG, TTE, Cardiology review
• Diagnosis
  • Insure correct diagnosis
    • Clinical signs and symptoms can be inaccurate in patients with long term immunosuppression
    • May present late with a complication
    • Keep a broad differential and liberal use of CT scan to confirm diagnosis
    • Appreciate alternative diagnosis (opportunistic infections, tumour) are increased in chronically immunosuppressed.
  • Higher index of suspicion regarding complications
• Protect the transplant kidney/liver
  • Serial Cr or liver function
  • Monitor UO
  • Check synthetic function
• Maintain immunosuppression
  • Review the current medication regimen and consider their risk
    • Most transplants are on triple therapy = Steroid + calcineurin +/- Anti-metabolite
      • Kidney typically requires more immunosuppression then liver and so are usaully on triples but liver often on double
    • Corticosteroids
      • Stress dose
    • Calcineurin inhibitor - Ciclosporin and Tacrolimus
      • Nephrotoxicity
    • Antimetabolites - Azathioprine or Mycophenolate Mofetil
      • Bone marrow suppression
      • Gastrointestinal symptoms
    • mTOR inhibitors - Sirolimus and Everolimus
      • Wound healing
      • Thrombocytopenia
  • Immunosuppression should continue to protect the transplant kidney

Management

• Overall
  • Judicious fluid management
  • DVT prophylaxis
  • Abx
  • May need stress dose steriods
  • Glycasemic control
• Surgery
  • Safe surgical techniques
    • Consider altered anatomy
  • Prophylactic antibiotics
  • Wound healing
    • Leave staples/sutures in longer
  • Consider staged or minimally invasive therapies

Intra-operative

• Abnormal anatomy
  • Low threshold to get cross sectional imaging: not only gives road map but also help clarify diagnosis
  • Kidney
    • Transplant kidneys usually placed right pelvis, via extraperitoneal
  • Liver
    • RUQ adhesions
• Approach
  • Laparoscopic an option but low threshold to convert to open
  • May displace normal anatomy e.g appendix
  • If history of peritoneal dialysis: likely difficult access

Avoid complications

• Meticulous hemostasis and wound closure
• Utilize endocatch bag to remove specimen
• Simple interrupted nylon sutures for skin, for ease of removal if infections arise

Post-operative

• Immunosuppression
  • Continue regular
  • Increase steroids
  • Careful monitoring of levels
• Kidney function
  • Careful fluid balance to ensure transplant kidney is protected
  • Any physiological derangements will affect transplant kidney therefore team should be on high alert
  • Close liaison with renal physicians
• Complications
  • Wound complications
    • Detect and treat early,
  • Intra Abdominal sepsis
    • May be difficult to detect clinally, monitor laboratory and vital signs
    • Low threshold for post-operative CT to rule out collections, hematomas
• Atypical infections
  • Increased risk of atypical infection
  • Early consultation with ID and transplant team
  • Chase histology and review for possible unusual diagnosis
• Prevention
  • Mobilize early: prevent complications
  • Ensure good nutrition (as they chronically malnutrition)

Appendices question

A 55 year old woman presents with right lower quadrant abdominal pain. She has a clinical picture consistent with acute appendicitis. Her past medical history includes being a recipient of a renal transplant 2 years previously. a) What do you need to consider before taking her to theatre? b) What operative challenges might you encounter? c) What issues may need to be addressed postoperatively?

a) Things to consider: Correct diagnosis

• Clinical signs and symptoms are highly inaccurate in patients with long term immunosuppression
• May present late with a complication of appendicitis (abscess, phlegmon)
• Keep a broad differential and liberal use of CT scan to confirm diagnosis
• Close monitoring and re-investigation if clinical course changes

Protect the transplant kidney

• Prone to acute kidney injury in setting of sepsis
• Should have careful U.O monitoring and fluid balance with IDC, and serum creatinine

Maintain immunosuppression

• Review the current medication regimen and consider their risk
  • mTOR inhibitors have high risk with non-healing wounds and should be switched to another drug - liaise with transplant team
• Immunosuppression should continue to protect the transplant kidney
• If long term steroid use, stress dosing of steroid should be considered in perioperative setting

Review of previous op note

• Have all the details of kidney transplant: review their approach, placement of the kidney and any complications that required further treatment (IR drainage, endovascular stenting re-do surgery)

b) Operative challenges Abnormal anatomy

• Transplant kidneys usually placed right pelvis, via retroperitoneal approach
• May displace the appendix from its usual location,
  • Put the camera port first and assess the best triangulation and place the working ports accordingly
• Transplanted ureter may be in close proximity - need to watch out

Avoid complications

• Meticulous hemostasis and wound closure
• Utilize endocatch bag to remove specimen
• Simple interrupted nylon sutures for skin, for ease of removal if infections arise

c) Kidney function

• Careful fluid balance to ensure transplant kidney is protected
• Any physiological derangements will affect transplant kidney therefore team should be on high alert

Wound complications

• Detect and treat early,

Intra Abdominal sepsis

• May be difficult to detect clinally, monitor laboratory and vital signs
• Low threshold for post-operative CT to rule out collections, hematomas

Atypical infections

• Increased risk of atypical infection
• Early consultation with ID and transplant team

A Barlett comment

Clinical signs and symptoms

• can be obtunded by immunosuppression, not inaccurate
• May have less of an inflammatory response (fever, WBC and CRp)
• and increased likelihood of more advanced peritonitis (perforation), esp. On steroids
• Higher index of suspicion regarding complications

What is their graft function:

• serial creatinine check

What immunosuppression are they on: usually triple

• Steroids, calcineurin inhibitor CyA or tacrolimus + anti-metabolise AZA or mycophenolate:
• rarely on mTOR inhibitors.
• agree on affect wound healing, but don’t stop: need to consider it in operative approach

Need to increase steroid dose:

• As suppression of adrenal axis having been on long term steroids, esp if septic and requiring surgery

Prior surgery:

• agree: KTx usually placed extraperitoneal ,
• can occasionally be placed intraperitoneally,
• also given most commonly placed RIF: need to be sure pain/peritonism in RIF isn’t graft or complications of KTx

Operative challenges:

• not retroperitoneal, rather extraperitoneal:
• low threshold to get cross sectional imaging: not only gives road map but also help clarify diagnosis:
• agree preference would be laparoscopic but low threshold to convert to open:
• D/W senior colleague prior to starting (seek assistance early):
• appreciate alternative diagnosis (opportunistic infections, tumour) are increased in chronically immunosuppressed.
• If hx of peritoneal dialysis: likely difficult access

Postoperative:

• Continue regular immunosuppression
• Increased steroids to account for stress response
• Careful monitoring of immunosuppression levels
• Strict fluid balance
• Close liaison with renal physicians
• Mobilize early: prevent complications
• Ensure good nutrition (as they chronically malnutrition)
• Chase histology and review for possible unusual diagnosis