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3823 results in Surgery

Page 115 of 192

  • Chapter 25 - Long-term management and outcomes

  • from Section 4 - Liver
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 212-219

  • Summary

    Bilateral living donor lung transplantation in which two healthy donors donate their right or left lower lobes is an alternative to cadaveric transplantation. The most common procedure involves a right lower lobectomy from a larger donor and a left lower lobectomy from a smaller donor. Potential donors should be competent, willing to donate free of coercion, medically and psychosocially suitable, and fully informed of risks, benefits, and alternative treatment available to the recipient. All recipients should fulfill the criteria for conventional cadaveric transplantation. Due to possible serious complications in the donor lobectomy, living donor lobar lung transplantation (LDLLT) should be reserved for critically ill patients who are unlikely to survive the long wait for cadaveric lungs. Postoperative immunosuppression usually consists of triple-drug therapy with cyclosporine (CyA), azathioprine (AZA) and corticosteroids without induction. LDLLT may be associated with a lower incidence of Bronchiolitis obliterans syndrome (BOS), especially in pediatric patients.

  • Chapter 24 - Peri-operative care and early complications

  • from Section 4 - Liver
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 199-211

  • Summary

    This chapter outlines the pathophysiology of liver disease as it affects patient selection and management in the peri-operative period and key aspects of anesthetic, surgical, and early postoperative care. The most important early complications are primary non-function, hepatic artery thrombosis, and bleeding. Pulmonary hypertension is seen in up to 20% of adult liver transplant candidates and is usually identified by transthoracic echocardiography. Full multi-system assessment should be performed before listing for transplantation, and the patient reviewed when a donor liver becomes available. Management of liver transplant recipients between transplantation and discharge is usually undertaken by a multi-disciplinary team that includes intensivists, hepatologists, and transplant surgeons. Most liver recipients are transferred to the intensive care unit (ICU) for postoperative care. Sepsis is common after transplant and is frequently associated with liver dysfunction. Culture results from the donor and targeted antimicrobial treatment should be considered in recipients with unusual presentations of sepsis.

  • Chapter 29 - Live donor kidney donation

  • from Section 5 - Kidney
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 248-252

  • Summary

    This chapter presents a commentary on the lung-specific complications following transplantation and this should be used to drive the investigation plan and management. Shared care protocols with effective communication should be organized in patients who live at a distance from the transplant center to ensure that local follow-up includes monitoring of the lung function and imaging. Acute rejection can be identified on lung biopsies obtained via transbronchial biopsy (TBBx) at fiberoptic bronchoscopy. Many transplant centers perform regular bronchoscopy and TBBx in addition to spirometry in the first year to enable early diagnosis and treatment of asymptomatic rejection, with the aim of preserving graft function and protecting against bronchiolitis obliterans syndrome (BOS). Recently the importance of detecting early, subclinical BOS before irreversible fibroproliferative disease has become established has been recognized, and a new stage of BOS 0-p has been added.

  • Chapter 31 - Peri-operative care and early complications

  • from Section 5 - Kidney
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 258-264

  • Summary

    A stringent process of selection of appropriate candidates for liver transplantation is necessary for a number of reasons. This chapter discusses deceased organ transplantation in adults. In liver transplant practice, a distinction needs to be made between the process of selection of appropriate candidates for transplant, which is the main focus of the chapter, and that of organ allocation for those candidates who have been placed on the waiting list for the procedure. Both of these processes are underpinned by similar considerations with respect to the relevant clinical end points and ethical standpoints. The practice of candidate selection and organ allocation is predicated on two fundamental ethical principles: justice (or equity) and utility. Most liver transplant programs have adopted the Milan criteria for selecting patients with hepatocellular carcinoma (HCC) for transplantation. Rarely, patients with heart and liver failure will be considered for combined heart-liver or heart-lung-liver transplant.

  • Chapter 18 - Postoperative care and early complications

  • from Section 3 - Lung
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 145-154

  • Summary

    Donor to recipient matching is based primarily on ABO blood group compatibility. Median sternotomy is the standard approach for heart transplantation. Although the surgical technique of heart transplantation is simple, there are certain specific circumstances in which the operation can be technically demanding and require careful planning to get the best outcome. Ventricular assist devices (VADs) are more commonly used as a bridge to transplantation, and many patients wait for heart transplantation with a functioning VAD or are listed for urgent procedure due to VAD-related complications. Heart-lung transplantation and domino heart transplantation have largely been superseded by bilateral sequential lung transplantation. Heterotopic transplantation allows much more leniency on the donor and recipient mismatching. Careful consideration should be given to the adequacy of cardiac output in maintaining oxygen delivery to the tissues, bleeding, collections, pneumothorax, and position of the monitoring lines.

  • Chapter 6 - Recipient selection

  • from Section 2 - Heart
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 63-69

  • Summary

    Transplantation of organs represents the pinnacle of medical achievement in so many different ways. This chapter presents historical perspectives of organ transplantation such as abdominal organ transplantation, cardiothoracic transplantation, combined heart and lung transplantation and lung transplantation. The area of skin grafting became of greater importance for the treatment of war burns and other injuries, and the death from kidney disease also provided impetus to focus once more on kidney transplantation. The successful intrathoracic transplantation of the heart without interrupting the circulation led to the idea that a cardiac allograft might be able to assume some of the normal circulatory load. The indications for transplantation are widening, and although kidney, liver, heart, and even lung transplantation is now seen as routine, the necessary skills are being developed to transplant other organs, such as the small intestine, pancreas, face, hand, and uterus.

  • Chapter 21 - Recipient selection

  • from Section 4 - Liver
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 173-181

  • Summary

    Heart transplantation has excellent long-term survival, with 50% of patients living 10 years, and significant improvement in quality of life. Various factors contribute to increased early graft failure and morality, including changing donor and recipient profiles in recent years. Changes in recent years that have improved very long-term survival include modern immunosuppression, statin use, systematic post-transplant care/surveillance, and better management of renal dysfunction. The long-term complications following heart transplantation are similar to those of other organ transplants and include vasculopathy and complications of immunosuppressants. Coronary artery vasculopathy (CAV) is a leading cause of graft failure. The incidences of various metabolic syndrome risk factors including hypertension, obesity, diabetes mellitus, and hyperlipidemia are increasingly seen after heart transplantation. Acute and chronic renal failures are common after heart transplantation. Malignancy is a major cause of late morbidity and mortality after heart transplantation. Involvement of psychological and psychiatric support is important following heart transplantation.

  • Section 7 - Other

  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 313-334

  • Summary

    In recent years, face transplantation has become a clinical reality and in the future may become a standard procedure. Composite tissue allotransplantation (CTA) is a new developing field of modern plastic and reconstructive surgery. A series of cadaver dissections were performed in preparation for face transplantation. Using computer-based models, the face looks neither like the donor nor the recipient prior to injury, but carries more of the characteristics of the recipient skeleton than of the donor soft tissues. Imaging is required to analyze the details of the facial defect and determine necessary structures for allotransplantation. To date there have been two scalp transplants and 14 facial allotransplantation cases reported in the literature and in media. Functional MRI, electromyography studies, and volumetric analysis are objective measures of motor recovery of facial units, whereas temperature testing and Semmes-Weinstein monofilament tests are used to monitor the sensory recovery of the facial allograft.

  • Chapter 5 - Organ donor management and procurement

  • from Section 1 - General
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 53-62

  • Summary

    This chapter discusses the physiological changes of brain death, the management of complex patients, the organization of the recovery, and new technologies that may allow increased number of organs available for transplantation. Most lethal brain injuries follow a common pathway whereby a patient suffers brainstem death secondary to sudden or gradual increases in intracranial pressure (ICP). Hemodynamic instability seen after brain death is also consequent to loading conditions imposed on the heart. The physiological changes of brain death have direct and indirect effects on lung function. Traumatic brain injury accounts for one third of all trauma related deaths. Early assessment of renal and liver quality is performed in cases of donor death secondary to trauma, exclusion of liver injury. It has been shown that treatment of ex vivo human lungs with an adenoviral vector encoding for interleukin (IL)-10 decreased inflammatory cytokine expression and led to significant improvements in graft function.

  • Chapter Chapter 27 - Recipient selection

  • from Section 5 - Kidney
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 231-237

  • Summary

    Thoracic epidural analgesia should be considered in all cases, but may be most safely sited postoperatively. In addition to the usual anesthetic issues of aspiration risk, airway assessment, comorbidities, medications, and adverse reactions, assessment on the day of surgery focuses on the current illness state and amount of deterioration since investigations were performed, as the patient's physical state may be significantly worse than investigations may suggest. Mandatory monitoring includes five-lead electrocardiography, pulse goniometry, invasive measurement of arterial, central venous, and pulmonary artery (PA) pressures; urine output via an indwelling catheter, temperature, oceanography, pyrometer and anesthetic agent gas analysis. Maintenance of anesthesia by protocol infusion, inhalational anesthetic agent, or both has been described. Most patients with end-stage parenchyma lung disease can get symptomatic improvement with single lung transplantation (SLT). Primary graft dysfunction (PGD) is a devastating complication akin to acute lung injury due to the transplantation process.

  • Section 6 - Other abdominal organs

  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 286-312

  • Summary

    A successful pancreas transplant produces a normoglycemic and insulin-independent state virtually immediately after revascularization. There are important considerations of pancreas transplantation that currently precludes it as therapy for all patients with type 1 diabetes mellitus (DM1). Vascular thrombosis is a very early complication typically occurring within 48 hours. Transplant pancreatitis occurs to some degree in all patients. Bleeding from the vascular anastomotic site or cut surfaces of the pancreatic graft will result in an intra-abdominal hematoma. Peri-pancreatic infections can result in development of a mycotic aneurysm at the arterial anastomosis, which may rupture, and requires allograft pancreatectomy. The outcome of pancreas transplantation with respect to graft survival and rejection rates is dependent on the choice of immunosuppression agents used. The durability of the transplanted endocrine pancreas has been established with the demonstration that normalization of HbA1c is maintained for as long as the allograft functions.

  • Chapter 19 - Long-term management and outcomes

  • from Section 3 - Lung
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 155-163

  • Summary

    Heart transplantation is considered emergency surgery, and there is often little time for extensive evaluation in the immediate preoperative period. This chapter covers the preoperative considerations and reviews the intraoperative management of heart transplant patients. Patients with severe heart failure are often on many drugs, including diuretics, angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists. Many of these drugs interact with anesthesia and should be taken into account. Following pre-anaesthetic assessment, induction of anesthesia should be performed after placement of essential monitoring. Initial pharmacological support is required during the period of weaning from cardiopulmonary bypass (CPB), and this initial management is described with ongoing support and choice of agent. After CPB, the transesophageal echocardiography (TEE) should focus on the ventricular function. Finally, there should be a careful and thorough handover to the team taking over the patient's care following transfer to the intensive care unit.

  • Chapter 32 - Long-term management and outcomes

  • from Section 5 - Kidney
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 265-277

  • Summary

    This chapter concentrates on issues that arise from 6 months after transplant onwards and considers issues in the early post transplant period only insofar as they affect long-term management and outcome. With the advent of more powerful immunosuppressive medications and the expansion of the donor pool to include older donors with cardiovascular comorbidity, the impact of human leukocyte antigen (HLA) matching on outcomes in deceased donor transplantation has diminished considerably. Chronic graft dysfunction is the progressive loss of glomerular filtration rate (GFR) beginning months or years after transplantation. Many centers now advocate screening, by urine cytology or BKV polymerase chain reaction (PCR), for the first 2 years after transplantation. Strategies to reduce cardiovascular risk focus on minimizing time on dialysis, prevention and aggressive treatment of traditional cardiovascular risk factors and preservation of graft function. Women with renal transplants should be offered and encouraged to accept regular breast and cervical screening.

  • Chapter 8 - Ventricular assist devices

  • from Section 2 - Heart
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 76-82

  • Summary

    This chapter outlines the events involved in the adaptive and innate immune responses to a transplant and the subsequent mechanisms of rejection, concluding with current clinical and experimental strategies to protect transplants from immune-mediated damage. The recognition of foreign antigens by naive host (recipient) T cells is a principal step in the rejection process. Allorecognition in the presence of costimulation results in the activation and expansion of T-cells that recognize the mismatched donor alloantigens. Immunosuppressive therapy can be credited with the vast improvements in transplant survival. The chapter explores the underlying mechanisms of action in relation to the immunobiology. Newer monoclonal antibodies include alemtuzumab, rituximab, basiliximab, and daclizumab, which target specific T-cell surface proteins. The advances in immunosuppression have improved short- and medium-term graft survival rates and reduced the rates of acute rejection, but this has not been followed by a comparable reduction in long-term graft dysfunction rates.

  • Chapter 13 - Pediatric heart transplantation

  • from Section 2 - Heart
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 112-121

  • Summary

    This chapter discusses the physiological changes of brain death, the management of complex patients, the organization of the recovery, and new technologies that may allow increased number of organs available for transplantation. Most lethal brain injuries follow a common pathway whereby a patient suffers brainstem death secondary to sudden or gradual increases in intracranial pressure (ICP). Hemodynamic instability seen after brain death is also consequent to loading conditions imposed on the heart. The physiological changes of brain death have direct and indirect effects on lung function. Traumatic brain injury accounts for one third of all trauma related deaths. Early assessment of renal and liver quality is performed in cases of donor death secondary to trauma, exclusion of liver injury. It has been shown that treatment of ex vivo human lungs with an adenoviral vector encoding for interleukin (IL)-10 decreased inflammatory cytokine expression and led to significant improvements in graft function.

  • Chapter 16 - Surgical procedure

  • from Section 3 - Lung
  • Edited by Andrew A. Klein, Clive J. Lewis, Joren C. Madsen
  • Book:
    Organ Transplantation
    Published online:
    07 September 2011
    Print publication:
    11 August 2011, pp 133-137

  • Summary

    Advances in surgical techniques, postoperative care, and immunosuppression have led to greatly improved survival following cardiac transplantation in the past two decades. Patients expiring from overwhelming infection have traditionally been excluded from donor evaluation due to potential transmission of pathogens. Studies of donor-related tumor transmission to transplant recipients usually distinguish between central nervous system (CNS) and non-CNS donor malignancies. Case reports have described the transplantation of hearts from donors poisoned with tricyclic antidepressants with satisfactory graft function. Recent case series report a 15-30 percentage prevalence of left ventricular hypertrophy (LVH) in donor hearts accepted for transplantation. LV dysfunction is the most frequently cited reason for non-utilization of potential cardiac allografts. Due to the severe donor organ shortage, with long recipient waiting times, non-standard or marginal donor hearts are increasingly being used for higher risk recipients and critically ill patients, leading to an expansion of both the donor and recipient pools.

Page 115 of 192