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3823 results in Surgery

Page 116 of 192

  • Chapter 41 - US transplant service – legal and operational framework

  • from Section 8 - The transplant service
  • 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 347-354

  • Summary

    For a patient with end-stage renal disease, the best option is a living donor transplant. The major concern about living donor transplantation is the risk to the donor. The donor operation is a major procedure that is associated with morbidity, mortality, and the potential for adverse long-term consequences, secondary to living with a single kidney. The surgical risks for laparoscopic and open nephrectomy are similar. The most common causes of death have been pulmonary embolism, bleeding, and infection. Living donors report a similar or better quality of life, as compared with the general population. Risk factors for less positive quality of life after donation have also been identified, including poor donor or recipient physical outcome, a negative personal donor-recipient relationship, and financial hardship. Population studies have shown that smoking, obesity, hypertension, and elevated blood glucose levels are associated with an increased risk of proteinuria and kidney disease.

  • Section 8 - The transplant service

  • 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 335-356

  • Summary

    This chapter describes the legal and operational frameworks that are necessary at a national or supra-national level in order to support and regulate organ donation and transplantation. Although there are differences in detail between countries, all those with a well established donation program have in place a legal framework, a national donation system, and processes to ensure quality and safety of organs. The UK Code of Practice is based on the essential prerequisite that the cause of the patient's deep coma must be known. In all European countries, organ transplantation is guided by the overarching ethical requirement known as the dead donor rule which states that patients must be declared dead before the removal of any vital organ for transplantation. Organ allocation rules vary substantially between the different European countries. There are several specific databases in the UK, such as that on antibody-incompatible transplants and the paired-exchange living donor program.

  • Chapter 10 - Management during surgery

  • 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 88-93

  • Summary

    This chapter is based on the study of data collected by Cincinnati Transplant Tumor Registry (CTTR) and the available literature published by both North American and European organ transplant centers. It reviews the characteristics of the most important de novo malignancies in organ allograft recipients. The most frequent cancers in transplant recipients are skin and lip cancer, solid organ malignancies, and post-transplant lymph proliferative disorder (PTLD). Two epidemiological studies have shown a 20- to 40- fold increased incidence of hepatocellular carcinoma (HCC) in transplant recipients compared with age-matched controls. Sarcomas, breast carcinoma, bladder, and bowel cancers are particularly seen after transplantation. Skin cancer is the second most common malignancy after PTLD, and melanomas comprised 16% of all skin cancers in children compared with 5% among adults. Understanding the increased risk of malignancy of transplant recipients, careful surveillance and screening for selected malignancy should be undertaken.

  • 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 122-172

  • Summary

    This chapter focuses on how to select patients who will gain maximum benefit from lung transplantation (LT). It outlines the general considerations and exclusions pertaining to all potential recipients and focuses on disease specific guidance for the major recipient groups: chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), idiopathic pulmonary fibrosis (IPF), and idiopathic pulmonary arterial hypertension (IPAH). Pulmonary infections with highly resistant bacteria have been shown to have poorer outcomes in comparison with non-infected patients. The presence of fungus in the native lungs can cause problems after LT and needs careful assessment in each individual. The presence of comorbidities outside of the failing respiratory system is important considerations that can impact patient outcomes. COPD accounts for approximately 40% of LTs performed, with CF and IPF accounting for 20% each. In the current era there remains a critical shortage of donor organs, and thus unfortunately, recipient selection remains extremely important.

  • Chapter 22 - Living donor liver transplantation

  • 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 182-189

  • Summary

    Heart transplantation remains the only realistic therapeutic option for children with end-stage heart disease. The main indication for transplantation in children is severe heart failure (HF) associated with impaired function of the systemic ventricle. Extensive evidence supports the use of cardiopulmonary exercise testing to select patients with increased short-term mortality who should be offered transplantation. Transplantation for congenital heart disease illustrates best many of the peculiarities of heart transplant in the pediatric age group. The assessment of pulmonary vascular resistance (PVR) is particularly crucial in order to reduce the rate of right HF post-transplant, but it can be technically difficult, particularly in congenital heart disease. Maintenance therapy is commonly a combination of a calcineurin inhibitor (CNI) and cell cycle inhibitor. A problem in pediatric transplantation is the presence of pre-existing human leukocyte antigen (HLA) antibodies, which have been linked to increased hyperacute, cellular, and humoral rejection and increased mortality posttransplant.

  • 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 1-62

  • 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 38 - Hematopoietic stem cell transplantation

  • from 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 320-329

  • Summary

    The preoperative evaluation of kidney transplant candidates involves transplant surgeons, nephrologists, mental health professionals, social workers, dieticians, financial coordinators, and transplant coordinators. There are several absolute and relative contraindications to kidney transplantation. Immunologic evaluation begins with a thorough history of potential antigen exposure, including prior transplantation of any kind, blood product transfusion, and, in female candidates, prior pregnancy. Cardiovascular disease is the leading cause of death, and therefore graft loss, in the first year post transplant. Depending on the malignancy, a disease-free period of between 2 and 5 years is generally accepted as adequate. As the transplanted kidney usually drains into the native lower urinary tract, underlying urologic disease can affect the transplant outcome. In the future, diabetes management via islet cell transplantation, coupled with kidney transplantation, may be considered. A multi-disciplinary approach considering cognitive and other psychosocial factors is necessary to ensure successful transplantation.

  • Chapter 3 - Immunosuppression

  • 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 19-30

  • Summary

    This chapter focuses on current practice, as informed by past experiences and as a basis for understanding newer therapeutics on the horizon. Long-term survival of allograft in humans first occurred with the introduction of azathioprine (AZA). Early use of cyclosporine (CyA) in animals and humans as monotherapy seemed effective in preventing acute rejection crises. Mycophenolate mofetil (MMF) was a new modified preparation of an older agent that enhanced its absorption and stability. Maintenance immunosuppression is the long-term therapy required to ensure allograft survival, administered with the dual intentions of avoiding both immunological injury and drug-related toxicity. Discovery of new agents is informed by our evolving understanding of how immunological processes injure allograft, with substantial attention now being devoted to antibody-mediated injury and lymphoid tissue of B-cell lineage. It is now common to use biologics, such as polyclonal or monoclonal antibodies, for a short time as induction of acute rejection.

  • Chapter 23 - Surgical procedure

  • 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 190-198

  • Summary

    This chapter focuses on how to select patients who will gain maximum benefit from lung transplantation (LT). It outlines the general considerations and exclusions pertaining to all potential recipients and focuses on disease specific guidance for the major recipient groups: chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), idiopathic pulmonary fibrosis (IPF), and idiopathic pulmonary arterial hypertension (IPAH). Pulmonary infections with highly resistant bacteria have been shown to have poorer outcomes in comparison with non-infected patients. The presence of fungus in the native lungs can cause problems after LT and needs careful assessment in each individual. The presence of comorbidities outside of the failing respiratory system is important considerations that can impact patient outcomes. COPD accounts for approximately 40% of LTs performed, with CF and IPF accounting for 20% each. In the current era there remains a critical shortage of donor organs, and thus unfortunately, recipient selection remains extremely important.

  • Chapter 4B - Major complications – pathology of chronic rejection

  • 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 38-45

  • Summary

    Chronic rejection is widely regarded as difficult to diagnose, of obscure etiology, untreatable, and irreversible. The immunological basis of transplant arteriopathy (TA) is under active investigation. The belief that the process is immunologically mediated is based on the observations that TA rarely arises in auto grafts. Three separate and possibly synergistic pathways have been identified: T-cells, antibody-mediated injury, and natural killer (NK) cells. The majority of late kidney graft losses are associated with donor-specific antibodies (DSA) and/or C4d deposition, and the risk of subsequent graft failure is significantly worse after a C4d+ biopsy. Transient lobular hepatitis may also be a feature of chronic rejection and is potentially reversible, although vanishing bile duct syndrome (VBDS) and TA are resistant to current therapy. The lesions of chronic rejection in the lung consist of TA and a lesion occluding airways that is termed obliterative bronchiolitis (OB).

  • 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 63-121

  • Summary

    Heart transplantation (HT) remains the best treatment for selected patients with advanced heart failure (HF). Patients with New York Heart Association (NYHA) class IIIB and class IV HF are best discussed with the local HF/transplant center to optimize medical management and to consider high-risk non-transplant surgery where appropriate. Patients who require HT may have severe ventricular dysfunction. Exercise capacity is known to correlate with prognosis in advanced HF. Chronic HF is associated with a high left ventricular end-diastolic pressure (LVEDP), which in turn leads to pulmonary venous and pulmonary arterial hypertension. The best studied scoring system in the context of predicting the need for HT is the HF Survival Score (HFSS). Older patients run a higher risk of post-transplant malignancy and renal dysfunction as compared with younger recipients. Combined heart-liver transplantation has been increasingly performed, but data on patient and graft outcomes remain limited.

  • Chapter 7 - Donor heart 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 70-75

  • 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.

  • Chapter 15 - Living donor lobar lung transplantation

  • 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 128-132

  • 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 9 - Surgical procedure

  • 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 83-87

  • Summary

    This chapter focuses on current practice, as informed by past experiences and as a basis for understanding newer therapeutics on the horizon. Long-term survival of allograft in humans first occurred with the introduction of azathioprine (AZA). Early use of cyclosporine (CyA) in animals and humans as monotherapy seemed effective in preventing acute rejection crises. Mycophenolate mofetil (MMF) was a new modified preparation of an older agent that enhanced its absorption and stability. Maintenance immunosuppression is the long-term therapy required to ensure allograft survival, administered with the dual intentions of avoiding both immunological injury and drug-related toxicity. Discovery of new agents is informed by our evolving understanding of how immunological processes injure allograft, with substantial attention now being devoted to antibody-mediated injury and lymphoid tissue of B-cell lineage. It is now common to use biologics, such as polyclonal or monoclonal antibodies, for a short time as induction of acute rejection.

Clinical Fluid Therapy in the Perioperative Setting
  • Edited by Robert G. Hahn
  • Published online:
    05 August 2011
    Print publication:
    04 August 2011
  • Clinical Fluid Therapy in the Peri-Operative Setting brings together some of the world's leading clinical experts in fluid management to explain what you should know when providing infusion fluids to surgical and critical care patients. Current evidence-based knowledge, essential basic science and modern clinical practice are explained in 25 focused and authoritative chapters. Each chapter guides the reader in the use of fluid therapy in all aspects of peri-operative patient care. Guidance is given on the correct selection, quantity and composition of fluids required as a consequence of the underlying pathology and state of hydration of the patient, and the type and duration of surgery. Edited by Robert G. Hahn, a highly experienced clinician and award-winning researcher in fluid therapy, this is essential reading for all anaesthetists, intensivists and surgeons.

Page 116 of 192