Solid organ transplantation

The field of organ transplantation has been revolutionized over the past decades. Major advances have been made in surgical technique, immunosuppressive management, prevention and treatment of the infections that occur in the immunocompromised host, as well as in the screening and selection of candidates for transplantation. These advances have translated into a steady improvement in organ and patient survival, and have allowed transplantation to be made available to an increasing number of patients. This chapter will review lung, liver, kidney, and pancreas transplantation with a special emphasis on perioperative medical care.

Lung transplantation

Introduction

Lung transplantation (LTx) is the standard of care for end-stage lung diseases that do not respond to conventional medical or surgical treatments. The annual number of lung transplants has significantly increased to approximately 2,800 worldwide due to consistent growth in the number of bilateral lung transplants (BLTx) during the past 15 years [1,2]. Of the 28,664 solid organ transplants performed in the USA in 2010, 1,770 were adult lung transplants [3].

For end-stage lung diseases, LTx offers better survivaland quality of life. As the technical difficulties with surgeryhave been addressed and critical care management improved,the first-month mortality has declined to 5–7% resulting in3 month-, 1-, 5-, and 10-year survivals of 92.6%, 84%, 53.5%,and 27% respectively [2]. Long-term survival continues tobe limited due to chronic rejection (bronchiolitis obliteranssyndrome) and ensuing recurrent infections [4].

Candidates should have end-stage lung disease with limitedlife expectancy of 12–24 months despite optimal medical therapy.Disease-specific selection guidelines can be found in theliterature [5]. Since 2005, a new lung allocation algorithm wasinitiated in the USA based on the diagnosis, severity of illness,and net transplant benefit within 1 year. Diagnostic groups are summarized in Table 42.1. Median time to transplant variesand is less than 35 days for those in the highest quartile [6].

During surgery there is a coordinated response to stress that includes the nervous, endocrine, and immune systems. Inappropriately low response or inappropriately excessive response to stress may lead to disease and possible premature death [1,2]. The hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic nervous system react to stress by releasing hypothalamic CRH and vasopressin (AVP). These hormones synergistically stimulate systemic ACTH secretion, which, in turn, stimulates the adrenal cortexes to secrete glucocorticoids. Central activation of the sympathetic neurons leads to activation of both the systemic sympathetic nervous system and the adrenal medullae [2,3]. The immune system through inflammatory mediators, especially cytokines, stimulates the release of corticotropin-releasing factor from hypothalamic neurons. This central activation of the HPA axis and the direct stimulation of the adrenal glands by the sympathetic system may be a regulatory mechanism for preventing an excessive immune reaction [4,5].

Adrenocorticotropic hormone (ACTH) is released in quick, pulsatile bursts followed by a slower, more sustained rise in cortisol and metabolites [6,7]. Free cortisol is the active hormone and acts directly on tissues [6]. Normal ACTH release and production of cortisol follows a circadian rhythm and is connected to light. It is the highest on awakening in the morning (peaking about 8 hours after the onset of sleep), declines over the day, and is lowest in the middle of the night [7]. The cortisol secretory pattern is usually resistant to acute change. Prolonged bed rest, continuous feeding, or 5 days of fasting, do not alter the rhythm [8]. Occasionally, abrupt time changes of the sleep–awake cycle, as during shift work rotations and jet lag, may have some effect on the 24-hour cortisol patterns [9–11]. Critical illness, chronic inflammatory conditions, chronic insomnia, coronary artery disease, and severe stress often alter the daily rhythm [12–14]. These conditions exert their effect by cytokines, interleukins, and tumor necrosis factors. Circulating interleukin-6 is a potent activator of the HPA axis. By stimulating pituitary ACTH and therefore cortisol, response to inflammation can enhance resistance to inflammatory disease, while a decreased or defective response can increase susceptibility [4,5,13].

In addition to treating critical injuries, major hepatic resection is performed to remove malignant neoplasms (hepatoma, cholangiocarcinoma, metastases, carcinoid tumor), benign neoplasms (liver cell adenoma, focal nodular hyperplasia, cavernous hemangioma), cysts (congenital, multicystic disease, echinococcal), and certain abscesses. If the remaining hepatic tissue is normal, as much as 80–90% of the liver can be removed in children and adults.

The availability of MRI and CT scans is leading to earlier detection of hepatocellular carcinoma or hepatic metastases from colorectal cancer. Other biochemical measurements such as elevated alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) may prompt earlier imaging.

Preoperative screening with MRI for major hepatic resectionsis very sensitive in detecting small nodules, showing therelationship between tumor nodules and major intrahepaticand retrohepatic blood vessels, and determining resectability.MRI can also be used to assess volume reserve in patients withcirrhosis who need major hepatic resection.

Major hepatic resection is performed under general anesthesiathrough an upper abdominal incision for left lobe resection,and a right subcostal resection for right lobe resection. Inskilled centers, minimally invasive techniques have been usedsuccessfully for major resections. The general stages of majorlobectomy include either vascular inflow occlusion (Pringlemaneuver or clamping of the porta hepatis) or individualligation of the lobar hepatic artery, portal vein, and right orleft branch of the hepatic duct. Division of the hepatic parenchymais accomplished using finger fracture techniques, bluntknife handle dissection, cutting staplers, and ultrasonicvibrating-suction device or ultrasonic shears. Blood lossdepends on the extent of the resection and involvement ofthe retrohepatic vena cava. The median blood loss was 600mL in one recent large series, and only 49% of patients weretransfused at any time. In general, intraoperative fluid restrictionreduces back-pressure bleeding during major hepaticresection. The operative time is 3–4 hours in experiencedhands, and the stress of a major hepatic resection is moderateto severe.

The treatment of hip fractures is the prototype for the orthopedic management of geriatric patients. Because of the demographics of the USA (increasing age of the population), the incidence of hip fractures will increase in the next few decades, with the yearly incidence increasing to 500,000 in 2040 from 250,000 in 1990. Prevention of hip fractures is becoming increasingly important due to significant morbidity and mortality associated with a hip fracture. Modalities that have been shown to decrease the incidence of geriatric hip fractures include analysis of conditions that predispose to falls, prevention, and treatment of bone fragility, and, possibly, the use of hip protectors. Therefore, especially in patients who already have sustained a hip fracture, reviewing the patient's medications to identify those that may interfere with cognition and balance (e.g., diazepams), evaluating eyesight (poor vision may predispose to a fall), and diagnosing and treating osteoporosis may decrease the risk of subsequent hip fractures.

Classification of hip fractures

It is not the purpose of this chapter to discuss the complete classification of hip fractures and subsequent treatment; however, it is useful to describe hip fractures and the goal of surgical treatment. Femoral neck fractures occur mostly in elderly patients; displaced fractures often are treated with arthroplasty to avoid the known complications of non-union and avascular necrosis and to allow for immediate ambulation. Intertrochanteric hip fractures are almost always treated with internal fixation. This intervention provides a high union rate; with newer implants, unrestricted weightbearing is usually allowed. The goal of treatment of all geriatric hip fractures is a rapid return to the pre-injury ambulatory status, as this has been shown to decrease the morbidity of hip fractures.

Surgical resection remains the treatment of choice for most thyroid tumors. Goiters and thyroid nodules are problems of enormous magnitude, present in more than 7% of the world's population. Tracheal compression from goiter may respond only to thyroidectomy, and thyroid nodules may harbor carcinoma, occurring in approximately 15% of solitary thyroid nodules and 5% of multinodular goiters.

Thyroid nodules have an annual incidence of 90 per million (approximately 29,000 new cases of thyroid carcinoma occur each year in the USA). The overall mortality is low, four per million per year (approximately 1,000 deaths per year in the USA). In patients with thyrotoxicosis a thyroidectomy can result in an expedient return to a euthyroid state. Included among these are children and women of childbearing age with Graves' disease, those who have failed medical or radioiodine therapy for Graves' disease, those with toxic multinodular goiter (Plummer's disease), and those with toxic adenomas. For the most part, goiter is a benign process, responsive to iodine repletion therapy. However, subtotal or total thyroidectomy is conventional therapy for hyperthyroidism and symptomatic goiter, particularly for patients with ophthalmopathy, or when airway compromise is present. Thyroid lobectomy is generally reserved for benign thyroid nodules or other, appropriately selected clinical circumstances.

Pheochromocytomas are not a common medical/surgical problem. They are estimated to cause only 0.1–0.5% of all cases of hypertension [1,2], and are seen in 4–7% of patients with incidentally found adrenal adenomas [2,3]. That being said, at some time in their careers medical consultants are likely to be asked to evaluate a patient with a suspected pheochromocytoma. Because catecholamines have major regulatory effects on many different body systems, it is vital that these be anticipated and properly managed in the perioperative period. Pheochromocytomas are associated with an increased risk of adverse reactions to many commonly prescribed drugs and clinicians must also be aware of this potential hazard. The removal of a pheochromocytoma has great potential for complications, both during and after surgery because of the release of catecholamines during manipulation or stimulation of the tumor.

Pathophysiology

Pheochromocytomas arise from chromaffin cells of the neural crest that migrate to form the adult adrenal medulla and sympathetic ganglia. These cells synthesize catecholamines through a series of enzymatically controlled steps, starting with the conversion of tyrosine to dihydroxyphenylalanine (dopa) by tyrosine hydroxylase. This is the rate-limiting step in catecholamine synthesis. Dopa is then converted to dopamine, which is subsequently decarboxylated to norepinephrine. The methylation of norepinephrine to epinephrine is accomplished through the action of phenylethanolamine-N-methyl transferase, an enzyme that is induced by glucocorticoids that reach the adrenal medulla in high concentrations through the corticomedullary venous sinuses from the adrenal cortex. Norepinephrine and epinephrine are the major products of most pheochromocytomas [4]. Epinephrine is produced mainly in the adrenal medulla; thus, a pheochromocytoma that produces epinephrine is nearly always located in the adrenal gland. Norepinephrine is produced and secreted in the central nervous system and the sympathetic post-ganglionic nerve endings as well as in the adrenal medulla. Dopamine is also produced and secreted by some pheochromocytomas. The metabolism of catecholamines takes place mostly in the same cells where the catecholamines are synthesized [4]. Once catecholamines reach the plasma, they have a half-life of only 1–2 minutes before they are taken up by cells or enzymatically degraded [5]. Metanephrine, normetanephrine, and vanillylmandelic acid are the major metabolites.

Liposuction is one of the most popular treatment modalities in aesthetic surgery in the USA. According to the American Society for Aesthetic Plastic Surgery, more than 341,000 liposuction procedures were performed in 2008 and it was ranked second among all invasive cosmetic procedures. Liposuction is used to recontour specific areas of the face and body by removing unwanted deposits of fat. It is best performed on localized areas that do not respond well to diet or exercise, and it is not an alternative to weight loss. The ideal liposuction patient is healthy, exercises, eats a well-balanced diet, has good skin elasticity, desires treatment of minimal-to-moderate localized fat deposits, and is within 20–30% of ideal body weight.

The patient consultation includes evaluation of the patient's goals and realistic expectations. The history is performed to evaluate the patient's suitability for surgical intervention. The physical exam is best performed in front of a mirror to stimulate dialogue and understanding of patient concerns and to reiterate realistic expectations. The exam should detail prior scars, evaluate for hernias, rule out venous insufficiency, and document asymmetry and contour irregularities. It is also important to evaluate skin quality and amount of excess skin. Patients with good skin tone and without excess skin are more likely to have better results. Medical images should be obtained for objective comparison and documentation of postoperative results.

Cardiac transplantation and ventricular assist device therapy have become effective therapeutic options for patients with end-stage heart failure. Unfortunately, due to the shortage of organ donors, the annual number of heart transplants in the USA has remained relatively constant, between 2,200 and 2,400.

The development of implantable left ventricular assist devices (LVADs) for use as mechanical circulatory support also spanned several decades, dating back to the 1960s. However, LVADs were only applied for clinical use on a more routine basis in the mid 1980s. Since then, research and development of VAD technology continues to advance as the clinical experience with LVADs evolves over time. The number of LVADs being implanted in the USA continues to grow, with more than 1,000 devices implanted annually.

Heart transplantation and VAD therapy are complementaryforms of therapy. Patient selection for both requiresextensive evaluation by a multidisciplinary team. Transplantationis reserved for a group of patients with end-stage heartdisease not amenable to optimal medical or surgical therapies.The indications for heart transplantation include patientswith symptomatic New York Heart Association (NYHA)class III to IV heart failure despite optimal medical therapy,inability to wean from inotropic therapy, poor functionalstatus on exercise testing, refractory ventricular arrhythmia,severe coronary artery disease with poor short-term prognosis,or complications of congenital heart disease that are refractoryto medical and surgical intervention.

Clinical scenario

Ms. P is a 49-year-old-female with obesity and depression who has arrived this morning for her elective cholecystectomy. She initially presented to Surgery Clinic following hospitalization for cholecystitis that was managed medically. Your colleague saw her in clinic and after a discussion of possible options, he scheduled her for the surgery 2 weeks later. His note documents that he discussed “the surgery, the risks, and likely outcomes.”

In the preoperative area the patient is notably nervous about surgery, but wants to be rid of her right-upper quadrant pain. Just prior to surgery you approach her with a consent form in hand. You ask, “Do you have any questions about the surgery, prior to signing the consent?” She responds, “No, he said my pain would go away after putting a few holes in my belly.” She signs the consent form and you walk back to the operating room.

Introduction

Postoperative pulmonary complications are defined as pulmonary abnormalities occurring in the postoperative period that produce clinically significant identifiable disease or dysfunction that adversely affects the clinical course [1]. The definition includes pneumonia, atelectasis, respiratory failure, pulmonary embolism, pleural effusion, pneumothorax, pulmonary edema, and hypoxemia. These problems complicate approximately 2–3% of all surgeries varying with the invasiveness of the procedure and the presence of patient-related risk factors [2]. Pulmonary complications are described in 19–59% of thoracic procedures, 16–17% of upper abdominal surgeries, but only 0–5% of lower abdominal procedures [1]. They are most commonly seen in the first week after surgery, especially in the first 24–72 postoperative hours and can be particularly problematic because attention may be relaxed after transfer from a post-anesthesia care unit.

Taken together, they are the most expensive form of postoperative complication, are more common than postoperative cardiac complications, lead to longer hospital stays, and increase the relative risk of death to 14.9 (95% confidence limits 4.76–26.9) particularly from pneumonia [3]. They may cause as much as 84% of postoperative thoracotomy deaths [1].

The most common indication for an esophagogastrectomy is esophageal cancer. Other indications include Barrett's esophagus with high-grade dysplasia, non-dilatable esophageal stricture, and irreparable esophageal rupture. There are multiple surgical techniques that present specific advantages and disadvantages. However, the postoperative management and complications associated with any esophagogastrectomy are very similar. The two most common methods for removing the esophagus are the transhiatal esophagectomy (THE), which consists of incisions on the neck and abdomen, and the Ivor Lewis esophagectomy (ILE) which consists of a laparotomy and a right lateral thoracotomy. Both approaches allow resection of the esophagus and mobilization of the gastric conduit. The stomach is the typical conduit used for the neo-esophagus; however, the colon and jejunum may also be used if the stomach is not ideal. Preoperative gastrostomy tubes should be avoided since they can damage the stomach and prohibit its use as the preferred replacement conduit.

The esophagus must be carefully dissected away from other mediastinal structures. Esophageal blood supply originates from small branches off the aorta. Vasoconstriction often controls these small vessels when bluntly transected; otherwise, simple electrocautery suffices. To mobilize the stomach as a conduit, the short gastric, left gastroepiploic, and left gastric arteries are sacrificed. The stomach blood supply is maintained by the carefully preserved right gastroepiploic and right gastric arteries. The stomach is fashioned into a gastric conduit by stapling along the lesser curve of the stomach to create a tubularized gastric conduit. Oversewing the gastric staple line is theorized to reduce gastric conduit leak. Since the gastric conduit is denervated, a gastric emptying procedure should be considered. Either a pyloromyotomy or pylorplasty is most commonly done. Botox injection of the pylorus has also been used to facilitate conduit emptying during early healing. The duodenum is often mobilized with a Kocher maneuver to provide additional conduit length and reduce tension. The gastric conduit is passed through the esophageal hiatus into the native esophageal bed in the posterior mediastinum. Alternate routes for the conduit include the chest hilum and subxyphoid pathways. An esophagogastric anastamosis is performed in the chest for ILE; in the neck for THE. Hand sewn, stapled, and combination anastomoses have been described.

Uterine curettage is the second most frequently performed gynecologic procedure. The primary indications for uterine curettage are both diagnostic and therapeutic:

1. Polymenorrhea: menstrual cycle interval less than 21 days.

2. Oligomenorrhea: menstrual cycle interval more than 37 days.

3. Menorrhagia: excessive or prolonged menstrual bleeding.

4. Postmenopausal bleeding: uterine bleeding occurring more than 12 months after the last menstrual period in a menopausal woman.

5. Breakthrough bleeding: intermenstrual bleeding in a menstrual cycle that is the result of exogenous hormones.

6. Dysfunctional uterine bleeding: any abnormal uterine bleeding in the absence of pregnancy, neoplasm, infection, or uterine lesion.

7. Other: spontaneous abortion, incomplete abortion, inevitable abortion, fetal demise in utero, septic abortion, termination of pregnancy, dilation and evacuation of gestational trophoblastic neoplasms.

The operation involves dilating the cervix and removing uterine contents and endometrial tissue. The patient is placed on the table in the lithotomy position. The perineum and vagina are cleaned with a povidone-iodine (Betadine) solution. A straight Jacobs (double-tooth) clamp or single-tooth tenaculum is used to grasp and stabilize the cervix. A bimanual exam is performed to confirm the size and position of the uterus and a uterine sound is carefully passed to confirm the length of the uterine cavity and the angulation between the cervical canal and the uterine cavity. Sounding the uterus is contraindicated in the presence of a pregnancy because the increased risk of perforating the soft myometrium. Dilators are subsequently passed through the cervix to achieve the desired cervical canal diameter. After dilation, ureteral stone forceps can be introduced into the uterine cavity to remove endometrial polyps. Curettage is performed with a small serrated curette which can be used to systematically scrape the uterine cavity until a uterine “cry” (vibrations felt as the curette is gently dragged across denuded endometrium) is appreciated. When curettage is performed for the removal of placental tissue, a large, blunt, smooth curette is used to lessen the possibility of perforation and endometrial sclerosis.

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that affects nearly 1% of the adult population, with women being affected earlier and more often than men. The disease typically strikes between the third and sixth decades of life, but children and the elderly can be affected as well.

Despite markedly improved and more aggressive medical management, rheumatoid arthritis continues to be, for many, a progressive disease that ultimately leads to significant joint destruction, severe disability, a lower quality of life, and a shorter life expectancy.

Patients with RA typically present with complaints ofoverall fatigue, morning stiffness that may improve throughoutthe day, joint swelling, and pain. Patients have serologypositive for rheumatoid factor (Anti-IgG IgM antibodies) andantibodies to cyclic citrullinated peptides (CCP) in additionto plain radiographic findings including subchondral bonyerosions, periarticular osteopenia, and soft-tissue edema.Synovial hypertrophy precedes joint destruction and can bediagnosed on ultrasound or MRI. Anti-CCP antibodies canbe present and detected months to years before the autoimmuneattack on the articular surfaces. These antibodies arepositive in 50–60% of individuals with RA; antibodies may bepresent in otherwise seronegative patients (negative serologyfor rheumatoid factor). Clinical RA will develop in 95–98% ofpatients with a positive anti-CCP antibody screen. Early diagnosisis paramount as any delay can often lead to irreversiblejoint destruction and the resultant morbidity.

Introduction

Kidney disease encompasses a wide spectrum of disorders, ranging from those with normal glomerular filtration rates (GFR) but with urinary abnormalities (nephrotic syndrome or nephritic syndrome), to those with GFR impairments. Patients with a long-standing history (months to years) of renal disease are deemed to have chronic kidney disease (CKD). A staging system has been developed by the National Kidney Foundation to categorize CKD by GFR levels: Stage 1 (GFR ≥ 90 mL/min, but with persistent urinary abnormalities such as proteinuria); Stage 2, mild CKD (GFR 60–89 mL/min); Stage 3, moderate CKD (GFR 30–59 mL/min); Stage 4, severe CKD (GFR 15–29 mL/min); and finally Stage 5, kidney failure or end-stage renal disease (ESRD) (GFR < 15 mL/min or on some form of renal replacement therapy). There is clinical rationale in dividing CKD into these stages; patients with more advanced stages, especially those at stage 3 or higher, have higher rates of death, cardiovascular events, and hospitalizations [1]. In contrast to established kidney disease, acute kidney injury (AKI), previously termed “acute renal failure,” reflects renal dysfunction that arises in the span of hours to days. AKI can develop in those with previously normal kidney function or can be superimposed upon existing CKD. More advanced CKD stages 3 through 5 and AKI are most commonly associated with perioperative complications, and these patients will be the focus of this chapter.

Approximately one woman in eight will develop breast cancer at some point in her life. Among women who undergo mastectectomy, 16–30% will undergo breast reconstruction. Partial and total mastectomies may leave patients with breast defects that produce a tremendous amount of psychological distress. The goal of breast reconstruction is to safely create symmetrical natural-appearing breasts, improving self confidence and relieving the psychological impact of mastectomy or breast conservation therapy. Reconstruction may be performed immediately after mastectomy, or in a delayed fashion months to years after breast removal. Immediate reconstruction allows for several advantages including an additional operation under the same anesthetic, preservation of breast skin by occupying mastectomy space, and placement of an optimally sized structure during single stage procedures. An advantage of delayed reconstruction is that patients have more time to think about reconstructive options; they may postpone reconstruction until after other interventions such as radiation therapy or chemotherapy have been completed.

Breast reconstruction can be divided into two types: autologous tissue reconstruction or implant-expander reconstruction. Several factors are considered to determine the optimal type of reconstruction for each patient including health status, emotional state, cancer stage, and adjuvant therapy. A multidisciplinary approach is essential for the often challenging journey taken by breast cancer patients and their caregivers.

Indications for colon replacement of the esophagus include gastroesophageal malignancy; benign non-dilatable distal esophageal strictures caused by reflux esophagitis; extensive chemical strictures; benign tumors of the esophagus that are extensive or multiple and are not amenable to simpler measures; congenital atresia of the esophagus for which a primary anastamosis is impossible or impractical; rare cases of achalasia (megaesophagus) in which Heller myotomy fails or is complicated by malignancy; bleeding varices for which shunting fails or stricture formation follows disconnection operation; and rupture of the esophagus for which conservative repair fails or is impossible.

The right or left colon may be used, based on the right or left branch of the middle colic artery. Depending upon the surgeon's preference, the prepared colonic segment is passed through a retrosternal tunnel or brought into the posterior mediastinum through the right or left pleural cavity. An anastomosis is then constructed to the cervical esophagus. Regardless of the approach used, the procedure is of great magnitude. A general endotracheal anesthetic is administered and the procedure usually lasts 4 to 6 hours. Two to four units of blood are frequently required. Intensive preoperative preparation, including correction of fluid, caloric, and protein deficiencies, substantially improves outcome, particularly for elderly or debilitated patients. Careful mechanical bowel preparation is also required.

The most common indications for surgery in adults with scoliosis or kyphosis are debilitating pain from the deformity or associated spinal stenosis with neurological symptoms. Other indications include documented progression of deformity or instability that hinders erect posture. Although surgery may be considered in the adolescent with spinal deformity to prevent long-term development of restrictive lung disease or cor pulmonale (which may occur in patients with scoliosis > 90–100°), adult deformity correction surgery is rarely if ever indicated to improve established cardiopulmonary impairment. In fact, spinal deformity surgery in the adult may actually lead to long-term deterioration of pulmonary function, particularly if the chest is entered during the approach.

Because of the potential for major physiologic insult, an extensive preoperative medical work-up should be conducted when indicated in the patient considering surgery for spinal deformity correction. The combination of careful preoperative screening, risk stratification, and medical optimization in consultation with medical specialists is paramount to successful outcomes. Depending on the magnitude of associated comorbidities, the surgical procedure may need to be appropriately curtailed to address the underlying medical conditions. Therefore, complete correction of the deformity may not be achieved. However, because adequate correction of deformity (in particular, deformity in the sagittal plane) has been shown to be associated with significantly better outcomes, the majority of operations for spinal deformity should be designed to achieve, at a minimum, the restoration of spinal balance in both the coronal and sagittal planes.

Lower extremity amputations are performed for tumors, trauma, peripheral vascular disease, infection, or congenital deformity. The goal of treatment is to return the patient to a functional level allowing pain-free ambulation, which is best achieved through a multidisciplinary approach involving physician, physical therapist, and prosthetic team. Due to the psychological aspects of care, it is important to involve the patient in the decision-making process. This will help the patient to understand the intervention and (hopefully) to concur with the medical staff regarding the importance and necessity of performing the amputation, as well as postoperative expectations.

The vast majority of amputations are performed for vascular disease and infection resulting from diabetic neuropathy; the most common level is a below-knee amputation. The more proximal the amputation, the greater the metabolic cost of walking. Studies have shown that walking speed is decreased and oxygen consumption is increased with more proximal amputations.

Preoperative consideration of several important factors willdirectly affect the patient’s ability to successfully recover fromthe amputation. The goal of surgery is to leave enough viabletissue that will heal and allow for prosthetic fitting. A serumalbumin level below 3.5 g/dL indicates a malnourished patientand an absolute lymphocyte count below 1,500/mm3 is a signof immune deficiency; these values should be corrected priorto any elective amputation. Some advocate the optimization ofserum glucose levels in patients with diabetes, but this treatmentchoice is not entirely clear. To maximize the health andnourishment of the patient, an internist and nutritionistshould be included in the treatment team.