Preparation (cid:142)(cid:3) Clean skin of chest (cid:142)(cid:3) Ensure all equipment avai lable and connects together (cid:142)(cid:3) Fill drain bottle to fill line. Anesthetic Local infiltration of lignocaine in conscious patients. Anesthetic to skin and s ubcutaneous tissue, including periosteum and pleura. Anesthetized patients do not require l ocal anesthetics. Procedure (cid:142)(cid:3) Position the patient. (cid:142)(cid:3) Identify the 5th intercos tal space anterior to the mid-axillary line. (cid:142)(cid:3) Local infiltration with ligno caine, infiltrate the skin and deep to the 6th rib. Infiltrate around the rib and into the 5th space. Infiltrate the pleura. (cid:142)(cid:3) Clean area with appropriate skin prep. (cid:142)(cid:3) Make 2 \200\2233cm skin incision parallel to ribs in 5th intercostal space. INTERCOSTAL DRAIN INSERTION1 825 (cid:142)(cid:3) Dissect down to pleura using blunt dissection with artery forceps. (cid:14 2)(cid:3) Puncture pleura with artery forceps and enlarge the opening by spreading forceps within wound. (cid:142)(cid:3) Explore the wound with finger and pass it through the pleura into the chest cavity. Check for any adhesions or abdominal contents within the cavity. (cid:142)(cid:3) Guide the drain using the artery forceps to avoid any structures within the thoracic cavity. (cid:142)(cid:3) Attach to underwater drain or Heimlich valve. (cid:142)(cid:3) Secure in p lace using horizontal mattress suture and drain sutures. (cid:142)(cid:3) Apply dressing an d secure drainage tube. (cid:142)(cid:3) Check tube position with a chest X-ray. (cid:142)( cid:3) Reassess the patient. Complications (cid:142)(cid:3) Malposition of tube \200\224ext ra-thoracic, drain in thoracic cavity but drainage hole extra-thoracic (cid:142)(cid:3) Local infection (cid:142)(cid:3) Blockage of drain (cid:142)(cid:3) Subcut aneous emphysema (cid:142)(cid:3) Infection; wound, empyema (cid:142)(cid:3) Blockage of dr ain; kinking of tubing, clogging with solid debris, clotted blood, inappropriate clamping (cid:142)(cid:3) Damage to intra-thoracic or abdominal viscera (cid:142)(cid:3) Damage to n euro-vascular bundle under 5th rib. CHAPTER 18 Trauma surgery 826 Venous cutdown This technique is a surgical emergency technique to establish venous access when peripheral access is unobtainable. Any superficial vein can be used; the most common c hoices are the long saphenous vein at the ankle and the basilic vein in the ante-cubital fo ssa. This section will describe the procedure for the long saphenous vein. Indication Venou s access when peripheral route not available. Contraindications (cid:142)(cid:3) Previous h arvesting of long saphenous vein for arterial bypass procedure. (cid:142)(cid:3) Trauma to limb proximal to vein. Position Supine. If not cleared the neck should be maintained in neutral with collar, sandbags and tape (or equivalent) or manual in -line immobilization. Leg rotated laterally. Equipment (cid:142)(cid:3) Lignocaine (cid:142 )(cid:3) Syringe and needles for administration of local anesthetic (cid:142)(cid:3) 14 gau ge cannula (cid:142)(cid:3) IV fluids with giving set (cid:142)(cid:3) Sutures. Preparation Clean skin with appropriate antiseptic. Anesthetic Local infiltration with lignocaine. Pro cedure (cid:142)(cid:3) Identify the anatomical landmarks for the long saphenous vein. (cid :142)(cid:3) 2cm proximal and posterior to medial malleolus (cid:142)(cid:3) Infiltrate wit h local anesthetic (cid:142)(cid:3) 2cm transverse incision at identified site (cid:142)(ci d:3) Blunt dissection with artery forceps down to vein and behind vein (cid:142)(cid:3) Pas s two ties behind vein (cid:142)(cid:3) Tie one tie as distal as possible and use this to s ecure vein (cid:142)(cid:3) Pass second tie proximally (cid:142)(cid:3) Make a small transv erse venotomy. Dilate the venotomy with the tip of the artery forceps and pass the cannula into the vein lumen (cid:142)(cid:3) Secure the cannula in place using the proximal tie (cid:142)(cid:3) Attach IV tubing, close the wound and dress the wound. Complications (cid:142)(cid:3) Damage to v ein and/or surrounding structures (especially nerve) (cid:142)(cid:3) Extravasation (cid:14 2)(cid:3) Local infection (cid:142)(cid:3) Cellulitis (cid:142)(cid:3) Thrombo-phlebitis (c id:142)(cid:3) Venous thrombosis. This page intentionally left blank CHAPTER 18 Trauma surgery 828 Diagnostic peritoneal lavage This procedure provides a rapid sensitive assessment for intra peritoneal blood. It should be performed by the surgeon responsible for managing the patien t as it prevents accurate further assessment by clinical examina- tion or ultrasound scanni ng. Indication In the haeodynamically abnormal patient: (cid:142)(cid:3) Change in level of con sciousness (unreliable clinical examination) (cid:142)(cid:3) Change in normal sensation (s pinal cord injury) (cid:142)(cid:3) Injury to neighboring structures (rib, pelvis). Patient away from regular clinical assessment for a long time (in theater for limb/other non-abdom inal procedure, or transfer to other provider including X-ray). If a patient is not stable haemodynamically they should not be trans- ferred to the imaging department. Contraindications (cid:142)(cid:3) Patient requires laparotomy (cid:142)(cid:3) Relative co ntraindications include technical problems such as the possibility of adhesions or an obese patient (cid:142)(cid:3) Ultrasound may be considered and will be discussed later. Position Supine. If not cleared the neck should be maintained in neutral with collar, sandb ags and tape (or equivalent) or manual in-line immobilization. Equipment (cid:142)(cid:3) Lignocaine with adrenaline (cid:142)(cid:3) Syringe and needles for administration of local anesthetic (cid:142)(cid:3) Peritoneal dialysis catheter (cid:1 42)(cid:3) Minor procedures tray including small haemostats, small skin retractors. (cid:142)(cid:3) Antiseptic skin preparation fluid. (cid:142)(cid:3) 1 liter warmed Hartman n \200\231s solution (cid:142)(cid:3) IV giving set (cid:142)(cid:3) Urinary catheterisatio n equipment (cid:142)(cid:3) NG tube. Preparation (cid:142)(cid:3) Decompress the stomach with oro-gastric tube (cid:142)(cid:3) Insert urinary catheter to ensure bladder is empty (cid:142)(cid:3) Clean skin. Include who le of abdomen. Anesthetic Local infiltration with lignocaine in the midline over site of procedure. DIAGNOSTIC PERITONEAL LAVAGE1 829 Procedure (cid:142)(cid:3) Identify the operative area \200\2241/3rd distance from umbilicu s to symphysis pubis. (cid:142)(cid:3) Infiltrate the local anesthetic. (cid:142)(cid:3) Vertical incision throug h the skin and subcutaneous tissue. This should be a bloodless field down to the linea alba. (cid:142)(cid:3) Lift the fascia with the haemostats and incise the peritoneum. (cid:142)(c id:3) Insert a peritoneal dialysis catheter into the peritoneum, and advance it down to the pelvis gently. (cid:142)(cid:3) Aspirate from the dialysis catheter with a syringe. If gross blood is aspirated the test is positive. (cid:142)(cid:3) If blood is not aspirated attach the catheter to 1 liter of warmed Hartmann \200\231s solution, and instill 10ml/kg into the abdominal cavity, via an IV givin g set. (cid:142)(cid:3) Gently agitate the abdomen to distribute the fluid instilled. (cid:142)(ci d:3) Allow the fluid to remain for 5 \200\22310min then drain by lowering the IV bag to the floor. Drainage by siphoning. The IV bag should be vented to allow easy flow. (cid:142)(cid:3) Analyze the fluid in the pathology laboratory \200\224inform the hematolog y department that the sample is DPL fluid. (cid:142)(cid:3) A positive result is represented by RBC \211 100 000 per mm3 or WBC \211 500 per mm3. Any food or fecal material is also indicative of the need for laparotomy. NB A negative lav age does not rule out retroperitoneal injury. Complications (cid:142)(cid:3) Hemorrhage from skin or subcutaneous tissues giving a false positive result (cid:142)(cid:3) Intestinal injury or other abdominal structures (cid:142)(cid:3) Bladder i njury (cid:142)(cid:3) Wound infection. A positive DPL is used as an indicator for the need for laparotomy. If after blood is identified intra-abdominally the decision is made to treat conservatively , then subsequent observation is made more difficult due to the performance of the DPL. If non-operative treatment is to be considered then a senior clinician should consider the inv estigation to be performed. Abdominal ultrasound can be repeated and is non-invasive. It al so allows for recurrent clinical examination to be performed. CHAPTER 18 Trauma surgery 830 DPL, ultrasound, CT, or laparotomy Haemodynamically, trauma patients may be categorized int o three classes: 1. Haemodynamically normal 2. Haemodynamically abnormal BUT stable 3. Haem odynamically abnormal AND unstable In the first group it is unlikely that surgically signif icant blood loss has occurred, or that ongoing bleeding is present. This group may be inves ti- gated with less urgency and are safe to be transferred to a radiology department for de partmental ultrasound or computed tomography. The third group of patients require surgical intervention to identify the source of bleedin g and to arrest further hemorrhage. If the site of bleed- ing is thought to be abdominal (o ther sites excluded \200\223thoracic, pelvic, external, long bones) investigation is not in dicated and the patient re- quires laparotomy. In the second group the patient may have improved with resuscitation but not have normal pa rameters. If no further hemorrhage occurs they will remain abnormal but stable. These patie nts require further resuscita- tion to normalize their condition. It may be that they have a slow bleed and haemodynamic normality is not achievable. There is time to investi- gate t hese patients but they should not be transferred to a radiology department for CT. The opti on is DPL or ultrasound. These are summa- rised in the table opposite. DPL, ULTRASOUND, CT, OR LAPAROTOMY1 831 Table 18.1 Comparison of DPL and ultrasound in the assessment of abdominal trauma DPL (cid:142)(cid:3) Surgeon (cid:142)(cid:3) Not affected by bowel gas or subcutaneous air Ultrasound (cid:142)(cid:3) Operator dependent (cid:142)(cid:3) Obscured by bowel gas and s ubcutaneous air Operator Gas shadowing (cid:142)(cid:3) Only diagnoses (cid:142)(cid:3) Can pick up some Limitations haemoperitoneum or bowel contents from ruptured viscus retroperitoneal injuries (cid:142)(cid:3) Will pick up peritoneal fluid (blood or fecal) bu t will miss some bowel injuries (cid:142)(cid:3) Readily available in resus (cid:142)(cid:3) Readily available in resus Speed Ongoing monitoring (cid:142)(cid:3) Not easily repeatable (cid:142)(cid:3) Easily repeatable (cid:142)(cid:3) High but variable dependent upon operat or (cid:142)(cid:3) High Sensitivity and accuracy This page intentionally left blank Chapter 19 833 Transplantation M. El-Sheik and P. A. Lear Organ donors 834 Organ recipient preparation 836 Immunosuppressi on 838 Kidney transplantation 842 Pancreas transplantation 846 Liver transplantation 848 Ca rdiac transplantation 852 Lung transplantation 854 CHAPTER 19 Transplantation 834 Organ donors Specific organ criteria (cid:142)(cid:3) Kidney Age 4 \200\22370 years with ac ceptable renal function. (cid:142)(cid:3) Liver Age 1 month \200\22355 years, with no known liver disease, viral hepatitis, or intravenous drug use. (cid:142)(cid:3) Heart Age 1 month \200\22350 years, with no known cardiac disease. (cid:14 2)(cid:3) Lung No pulmonary disease or trauma. PaO2, PaCO2 acceptable on <50% FiO2. Living donors (cid:142)(cid:3) The number of patients waiting for transplantation increases by over 3% per year. Cadaveric donor numbers have declined over the past decade. (cid:142)(cid:3) In an attempt to reduce disparity, utilization of living donor transplants has increased in recent years, particularly in kidney transplantation. (cid:142)(cid:3) Li ving donors comprise a first degree relative (parent, child, or sibling) or genetically unr elated (spouse or partner). Transplants between genetically unrelated individuals in the UK , are screened by ULTRA, the Unrelated Live Transplant Regulatory Authority. (cid:142)(cid:3) Donation requires meticulous work up. All donors must be fit and screened for any unrecognized disease which would prohibit safe donation. Cadaveric donors (cid:142)(cid:3) Cadaveric donors comprise the majority of solid organ don ors in the UK \200\224770 (13 per million population) each year. Donor rates vary worldwide (e.g. Spain has 33.7 per million population). (cid:142)(cid:3) The UK adopts an \200\230opting in \200\231 policy whereby organ donation is only legally possible with consent from relatives and the Coroner. (cid:142)(cid:3) Suitability for donation is dependent upon the organ or tissue being considered and any pre morbid disease. (cid:142)(cid:3) All donors undergo blood grouping, tissue typing and assessment of viral status for hepatitis B, C, HIV, and cytomegalovirus. The presence of active extra cra nial malignant disease precludes organ donation. (cid:142)(cid:3) Most commonly donors are heart beating (brain stem dead). (cid:142)(cid:3) Shortage of organ supply has resulted in re-extending the cadaveric donor pool to non-heart beating (NHB) donors. Management of the heart beating (brain dead) cadaveric donor (cid:142)(cid:3) Causes of bra in stem death: intra-cranial hemorrhage, trauma, viral/bacterial infection or primary intra-cerebral tumor. (cid:142)(cid:3) Diagnosis confirmed by CT and a series of clinical tests, performed by two senior doctors, establish brain stem death (Code of Practice 1983). (cid:142)(cid:3) Resuscitation of donors requires early recognition and assiduous support. Brain death causes a variety of scenarios which include hypothermia, coagulopathy, fall in T3 and T4, myocardial depression and diabetes insipidus. ORGAN DONORS1 835 Cardiovascular support (cid:142)(cid:3) Aim for mean arterial pressure of 60 \200\22370mmHg , central venous pressure \211 12cm H2O, urine output \211 100ml/hour (cid:142)(cid:3) Inotropes are avoided if possible (cid:142)(cid:3) Adrenaline may be used for refractory hypotension (cid:142)(cid:3) Dopamine may exacerbate any polyuria and cause vaso-constriction; dobutamine may exacerbate hypotension. Respiratory support (cid:142)(cid:3) Meticulous asepsis, especially if lung harvesting is e nvisaged. (cid:142)(cid:3) Oxygen delivery is optimized to achieve a normal PaCO2; high PEE P should be avoided. Hormone replacement therapy Hormone replacement may be necessary. (cid:142)(cid:3) T3 \200 \223bolus of 4mcg then infusion of 3mcg/hour. (cid:142)(cid:3) Diabetes insipidus \200\223r eplace urine loss with 5% dextrose and water via a nasogastric tube. Vasopressin via an inf usion may exacerbate the vasoconstriction. Desmopressin is a better anti diuretic. The aim is to achieve a 1.5 \200\2233ml urine/kg/hr output. Hematological support (cid:142)(cid:3) Hematological support \200\224coagulopathies are tre ated with blood products as guided by the local laboratory. Management of the non-heart beating cadaveric donor (cid:142)(cid:3) NHB donors may be clas sified into 4 categories using the Maastricht criteria. Category (1) Category (2) Category (3) Patients dead on arrival to A&E Unsuccessfully resuscitated patients Patients awaiting card iac arrest, where the treating clinicians have withdrawn treatment ( \200\230controlled \200\231 NHB donor) Patients with cardiac arrest after being declared brain dead. Category (4) (cid:142)(cid:3) Following cardiac arrest there is a stand off period (5 \200\22310min) to establish that an individual has changed from a dying patient to a donor. (cid:142)(cid:3) Minimizing the time between death and administration of organ preservation fluid and cold storage, reduces detrimental effects on tissue viability and subsequent org an function. (cid:142)(cid:3) NHB donors have been mainly used for kidneys. The incidence of delayed graft function is higher in organs from NHB donors. There is no difference in long term outcome. (cid:142)(cid:3) Also now been used widely for livers; case reports of other organs. CHAPTER 19 Transplantation 836 Organ recipient preparation Blood group compatible grafting is performed in heart and liver trans- plantation, tissue type-matched transplants are performed in all kidney and some pa ncreas transplants. Patients receiving a second graft must be screened for HLA antibodies w hatever the organ. Investigation of patients for suitability for organ transplantation in a ll categories should include the following investigations: (cid:142)(cid:3) Full blood coun t and coagulation screen (cid:142)(cid:3) Blood group and antibody screen (cid:142)(cid:3) Urea and electrolytes (cid:142)(cid:3) Liver function tests (cid:142)(cid:3) Glucose and li pid profiles (cid:142)(cid:3) Hepatitis B, C, and HIV (cid:142)(cid:3) Cytomegalovirus (CMV ), herpes simplex virus (HSV) and Epstein \200\223Barr virus (EBV) status (cid:142)(cid:3) Chest X-ray (cid:142)(cid:3) Electrocardiogram (cid:142)(cid:3) MSU/sputum for culture and sensitivity (cid:142)(cid:3) Tissue typing \200\224the recipient \200\231s lymphocytes are used to type the human leucocyte antigens (HLA) A, B, and DR. (cid:142)(cid:3) Detection of pre-formed anti-HLA antibodies in the serum. Performed agains t a panel of donors whilst on the waiting list, to detect sensitisa- tion (panel reactivity ) and immediately pre-transplant (crossmatch against the donor) in most cases. Sensitisatio n to foreign-HLA may occur by pregnancy, blood transfusion, or previous HLA mismatched tran splantation. Contra indications to organ transplantation (cid:142)(cid:3) Multi organ failure (cid:142)( cid:3) On-going sepsis (cid:142)(cid:3) \200\230Current \200\231 malignancy This page intentionally left blank CHAPTER 19 Transplantation 838 Immunosuppression (cid:142)(cid:3) Drugs used in combination to provide optimal prophylaxis against rejection (cid:142)(cid:3) Ideally tailored to the specific requirements of both patient and organ graft. Corticosteroids (e.g. prednisolone) (cid:142)(cid:3) Anti-inflammatory and immunosuppressiv e properties. Inhibit gene transcription of interleukin 1 (IL-1) and tumor necrosis factor (TNF). Non specific effects on immune response include lymphopenia and inhibition of monocyte migration. Induction dos e (0.25mg/kg/day) then reducing dose (0 \200\2230.1mg/kg/day). Intravenous doses of methylp rednisolone (500mg tds) used as first line treatment for acute rejection episodes. (cid:142)(cid:3) Side-effects: iatrogenic cushingoid syndrome, glucose intolerance, hyperte nsion, osteoporosis, aseptic necrosis of femoral head. Immunophillin binders: calcineurin inhibitors (e.g. cycoclosporin, tacrolimus) (cid:142)(ci d:3) Cyclosporin binds to cyclophilin, and tacrolimus binds to FK-binding proteins. Leads t o inhibition of the intracellular enzyme calcineurin, essential for the transcription of cy tokines (IL-2, IL-4, interferon gamma and TNF-(cid:167)). Inhibit T cell function. Inductio n dose (cyclosporin 12mg/kg/day; tacrolimus 0.15 mg/kg/day) then reduction to a maintenance level (ciclosporin 3 \200\2235mg/kg/day; tacrolimus 0.05 \200\2230.1mg/kg/day). Monitoring required (trough or levels 2 hours post dose). (cid:142)(cid:3) Side-effects: nephrotoxicity, neurotoxicity, impaired glucose metaboilism, hypertension, hypercholesterolaemia, gastrointestinal disturbance, hirsuitism, ginigival hyperplasia. Immunophillin binders: non-calcineurin inhibitors (e.g. sirolimus) (cid:142)(cid:3) Binds F K-binding protein but does not inhibit calcineurin. Complex of drug and immunophilin acts o n TOR (target of rapamycin) proteins and inhibits P7056 kinase which prevents the cell from moving G1 phase of the cell cycle. Prevents T cell proliferation in response to activation . (cid:142)(cid:3) Side-effects: thrombocytopaenia, hyperlipidaemia. Impaired wound healing. Possible increase incidence of lymphocoeles in renal transplantation. Antimetabolites: (1) Azathioprine (cid:142)(cid:3) Metabolized in the liver to the active a gent 6-mercaptopurine. Inhibits de novo purine synthesis, thus impair DNA synthesis and cel lular proliferation. Dose 1 \200\2232mg/kg/day, monitor FBC. (cid:142)(cid:3) Side-effects: bone marrow suppression, hepatotoxicity, gastrointestinal disturbance, pancreatitis. IMMUNOSUPPRESSION1 839 Antimetabolites: (2) Mycophenolate mofetil (MMF) (cid:142)(cid:3) Inhibits enzyme inosine m onophosphate dehydrogenase (IMPDH), which is needed by activated lymphocytes to synthesize guanosine nucleotides and clonally expand. Most other cell types can bypass this pathway, s o drug is selective for lymphocytes. Dose 1 \200\2232g/kg/day in divided doses, monitor FBC . (cid:142)(cid:3) Side-effects: Gastrointestinal side-effects (diarrhea, gastritis, vomiting ), bone marrow suppression. Antibodies: polyclonal (e.g. ATG, ALG) (cid:142)(cid:3) Antibody binds to lymphocytes, whic h are cleared from the circulation, producing a profound drop in lymphocyte count. Used for induction therapy at transplantation or treatment of rejection. Monitor using absolute lym phocyte counts. (cid:142)(cid:3) Side-effects: Allergic reaction, thrombocytopaenia. Antibodies: monoclonal (1) Anti CD3 (e.g. OKT3) (cid:142)(cid:3) OKT3 causes the T-cell rec eptor to be lost from the surface, and prevents T-cell activation. Used for induction therapy/treatment of rejection. Monitor usin g absolute lymphocyte counts. (cid:142)(cid:3) Side-effects: Non-cardiogenic pulmonary oedema, encephalopathy, aseptic meningitis, nephrotoxicity, high risk lymphoproliferative disease. Antibodies: monoclonal (2) Anti-IL-2R (e.g. Basiliximab, Daclizumab) Binds IL-2 receptor (C D25) and thus prevents the IL-2 driven prolifera- tion of activated lymphocytes. Important side effects of immunosuppression Infection Increased susceptibility to all infec tions. (cid:142)(cid:3) Opportunistic e.g. Pneumocystis carinii ( jiroveci). (cid:142)(cid: 3) Cytomegalovirus (CMV): (cid:142)(cid:3) Transmitted within the graft. The latent virus may be activated and produce CMV disease particularly in CMV negative recipients. (cid:142)(cid:3) Prophylaxis g iven using Acyclovir or Gancyclovir (6 \200\22312 weeks). (cid:142)(cid:3) Patients treated with antibody therapy to combat rejection are most at risk of CMV disease. (cid:142)(cid:3) Present with fever, respiratory symptoms, gastrointestinal disease and inf ection of the allograft with dysfunction. Renders the host more susceptible to opportunisti c infection. (cid:142)(cid:3) Treat with IV Ganciclovir and usually requires withdrawal of immunosuppression. (cid:142)(cid:3) Epstein \200\223Barr Virus (EBV): active replication of virus predisposes to post-transplant lymphoproliferative disease (PTLD). CHAPTER 19 Transplantation 840 Malignancy (cid:142)(cid:3) Common neoplasms (e.g. breast, lung, colon) do not occur more frequently in transplant recipients. Neoplasms of the skin and lymphoid tissue are more com mon. (cid:142)(cid:3) Skin cancers are the most common malignant conditions in transplant recipients. (cid:142)(cid:3) Basal cell carcinoma is seen 10 times more frequently than the general population. (cid:142)(cid:3) Squamous cell carcinomas, which account for 90% of skin cancers in transpl ant patients, occur 65 \200\223250 times more in this population. (cid:142)(cid:3) PTLD (cid:142)(cid:3) Occurs in around 2% of patients post-transplantation often within a year o f transplantation. More common with more aggressive immunosuppressive regimens and in child ren. (cid:142)(cid:3) The tumors are initially confined to the graft and are B-cell non-Hodgkin lymphomas. Often resistant to treatment with a high mortality. This page intentionally left blank CHAPTER 19 Transplantation 842 Kidney transplantation Indications (cid:142)(cid:3) Treatment of choice for end-stage renal failure. Recipients having a greater survival and improved quality of life. More cost effective than dialysis. (cid:142)(cid:3) Patients suitable for kidney transplantation are usually already establish ed on dialysis. Transplantation pre-empting dialysis is becoming more common. (cid:142)(cid:3) Organs shared regionally and nationally, co-ordinated by UK Transplant. Selection of the most suitable recipient is primarily based on tissue matching of the HLA A, B, and DR antigens between the donor and recipient. Discrimination between eq ually matched pairs is performed using a scoring system based on age, matching, known sensi ti- zation of recipients to HLA antigens, and length of time on waiting list. (cid:142)(cid :3) Transplantation is only undertaken following a negative cytotoxic cross match between the donor cells and recipient serum. Living donor kidney transplantation (cid:142)(cid:3) 361 (6.3 per million population) live donor kidney transplants performed in the UK in 2002, an increase of nearly 10% on the prev ious year. (cid:142)(cid:3) Long term outcomes in live donor kidney transplants are better than cadaveric. (cid:142)(cid:3) Immunosuppression now enables transplants to be safely performed in tissue -type mismatched individuals and an increase in unrelated living donors. Organ retrieval \200\224living donor: open donor nephrectomy Incision Flank incision at the level of the 12th rib. Preserve the lower rib as the incidence of wound pain is less. Procedure (cid:142)(cid:3) Approach the kidney extra-peritoneally. Open Gerota \200\231s fa scia and mobilize the kidney using blunt and sharp dissection to facilitate an extra-capsular dissec tion. (cid:142)(cid:3) Carefully dissect the hilum and identify the renal vessels. Preoperative i maging is helpful to determine both the number of renal arteries and to identify any extra- renal branches of vein or artery which may be encountered at this point. (cid:142)(cid:3) Dissect the ureter with preservation of the peri-ureteric fat and thus its blood supply. Divide the renal vessels to give adequate length for transplantation. Complications (cid:142)(cid:3) The risks of death or major morbidity to the kidney donor ha ve been estimated in the era of open surgery to be 0.03% and 0.23% respectively. (cid:142)(cid:3) Most common complications are respiratory (atelectasis, pneumonia and pneumothorax) and infective (wound and urinary tract). KIDNEY TRANSPLANTATION1 843 Organ retrieval living donor: minimally invasive donor nephrectomy (MIDN) MIDN may be perfo rmed by hand-assisted or total laparoscopic approach. Position In the transperitoneal laparoscopic technique, the patient is placed in a modified lateral decubitus position. Procedure (cid:142)(cid:3) Establish four ports (iliac fossa, xiphoid, epigastric, and mid- axillary). (cid:142)(cid:3) Mobilize the colon and expose the kidney by a medial approach through Gerota \200\231s fascia. Dissect and divide the ureter. (cid:142)(cid:3) Expose the renal vein and artery and ligate tributaries by clips. (cid:142 )(cid:3) Make a small 6 \200\22312cm lower umbilical incision to enable the kidney to be delivered. (cid:142)(cid:3) Divide the renal artery and vein using an endovascular stapling device and the kidney removed. The hand assisted approach involves use of a hand-port device via the lower umbilical incis ion. Advantages (cf. open): reduced recipient hospital stay; analgesia require- ments and t ime off work. Disadvantages (cf. open): longer graft warm ischaemia time and operating time . Overall: donor and recipient outcomes appear to be similar. Cadaveric organ retrieval In multi-organ retrievals the kidneys are removed last. Both kidn eys are removed en bloc and then separated on the bench. (cid:142)(cid:3) Divide the aorta in the posterior midline and the long left renal vein with a cuff of IVC. The rest of the preparation is undertaken at the transplant center. This involves the remov al of the adrenal gland and perinephric tissue, and ligation of vessels not supplying the k idney. A Carrel patch of vena cava or aorta may be left around the renal vessels for anasto mosis. Ischaemic time, storage, and preservation (cid:142)(cid:3) Warm ischaemia is defined as the period from cessation of circulation until perfusion of the organ with cold perfusion fluid. (cid:142)(cid:3) The cold ischaemic time is defined as the time from cold perfusion to esta blishment of the new circulation within the transplant. The viability time of a kidney in s imple cold storage is variable. 26 hours between explantation and implantation is recognize d as being the maximum storage time if good immediate function is to be achieved. Transplantation (cid:142)(cid:3) Antibiotic prophylaxis is important and immunosuppression is started perioperatively. (cid:142)(cid:3) The kidney is placed heterotopically into the iliac fossa using an extra p eritoneal approach. The renal vessels are anastomosed to the exter- nal iliac vessels. The internal iliac artery end-to-end anastomosis has CHAPTER 19 Transplantation 844 been abandoned due to the significant incidence of postoperative erec- tile dysfunction. Th e ureter is anastomosed to the bladder which is close by. The ureter may be stented, depend ing on surgical preference. (cid:142)(cid:3) Preoperative native nephrectomy is rarely need ed. It is considered for continued/recurrent urinary infection, tuberculosis of kidney, or massive polycystic kidney disease and uncontrolled hypertension. Surgical complications Vascular complications (cid:142)(cid:3) Graft thrombosis (renal vein thrombosis: 0.9 \200\2237.6%; renal artery throm- bosis: 0.9 \200\2233.5%) results in pain , graft swelling and oliguria. Transplant nephrectomy is usually required. (cid:142)(cid:3) Stenosis (1.6 \200\22312%) of the renal artery presents initially with hyp er- tension and progressing to graft dysfunction. Doppler ultrasound is the first line investig ation. Treatment of arterial stenoses is by percutaneous transluminal angioplasty. Anastomo tic stenoses are more safely treated by open surgery with a skip vein bypass graft. Urological complications (cid:142)(cid:3) Urinary leaks (3%) may present with pain around t he graft; a boggy swelling over the pubis; excessive wound drainage (high fluid creatinine to plasma creatini ne ratio); reduced function or by ultrasound-detected perinephric collections. Small urinar y leaks may be treated conserva- tively; larger leaks from ureteric necrosis, usually assoc iated with damaged discrete lower pole vessels, require surgery (re-implantation, uretero-u retostomy, uretero-pyelostomy or Boari flap). (cid:142)(cid:3) Ureteric stenosis (6%) usually occurs distally and presents with oliguria and allograft dysfunction. Ultrasound shows hydronephrosis. \211 40% present more than 1 y ear following transplantation. Often associated with vessel occlusion concomitant with seve re graft rejection episodes. Initial management of the obstructed kidney requires nephrosto my. Definitive management of the stenosis may be endoscopic or open. Other complications (cid:142)(cid:3) Lymphocoele (0.6 \200\22318%). Result from damage to l ymphatics surround- ing the iliac vessels. Presents with pain, leg swelling, lower urinary tract symptoms, uret eric obstruction, or even vascular compression and thrombosis. Management options include p ercutaneous drainage (cid:140)(cid:3)sclerosant injection, or surgical marsupialization int o the peritoneal cavity. Rejection and function (cid:142)(cid:3) Graft function is monitored by daily urea and creat inine. (cid:142)(cid:3) Delayed graft function (DGF): the need for dialysis within the firs t week of transplantation. It should not be confused with primary non-function \200\224defi ned as a graft which has never worked. (cid:142)(cid:3) Causes for DGF: acute tubular necro sis (secondary to the preservation injury), acute rejection, vascular thrombosis, and drug nephrotoxicity. KIDNEY TRANSPLANTATION1 845 (cid:142)(cid:3) Investigations: renal Doppler and ultrasound scanning. Flow is confirmed in transplanted vein and artery (usually intra-renal arcuate vessels) and overall graft resistive index (RI) calculated. RI is a non-specific measurement calculated as the difference in peak systolic and end-diastolic velocities, divided by the peak systolic velo city. The RI is normally less than 0.7. An RI >0.8 suggests rejection. (cid:142)(cid:3) Management of DGF: avoid use of nephrotoxic immunosuppressant drugs. Maintain adequate fluid balance. (cid:142)(cid:3) Acute rejection usually occurs in the first 3 months and affects up to 30% of kidney transplant recipients. The vast majority resolve with treatment. (cid:142)(cid:3) Presentation: asymptomatic, allograft dysfunction. Diagnosis is confirmed on biopsy. These are graded histologically using the Banff criteria. (cid:142)(cid:3) Management: parenteral steroid (IV methylprednisolone 500mg x 3 daily doses) and further immunosuppression, usually antibody therapy, if required. (cid:142)(cid:3) Chronic allograft nephropathy (CAN) is the result of both immune and non-immune factors. CAN is the major cause of long term declining graft function and ev entual loss. 27 \200\22340% of all failed grafts between 1 \200\2233 years are due to CAN. Histological findings include tubular atrophy, interstitial fibrosis, intimal hyperplasia a nd glomerulo- sclerosis. Graft and patient survival (cid:142)(cid:3) 1, 3 and 5 year allograft survival rates are ap proximately 90%, 80%, and 70% respectively. (cid:142)(cid:3) Graft survival is influenced by numerous factors including donor type (living versus cadaver) and HLA-mismatching. The 10 year graft survival is greater for kidn eys from living donors (53 \200\22357%) compared to cadaveric organs (38%). 5 year patient survival is 90% and 80% for recipients of living donor and cadaveric kidneys respectively. CHAPTER 19 Transplantation 846 Pancreas transplantation Solid organ pancreas transplantation Indications (cid:142)(cid:3) Simultanous pancreas \200\223kidney transplantation (SPK) or pancreas after kidney transplantation (PAK) is indicated for diabetic patients in end-stage renal failure. Pancreas transplantation alone (PTA) is indicated in those patients who have hypoglycaemic unawareness, and/or aggressive non-renal complications of diabetes, e.g. neuropathy. (cid: 142)(cid:3) The majority of transplants performed are SPK, with between 10% and 15% being either PAK or PTA. (cid:142)(cid:3) Most pancreases used for transplantation are cadaveric; a few centers worldwide have living donor programs, using distal pancreatectomy. (cid:142)(cid:3) \211 14 000 transplants have been performed in the USA, with 1362 performed in 2001. Only 82 SPK transplants were performed in the UK in 2001. Organ retrieval (cid:142)(cid:3) Harvest the pancreas as either a segment (tail and body) o r whole organ with a cuff of duodenum. (cid:142)(cid:3) Carry out bench work at organ retrieval. Anastomose splenic and superior mesenteric arteries to a donor iliac artery bifurcated Y graft, which enables the arterial supply of the graft to be facilitated by a single anastomosis at transplantation. Transplantation (cid:142)(cid:3) The technique associated with least complications involves transplanta- tion into the opposite iliac fossa to the kidney (for SPK transplantation) us ing very similar extra-peritoneal techniques. (cid:142)(cid:3) The venous drainage of the pancreas is usually systemic (external iliac ve in), and the drainage of exocrine function is to the bladder. Bladder drained exocrine secr etions cause chemical cystitis or metabolic acidosis, and this requires changing the method of drainage. Portal venous drainage via a mesenteric vein is performed in less than 20% of transplants. (cid:142)(cid:3) Achieve enteric exocrine drainage via a Roux-en-Y loop of small intestine. Exocrine leakage of the enterically drained graft gives rise to peritonitis, int ra-abdominal sepsis and the need for re-laparotomy in up to 70%. Surgical complications (cid:142)(cid:3) Re-laparotomy within 3 months (cid:142)(cid:3) Intr a-abdominal sepsis (cid:142)(cid:3) Pancreatitis (cid:142)(cid:3) Exocrine leak rates (cid: 142)(cid:3) Vascular graft thrombosis Rejection and function (cid:142)(cid:3) Rejection may cause graft loss due to difficulty in detection. Immuno- logical damage to the pancreas is advanced before changes in blood sugar are recognized. 15 \200\22335% in most large series 10 \200\22320% 2 \200\2233% 10% 2 \200\22314%. PANCREAS TRANSPLANTATION1 847 (cid:142)(cid:3) Monitoring graft function in transplants drained by the bladder is performed by urinary amylase. C peptide/insulin levels also used as markers of function. In SPK transplants, kidney rejection is usually accompanied by rejection in the pancreas. Graft and patient survival (cid:142)(cid:3) 1 year patient survival as 94 \200\22395% for S PK, 95 \200\223100% for PAK, and 97% for PTA. Graft survival at 1 year is 82 \200\22383% fo r SPK, 64 \200\22379% PAK, and 54 \200\22378% for PTA. (cid:142)(cid:3) 3 year graft/patient survival rates are approximately 83%/89% for SPK/PAK, and 60%/86% for PTA. Pancreatic islet cell transplantation In view of the surgical complications of solid organ transplantation the use of isolated pancreatic islets alone appears an attractive option. Technique (cid:142)(cid:3) Islets comprise only 2% of solid pancreatic mass. These insulin- secreting cells must be isolated from the tissue. Cell isolation involves enzymatic digesti on, mechanical disruption and purification using den- sity gradients. Currently only a prop ortion of available islets are able to be isolated. This can provide 500 000 islet equivale nt units, depending on the mass of the donor. (cid:142)(cid:3) Freshly isolated islets are infused via the radiologically cannulated portal vein (percutaneous transhepatic approach). This is done as a day case procedure. Complications Portal vein thrombosis ( \211 2%). Bleeding (requiring transfusion 5%). Graft and patient survival (cid:142)(cid:3) Between 1989 and 1999, 267 adult patients received i slet cell trans- plants; <10% were insulin-independent 1 year later. (cid:142)(cid:3) In 2000, the Edmonton group reported a series of islet cell transplants in 7 patients, all of whom were insulin independent at 1 year. (cid:142)(cid:3) Improvement s were due to better islet cell isolation, steroid free immunosuppression and an increase i n the total number of islets transplanted (average of 800 000 islets) by performing multipl e trans- plants as necessary. By 2002, over 40 patients have received transplants (82% insu lin independent at 1 year). A multi-center trial is examining whether the results can be su ccessfully replicated. (cid:142)(cid:3) The long term outcome of islet cell transplantation is unknown. The impact on secondary complications of diabetes is under review. CHAPTER 19 Transplantation 848 Liver transplantation Indications (cid:142)(cid:3) Patients with acute or chronic end-stage liver disease may be considered. (cid:142)(cid:3) Adults: primary biliary cirrhosis; sclerosing cholangitis; alcoholic