Splenomegaly-related symptoms are best palliated with splenectomy, but the cytopenias frequently recur. In addition, these patients are at increased risk for postoperative hemorrhage and thrombotic complications after splenectomy. Lymphoproliferative disorders a. Non-Hodgkin lymphoma NHL includes a wide range of disorders ranging from indolent to highly aggressive and includes a variety of clinical presentations. Splenomegaly exists in some forms. As with other malignant processes, splenectomy is indicated for palliation of hypersplenism and cytopenias or for diagnosis in patients with suspected persistent or recurrent disease after systemic therapy.
Splenectomy plays an important role in the diagnosis and staging of patients with isolated splenic lymphoma. In these cases, improved survival has been shown in patients undergoing splenectomy. The lymphocytes have cytoplasmic projections which can be identified on peripheral smear. Splenectomy does not correct the underlying disorder, but cell counts do return to normal with some alleviation of symptoms as well.
Splenectomy was previously regarded as the primary therapy for this disease, but improvements in systemic chemotherapy e. Hodgkin lymphoma historically had required splenectomy for diagnostic staging. However, due to refinements in imaging techniques and progress in the methods of treatment, splenectomy for Hodgkin lymphoma is rare. Indications for surgery are similar to those for NHL. Chronic lymphocytic leukemia CLL , a B-cell leukemia, is the most common of the chronic leukemias and is characterized by the accumulation of mature but nonfunctional lymphocytes.
Primary therapy is medical, with palliative splenectomy reserved for those patients with symptomatic splenomegaly to improve cytopenias and severe hypersplenism. Neutropenia a. Felty syndrome involves the triad of rheumatoid arthritis, splenomegaly, and neutropenia. The size of the spleen varies from nonpalpable to massively enlarged. The primary treatment is corticosteroids, but refractory cases may require splenectomy to reverse the neutropenia.
Besides symptomatic neutropenia, other indications for splenectomy include transfusion-dependent anemia and profound thrombocytopenia. Nonhematologic conditions a. Trauma is the most common indication for splenectomy. In the unstable trauma patient, the procedure is traditionally performed via laparotomy. With current imaging modalities, grading of splenic injuries allows for conservative management in selected patients J Trauma.
Incidental splenectomy occurs when the spleen is iatrogenically injured during an intra-abdominal procedure. Injury may result from a retractor placed in the left upper quadrant or during mobilization of the splenic flexure. Small injuries such as capsular tears may be controlled with hemostatic agents or electrocautery, but injuries resulting in significant blood loss may require splenectomy to achieve rapid hemostasis.
Wandering spleen is an uncommon abnormality in which the spleen floats inside the abdominal cavity due to anomaly of embryogenesis. The wandering spleen is not normally attached to adjacent viscera in the splenic fossa which may lead to splenic torsion and infarction.
Splenectomy or splenopexy is indicated. Splenic artery aneurysm is the most common visceral artery aneurysm and is typically an incidental finding. It occurs more commonly in females and is associated with a high incidence of rupture during pregnancy with significant maternal and fetal mortality. Primary infections of the spleen are infrequent. Parasitic infections account for more than two-thirds of splenic cysts worldwide but are rare in the United States.
The majority are hydatid cysts caused by Echinococcus species. They are typically asymptomatic but may rupture or cause symptoms due to splenomegaly. The primary treatment is splenectomy, with careful attention not to spill the cyst contents. The cyst may be aspirated and injected with hypertonic saline prior to mobilization if concern about rupture exists. Splenic abscesses are rare, but potentially lethal if not accurately diagnosed and treated.
Two-thirds arise from seeding of the spleen by a distant site, most commonly endocarditis and urinary tract infections. CT images reveal a low intensity lesion that does not enhance with contrast. The most common organisms are aerobic microbes Streptococci, Escherichia coli , but other microorganisms have also been isolated Mycobacterium tuberculosis, Salmonella typhi.
Treatment includes broadspectrum antibiotics for 14 days. Splenectomy is the operation of choice, but percutaneous and open drainage are options for patients who cannot tolerate splenectomy. Cystic lesion of the spleen may be either true cysts or pseudocysts, but this differentiation is difficult to make preoperatively. True cysts or primary cysts have an epithelial lining and are most often congenital. Rare true cysts include epidermoid and dermoid cysts.
Pseudocysts or secondary cysts lack an epithelial lining and make up more than two-thirds of nonparasitic cysts. They typically result from traumatic injury and will resorb. Treatment of splenic cysts depends on the size of the lesion and associated symptoms.
Most are typically asymptomatic, but they may present with left upper abdominal or shoulder pain. If smaller than 5 cm, the cysts can be followed with US and often resolve spontaneously. Larger cysts risk rupture and require cyst unroofing or splenectomy.
Percutaneous aspiration is associated with infection and recurrence and therefore not indicated. Laparoscopic management of splenic cysts yields shorter hospital length of stay and fewer complications with no adverse effects Surg Endosc. Tumors and metastasis. Sarcoma is the most common primary tumor of spleen. Most metastases to the spleen are carcinomas, commonly lung cancer. If isolated splenic metastasis is confirmed, a laparoscopic splenectomy with intact spleen retrieval should be considered.
Preoperative Preparation for Splenectomy 1. Imaging: CT or MRI may be required in patients with concern for malignancy or clinical splenomegaly to accurately estimate splenic size and evaluate for hilar adenopathy that may complicate a laparoscopic approach. Right upper quadrant US is indicated for preoperative assessment of gallstone disease in patients with hemolytic or sickle cell anemias for planning of possible concomitant cholecystectomy. Vaccination: Infection is the most common complication after splenectomy, and vaccination for encapsulated organisms is the mainstay of preventive therapy.
Asplenic patients are at higher risk of infection caused by Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis J Clin Pathol. Transfusions: Patients with hematologic disease, particularly those with autoimmune disorders, often have autoantibodies and are difficult to cross-match. Thus, blood should be typed and screened at least 24 hours prior to surgery, and patients with splenomegaly should have 2 to 4 units of packed RBCs cross-matched and available for surgery.
Robotic splenectomy offers a unique three-dimensional visualization. The overall outcomes of robotic approach are very similar to standard laparoscopy, although not as cost effective. Partial splenectomy is indicated to minimize the risk of postsplenectomy sepsis in children, in lipid storage disorders with splenomegaly Gaucher disease , and certain cases of blunt and penetrating splenic trauma. Both open and laparoscopic approaches have been well described.
The spleen must be adequately mobilized, and the splenic hilar vessels attached to the targeted segment should be ligated and divided, with the spleen then transected along the devascularized line of demarcation. Splenectomy Complications 1. Intraoperative complications a. Bleeding during laparoscopic splenectomy may necessitate conversion to a hand-assisted or open approach. Strong consideration should be given to splenorrhaphy in minor injuries. If pancreatic parenchymal injury is suspected during laparoscopic splenectomy, a closed suction drain should be placed adjacent to the pancreas, and a drain amylase obtained prior to removal after the patient is eating a regular diet.
Colonic injuries. Due to the close proximity of the splenic flexure to the lower pole of the spleen, it is possible to injure the colon during mobilization, but it is rare.
Mechanical bowel preparation is not indicated preoperatively. Identification and primary repair are appropriate. Gastric injuries can occur by direct trauma or can result from thermal injury during division of the short gastric vessels.
Use of energy devices too close to the greater curvature of the stomach can result in a delayed gastric perforation. High index of suspicion and low threshold to oversew any areas of concern is warranted. Diaphragmatic injury has been described during the mobilization of the superior splenic pole, especially with perisplenitis, and is of no consequence if recognized and repaired. In laparoscopic splenectomies, careful dissection of the splenophrenic ligament can minimize its occurrence.
The pleural space should be evacuated under positive-pressure ventilation prior to closure to minimize the pneumothorax. Early postoperative complications a. Treatment usually consists of percutaneous drainage and IV antibiotics. Ileus can occur after open splenectomy, but a prolonged postoperative ileus should prompt the surgeon to search for concomitant problems such as a subphrenic abscess or PVT. Thrombocytosis and thrombotic complications can occur after either open or laparoscopic splenectomy.
Late postoperative complications a. The estimated mortality with OPSI averages 0. Patients present with nonspecific flu-like symptoms rapidly progressing to fulminant sepsis, consumptive coagulopathy, bacteremia, and ultimately death within 12 to 48 hours. Encapsulated bacteria, especially S. Successful treatment of OPSI requires early supportive care and high-dose thirdgeneration cephalosporins.
OPSI appears to have a higher incidence in children, particularly below the age of 5. All patients who have had a splenectomy should be vaccinated and educated about the risk of OPSI Table Splenosis is the presence of disseminated intra-abdominal splenic tissue, which usually occurs after splenic rupture.
Care should be taken during splenic morcellation to avoid bag rupture and spillage of splenic tissue. Antibiotics and the Asplenic Patient. Early antibiotic therapy for the asplenic patient can be considered in three contexts: deliberate therapy for established or presumed infections, prophylaxis in anticipation of invasive procedures e. Daily prophylactic antibiotics oral penicillin have been recommended after operation in all children younger than 5 years and in immunocompromised patients because these patients are unlikely to produce adequate antibodies in response to pneumococcal vaccination.
Some also advocate continuation of prophylactic antibiotics into at least young adulthood, though this is not as widely practiced. The most common organism leading to overwhelming postsplenectomy infection OPSI is: a.
Streptococcus pneumoniae b. Haemophilus influenza type B c. Streptococcus B d. Staphylococcus aureus e. Escherichia coli 2. Which of the following is the correct set of vaccines to administer to a patient who is asplenic? Pneumococcal, pertussis, MMR, meningococcal, and influenza b. Pneumococcal, herpes zoster, meningococcal, and influenza c. Pneumococcal, Haemophilus influenzae, meningococcal, and influenza d. Pertussis, Haemophilus influenzae, meningococcal, and influenza e.
Pneumococcal, influenza, MMR, and herpes zoster 3. The most common etiology of splenic abscess is: a. Hematogenous spread b. Secondary infection of hematoma c. Local extension of colonic perforation d. Local extension of pancreatic abscess e. Secondary infection of cyst 4. Which of the following are not features of the post splenectomy patient?
Target cells b. Schistocytes c. Pappenheimer bodies d. Howell—Jolly bodies e. Leukocytosis that may persist for months 5. Which of the following individuals is at least risk for postsplenectomy sepsis?
Which of the following concerning thrombotic thrombocytopenic purpura TTP is true? Rituximab is standard first-line treatment b. Splenectomy is limited to patients who do not respond to medical management c. Plasmapheresis improves survival compared with plasma infusions d.
Results in a hemolytic anemia with a positive Coombs test 7. The most common indication for elective splenectomy is: a. Hodgkin lymphoma b. Thrombotic thrombocytopenic purpura c.
Sickle cell anemia d. Idiopathic thrombocytopenic purpura e. Hereditary spherocytosis 8. A year-old female presents with incidental finding of a proximal 2. Which of the following therapies would be most appropriate? Conservative management with routine surveillance b. Aneurysm exclusion and in situ reconstruction with vein graft c. Aneurysm exclusion and in situ reconstruction with PTFE d.
Resection with splenectomy e. Proximal and distal ligation of the splenic artery 9. A year-old female who underwent splenectomy 7 days ago for myelofibrosis and massive splenomegaly presents with abdominal pain, fever, and WBC of 17, CT of the abdomen reveals a small amount of pneumatosis in the small bowel and ascites. The most likely etiology is: a. Nonocclusive mesenteric ischemia b. Portal vein thrombus c.
Perforated viscus d. SMA occlusion e. Clostridium difficile colitis The most common site of an accessory spleen is: a. Splenorenal ligament b. Mesentery of the small bowel c. Bifurcation of the aorta d. Gastrohepatic ligament e. To understand why tissues from one individual are rejected by another, one has to appreciate the components of our immune system in its physiologic state. The innate immune system recognizes general distress as well as conserved moieties from ubiquitous pathogens, such as lipopolysaccharides of gram-negative bacteria.
The response is direct, nonspecific, and lacks memory. Mediators a. The complement cascade is a soluble group of proteins whose activation promotes the formation of the membrane attack complex MAC.
This embeds itself within cell membranes of pathogens causing disruption and cell lysis. In addition, byproducts of the complement cascade opsonize pathogens, which promote phagocytosis by antigen-presenting cells APCs. In humans, these complexes are referred to as human leukocyte antigens HLA and are located on chromosome 6. Classes of HLA a. They trigger an antibody humoral mediated immune response. Since each person has two MHC complexes, one on each copy of chromosome 6, everyone has a total of six HLA antigens that are relevant to organ transplantation.
Adaptive immune responses a. Cell mediated. Antigens in the peripheral tissues are presented to T-cells located in lymph nodes and the spleen. Following rearrangement, T-cells are selected based on their ability to bind self-MHC without activating a response.
MHC encountered in the tissues not involved in thymic education activates an immune response. This is the basis of alloreactivity. Activation releases IL-2, which causes B-cell maturation into plasma cells and IL-4, which causes maturation of cytotoxic T-cells. Antibody mediated humoral. B-cells bone activate antibodymediated humoral immunity. IL-4 from helper T-cells transforms B-cells into plasma cells, which secrete antibodies specific to the offending pathogen.
Tissue transfer from genetically identical individuals i. Tissue transfer between species. Tissue transfer among members of the same species. ABO blood compatibility is necessary for all transplants, except liver. It involves mixing recipient serum with donor lymphocytes. Patients who have been exposed to other HLAs via blood transfusion, pregnancy, or prior transplantation will have higher PRAs. Hyperacute rejection is the result of preformed anti-HLA antibodies that bind the allograft endothelium to initiate a cascade of events culminating in vascular thrombosis and ischemic necrosis.
The only therapeutic option is to remove the allograft immediately. This is extraordinarily uncommon in the modern era of cross-matching. Accelerated rejection is caused by sensitized T-cells that produce a secondary immune response. This generally occurs within 1 week of transplantation. Acute cellular rejection ACR is cell mediated and involves Tlymphocytes cytotoxic and helper. This typically occurs 1 week to 1 month after transplantation.
There are two basic treatment modalities: High-dose methylprednisolone and an antilymphocyte preparation. Chronic rejection is a poorly understood phenomenon that can occur weeks to years after transplantation. Emerging evidence suggests that the humoral immune response is an important contributor.
Plasmapheresis, IV immunoglobulin, and rituximab have been used to treat antibody-mediated rejection. In general, steroids and antithymocyte agents are used for induction with the primary aim of lymphocyte depletion and immune system downregulation. An ideal maintenance therapy regimen includes a calcineurin inhibitor CNI , an antiproliferative agent, and steroids.
In the treatment of rejection, it is important to choose medications that target the underlying mechanism. Doses given below are typical for kidney transplant recipients, however, specific combinations of medications and dosages are tailored for the patient and organ transplanted.
They are used for induction, maintenance, and treatment of rejection. Induction: Methylprednisolone up to 1 g IV initial dose followed by taper. Toxicities include poor wound healing, hyperglycemia, infections, cataracts, hypertension, weight gain, and bone disease. Used for maintenance therapy: a. Myelosuppression manifested as leukopenia and thrombocytopenia are its main toxicities.
Mycophenolic acid CellCept, Myfortic selectively inhibits lymphocyte proliferation resulting in suppression of T- and Blymphocytes. Mycophenolate mofetil CellCept : 1 to 3 g PO per day, divide over two doses. Use mg BID with tacrolimus, leukopenia, diarrhea, or in first week posttransplant. Toxicities include GI disturbance and leukopenia. CNIs 1. Nephrotoxicity, hypertension, tremors, seizures, hyperkalemia, hyperuricemia, hypercholesterolemia, gingival hyperplasia, and hirsutism are the main toxicities.
Toxicities are similar to CsA, but include more GI and neurologic changes. Used as maintenance therapy: a.
Dosing adjustments are made based on concomitant use of a CNI. Toxicity includes thrombocytopenia, hyperlipidemia, oral ulcers, anemia, proteinuria, and impairment of wound healing. Everolimus Zortress : mechanism of action and toxicities similar to sirolimus, but with greater bioavailability. Increasingly used for maintenance therapy in combination with low-dose tacrolimus to minimize CNI toxicity. Costimulation Blockade. Belatacept Nulojix prevents costimulation required for T-cell activation resulting in T-cell antigen-specific tolerance anergy.
FDA approved in for maintenance therapy in renal transplant, used only off label in liver transplantation: 1.
Associated with posttransplant lymphoproliferative disorder PTLD and should be avoided in patients who are EBV seronegative or who have received lymphocyte-depleting therapy. Antithymocyte Antibodies Fig. Thymoglobulin causes rapid T-cell depletion. It is the most commonly used antithymocyte antibody in the United States and is derived from rabbit serum after exposure to human thymocytes or Tcells.
Used as induction therapy or as rescue therapy following ACR, with premedication to avoid cytokine release syndrome: a. Premedication: diphenhydramine 50 mg PO, acetaminophen mg PO, hydrocortisone mg IV, given 1 hour before infusion. Induction: 4. Side effects include allergic reaction, leukopenia, and increased CMV infection and lymphomas. Side effects are minimal due to its specificity in binding. Bacterial Infections.
Pneumonia and urinary tract infections UTIs occur fairly commonly after transplantation. Infectious complications from opportunistic organisms are now uncommon because of appropriate prophylactic strategies.
Viral Infections 1. Cytomegalovirus CMV infection can occur at any time but is most common 1 to 4 months posttransplant in the absence of prophylaxis. Signs and symptoms include fever, chills, malaise, anorexia, nausea, vomiting, cough, abdominal pain, hypoxia, leukopenia, and elevation in liver transaminases. Prophylaxis may be useful in any patient who receives a CMV-positive allograft because many of these patients develop a significant CMV infection if left untreated.
Treatment consists of decreasing immunosuppression and administering ganciclovir, which inhibits DNA synthesis. Infiltration of the hematopoietic system, central nervous system CNS , lungs, or other solid organs may occur. The patient usually presents with fever, chills, sweats, enlarged lymph nodes, and elevated uric acid. Diagnosis is made by physical examination, EBV serology, computed tomography CT scan of the head, chest, and abdomen to evaluate lymph nodes or masses , and biopsy of potential sites or lesions.
Treatment consists of reducing or withdrawing immunosuppression. Herpes simplex virus HSV causes characteristic ulcers on the oral mucosa, in the genital region, and in the esophagus. Renal transplant patients, if not on ganciclovir, are given prophylactic acyclovir. BK virus is a member of the polyoma virus family.
There is no known effective treatment. Fungal infections can range from asymptomatic colonization to lethal invasive infections. Oral candidiasis can be prevented and treated with oral nystatin or fluconazole. Esophageal candidiasis can be treated with a short course of intravenous amphotericin B or fluconazole. Serious fungal infections are treated with intravenous amphotericin B, although use of less nephrotoxic agents such as caspofungin and anidulafungin is increasing.
Cancers that occur at a higher frequency in transplant recipients include squamous cell carcinoma, basal cell carcinoma, Kaposi sarcoma, lymphomas, hepatobiliary carcinoma, and cervical carcinoma. The gap between supply and demand grows daily, so a system exists that allocates solid organs to individuals based on two overarching themes: A. Each candidate is given fair consideration based on individual circumstances and medical need. The system tries to maximize the number of transplants performed and the survival of both patients and allografts.
The MELD score is derived from a logarithmic formula that incorporates the values for bilirubin, serum creatinine, and the international normalized ratio INR and ranges from 6 to 40 www. For patients with an initial MELD score greater than 11, the MELD score is recalculated with an adjustment formula for serum sodium Na , as hyponatremia was found to be an independent predictor of mortality in liver transplant candidates New Engl J Med.
Incorporating Na into the MELD score increases its predictive accuracy, particularly in patients with ascites Gastroenterology. Livers are allocated to appropriate patients with the highest MELD scores. Special exception points may be granted, such as in cases of hepatocellular carcinoma HCC , hilar cholangiocarcinoma, hepatopulmonary syndrome, or hepatorenal syndrome.
It includes an estimated posttransplant survival EPTS score for the recipient and kidney donor profile index KDPI , with priority given to candidates with less common blood types and a high calculated PRA score.
Waiting-list times are also included. EPTS is calculated based on age, time on dialysis, diabetes status, and history of previous solid organ transplant. It estimates the number of years of benefit from a transplant. KDPI is calculated for deceased donor kidneys only and provides a measure of donor quality to assist the transplant team in determining the suitability of donor kidney offers for potential recipients.
It includes 10 donor factors and results in a score reported as a percent. The reference population for KDRI is all deceased donor kidneys transplanted in the United States from the previous calendar year. The lower the KDPI, the longer the predicted graft survival. However, it should not be used in isolation when determining whether to use a kidney for transplantation.
Recipient factors and other donor factors not included in the calculation should be considered. Additionally, KDPI was developed using kidney transplant outcomes in an adult population and should be used with caution in the pediatric recipient, though the original analysis for KDRI included pediatric donors Transplantation. Living Donation. Given the significant number of candidates on the transplant waiting list, living donation is an important means for increasing the donor pool and has become an integral part of renal transplant practice.
The evaluation of potential living donors includes assessment of their overall health, comorbid conditions and psychosocial influences. Donors who are not compatible with their intended recipient may still donate through paired exchange and ABOincompatible protocols. Deceased Donation 1. Heart beating Donation after brain death, DBD.
Strict criteria for establishing brain death include irreversible coma and the absence of brain stem reflexes i. Other useful diagnostic tests include blood flow scan, arteriography, and an apnea test. Non-heart beating Donation after cardiac death, DCD refers to those potential organ donors who do not meet strict brain death criteria but who are considered to have nonrecoverable devastating neurologic insults.
Life support is discontinued in the operating room, and organ procurement is initiated after a specified interval following cardiac asystole. However, there is a growing body of evidence to suggest that in high volume centers and selected recipients, comparable outcomes can be achieved Liver Transpl.
Contraindications 1. Active infection. While evidence of HIV or TB are absolute contraindications to organ donation, patients with localized infections such as UTIs and pneumonia, in the absence of dissemination, are routinely given consideration.
Even in the presence of bacteremia, appropriate initiation of antibiotic therapy ensures a small risk of transmission. With the exception of primary CNS tumors, active cancer, whether treated or not, is an absolute contraindication to organ donation. While the blood—brain barrier protects CNS tumor cells from widespread dissemination in the heavily immunosuppressed patient, this is not the case for other malignancies.
Depending on the type of cancer, patients may be listed after a cancer-free wait time ranging from 2 to 5 years. General Considerations 1. As experience with less than ideal donors has grown, it has become apparent that arbitrary limits on donor age are unnecessary. Good allograft function has been achieved with kidney and liver donors with advanced age.
Overall health. As the donor pool ages, systemic diseases that can have an effect on specific organ function must be taken into consideration. Hypertension and atherosclerosis can hinder the suitability of kidney allografts, while obesity with hepatic steatosis limits the suitability of liver allografts. Social behaviors. While all donors are tested for HIV, hepatitis, and other viral infections, donors who engage in high-risk behaviors may still transmit an infection if donation were to occur within the window period prior to seroconversion.
Potential recipients are counseled regarding these socially high-risk donors and given the option whether to consider organs allocated from this group.
Identification of hepatic hilar structures aids later dissection in the cold. After cross-clamping the supraceliac aorta, the abdominal viscera are then flushed and cooled with University of Wisconsin UW preservation solution or histidine—tryptophan—ketoglutarate HTK.
The organs are packed with ice while the solution infuses. Evacuation of blood is into the chest via the inferior vena cava IVC. The donor liver is removed with its diaphragmatic attachments, a cuff of aorta surrounding the celiac axis and the superior mesenteric artery SMA , and a portion of the supraand infrahepatic IVC.
The liver is packaged in preservation solution and surrounded by iced saline during transportation. The donor kidneys are removed separately or en bloc.
The ureters are dissected widely to minimize devascularization and are divided near the bladder. The pancreas may also be removed for transplantation, with the pancreas, duodenum, and spleen removed en bloc. The blood supply for the pancreas allograft comes from the donor splenic artery and SMA, and outflow is via the portal vein Fig.
With the advent of modern preservation solutions, donor livers can be preserved for up to 12 hours before reperfusion kidneys up to 40 hours , with a low incidence of allograft dysfunction. Ideally, cold ischemia time is minimized to less than 6 hours for livers and 24 hours for kidneys. End-stage renal disease ESRD is the consequence of multiple disease processes; however, diabetes, hypertension, and polycystic kidney disease account for majority of cases Table From Sung R.
Pancreas and Islet Transplantation. Recipient selection. The evaluation identifies coexisting problems or disease entities that must be addressed to improve the outcome of the transplant. Recipient operation. A central venous pressure CVP line is inserted, and a first-generation cephalosporin is administered.
The transplant renal vein and artery typically are anastomosed to the external iliac vein and artery, respectively. A heparin bolus of 3, units may be administered before clamping the iliac vessels. The ureter can be anastomosed to either the recipient bladder or the ipsilateral ureter, although the bladder is preferred. Establishing an antireflux mechanism is essential for preventing posttransplantation reflux pyelonephritis.
This is accomplished by performing an extravesical ureteroneocystostomy Lich. A double-J ureteral stent is commonly used.
TABLE Causes of Renal Failure Requiring Transplantation Type Characteristics Congenital Aplasia, obstructive uropathy Hereditary Alport syndrome hereditary nephritis , polycystic kidney disease, tuberous sclerosis Neoplastic Renal cell carcinoma, Wilms tumor Progressive Diabetic neuropathy, chronic pyelonephritis, Goodpasture syndrome antiglomerular basement membrane disease , hypertension, chronic glomerulonephritis, lupus nephritis, nephrotic syndrome, obstructive uropathy, scleroderma, amyloidosis Traumatic Vascular occlusion, parenchymal destruction c.
Postoperative considerations 1 IV fluid replacement. In general, the patient should be kept euvolemic or mildly hypervolemic in the early posttransplantation period with a goal of mm Hg systolic BP to ensure adequate perfusion to the new allograft. More severe leukocytosis may indicate progression to necrosis or perforation. Urinalysis is frequently abnormal in patients with advanced appendicitis, especially in patients with suprapubic appendicitis and secondary bladder irritation.
Serum electrolytes, BUN, creatinine. Abnormalities may indicate dehydration and will require urgent correction. Serum or urine pregnancy test must be performed in all ovulating females to guide diagnosis and management, as well as evaluate for obstetric etiologies of pain.
Imaging 1. Computed tomography CT imaging is the most commonly ordered radiographic test to diagnose acute appendicitis. Sign up Log in. Web icon An illustration of a computer application window Wayback Machine Texts icon An illustration of an open book. Books Video icon An illustration of two cells of a film strip. Video Audio icon An illustration of an audio speaker. Audio Software icon An illustration of a 3. Software Images icon An illustration of two photographs.
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Concise, portable, and user-friendly, The Washington Manual of Surgery, 7th Edition , focuses on the essential information you need to know for successful care of patients with surgical disease. This bestselling reference presents brief, logical approaches to the management of patients with comprehensive surgical problems.
Throughout the manual, content has been completely updated, including new review questions, new chapters, and new treatment algorithms. This 7th Edition provides a clear view of the challenges surgical residents face, practical solutions, and expert guidance — all in one convenient and easily accessible source.
Key Features: Thoroughly revised with information on the latest advances in surgical technique, instrumentation, and standards of practice.
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