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Surgery in transplant patients
- Immunosuppression is not a contraindication and good outcomes can still be achieved
- Contact transplant team before operating
- Common conditions can present atypically - rely on imaging
- Don't stop immunosuppression, but medications will need to be adjusted/managed
- Assess graft function
- Kidney - urine output, ability to concentrate urine
- Liver - jaundice, pruritis, fluid retention
- Assess associated diseases
- Bloods
- Nutritional assessment
- Altered anatomy
- Immunosuppressants
- Azathioprine can be withheld for two days
- Mycophenolate can be withheld for 2-3 days or continued, and there is an IV alternative
- Cyclosporine can be given IV at 1/3 of usual dose
- Calcineurin inhibitors can be continued
- Sirolimus/everolimus - if elective, try and change to calcineurin inhibitor to allow wound healing
- Steroids
- Careful tissue handling - risk due to immunosuppression
- Always be careful of altered ureter if present
- Consider prolonged antibiotics
- Consider stress dosing steroids
- Often appropriate to perform emergency surgery locally then transfer to a transplant list
- Obviously consult transplant centre up-front
- Can generally be done laparoscopically
- Rarely have adhesions due to poor wound healing, so consider other causes
- Common, obviously if it is a liver transplant need to transfer
- High rates of complication and mortality
- Consider elective resection even after one episode
- No anastomosis in emergency
