© Springer Science+Business Media New York 2017Kathirvel Subramaniam and Tetsuro Sakai (eds.)Anesthesia and Perioperative Care for Organ Transplantation10.1007/978-1-4939-6377-5_43
43. Postoperative Management for Visceral (Intestine, Intestine/Liver, and Multivisceral) Transplantation
Thomas E. Starzl Transplantation Institute, UPMC Montefiore, 7 South 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
Westchester Medical Center/ New York Medical College, Division of Intra-abdominal, Transplantation and Hepatobiliary Surgery, 100 Woods Road, Taylor Pavilion O-128B, Valhalla, NY 10595, USA
KeywordsMultivisceral transplantationIntestineGraftNeurologic complicationsHypertensionTotal parenteral nutritionInfectionImmunosuppression
Patients who require intestine-containing grafts can be categorized into the following three groups:
Patients who need an isolated intestinal transplant a modified multi-visceral transplant including stomach, duodenum, pancreas, small intestine for gut failure (Group 1).
Patients who need both an intestine and liver transplant for intestinal failure with total parenteral nutrition (TPN) and liver disease (Group 2).
Patients with liver cirrhosis/complete mesoportal thrombosis who need either an intestine/liver or a full multivisceral transplant (Group 3).
Group 1 patients are TPN-dependent and tend to become chronically dehydrated. Renal dysfunction is not uncommon. Sometimes they need a simultaneous kidney transplant. Isolated intestinal transplantation is a relatively less intensive procedure since there is no portal hypertension. A patient can be extubated either on the day of surgery or postoperative day one.
Group 2 consists of the Group 1 population with liver disease. They are much sicker than Group 1. Patients who have short gut syndrome with TPN-associated liver disease may not present signs of portal hypertension until the liver becomes more cirrhotic than the livers of regular cirrhosis patients, as portal flow is decreased due to short gut syndrome. They may lose a large amount of blood due to relatively larger raw surface area with portal hypertension in the operating room. Therefore, intraoperative and postoperative fluid management can be difficult. More intensive postoperative management is necessary than for liver transplantation.
Group 3 is essentially the same as patients who undergo (isolated) liver transplantation. Liver/intestine or full multivisceral transplantation is needed because of difficulty securing inflow (portal vein flow) to the liver. Postoperative management of this group is similar to management of liver transplant patients, although the intestine needs special care.
Sixty-eight percent of visceral transplant patients may have neurological complications such as headache, encephalopathy, seizures, neuromuscular disorders, opportunistic central nervous system infections, and ischemic strokes . Tacrolimus (Prograf) especially can cause neurological toxicity such as tremor, headache, mental status change, seizure, and PRES (Posterior Reversible Encephalopathy Syndrome). Since many visceral transplant patients receive numerous kinds of medications, at least in the beginning, interaction between medication and their toxicities and metabolites can be frequent causes of neurological symptoms. Simplifying medications is advised if feasible.
Infection has to be ruled out when a patient develops unclear neurological problems. Sepsis, cytomegalovirus, herpes viruses, tuberculosis, Cryptococcus, and fungal infections need to be investigated.
Patients often have pretransplantation psychiatric conditions (depression and anxiety disorders) partly because they tend to have long-standing chronic illnesses with frequent hospital stays and surgeries. Chronic use of pain medications is one of the most difficult problems to deal with, presenting a big challenge after transplantation in terms of pain control. Therefore, it is important for a pain management team and psychiatrist to see a patient with these issues before transplantation. Tacrolimus and steroid use also can cause neurotoxicity, which can manifest as psychosis.
Group 2 and 3 patients are treated like liver transplant patients. The Swan-Ganz catheter is useful in the operating room and soon after transplantation for these groups.
In the operating room, fluid management and coagulation management are essential in these patients, especially those in Groups 2 and 3. Proper fluid resuscitation with 5 % albumin or blood products should be obtained before starting infusion of vasoactive medications. If a vasopressor is necessary in the operating room, starting with a small dose of norepinephrine of 0.05 mcg/kg/min and titrating to a minimum necessary dose is preferred.
In the postoperative period, we prefer to start a continuous infusion of Prostaglandin E1 (alprostadil, Prostin VR® Pediatric, Pfizer) at small doses of 0.2 mcg/kg/h titrated to a maximum dose of 0.6 mcg/kg/h when hemodynamic stability is achieved. The dose is titrated up if the blood pressure tolerates it. The vasodilator and anti-platelet aggregation properties of alprostadil aim to protect the microvasculature of the recently reperfused intestine .
Hypertension is common after transplantation. Tacrolimus can cause renal vasoconstriction and corticosteroid administration may lead to fluid retention, both of which can cause high blood pressure. Calcium channel blockers decrease the arterial vasoconstriction caused by tacrolimus. Amlodipine has less of an effect on tacrolimus concentrations than on nondihydropyridine calcium channel blockers such as verapamil. Other medications such as beta-blockers, clonidine, and angiotensin-converting enzyme (ACE) inhibitors can be added if Amlodipine alone is not enough to control blood pressure. It is important to avoid hypotension due to excessive treatment, since transplanted intestine seems more sensitive to hypotension.
Group 1 (isolated intestine) recipients have better overall reserves and normally are able to be extubated on the same day of the transplant or on the first postoperative day. If the patient cannot be weaned from the ventilator soon after transplant, early tracheostomy should be considered. In the postoperative period, the importance of avoiding aspiration pneumonia should be emphasized, since it is very common in intestinal transplant patients.
Liver management in Group 2 and 3 patients is similar to that of post liver transplantation patients. Liver enzyme and lactate trends and patient mental status are good indicators with which to evaluate liver functions. In general, liver enzymes trend down after transplantation. Doppler ultrasound is necessary for any uncertainty of liver functions, but we do not use it routinely.
In Groups 2 and 3, 16 % of patients have pancreaticobiliary problems, which include ampullary stenosis, bile duct stones, bile duck leak, necrotizing pancreatitis, edematous pancreatitis, and pancreatic duct fistula . Pancreatitis can be encountered due to ischemic perfusion injury and can be managed with a nonoperative approach (NPO and octreotide, etc.). However operative interventions are sometimes necessary if pancreatic fistula is suspected. When ischemic reperfusion injury such as swelling of pancreas or hemorrhage in the pancreatic parenchyma, is seen during the operation, an octreotide drip is used. Biliary complication may occur in patients receiving modified multivisceral grafts containing stomach, duodenum, pancreas, and small intestine due to lack of blood supply from gastroduodenal artery and duct to duct biliary anastomosis. Sphincter dysfunction can be treated by sphictorotomy .