© 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_40
40. Preoperative Recipient Evaluation for Visceral (Intestine, Intestine/Liver, 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
KeywordsMultivisceralGraftIntestinal failureLiver cirrhosisMesoportal thrombosis
Patients who require intestine-containing grafts are diverse and can be categorized into the following three groups:
Patients who need an isolated intestinal transplant or 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 transplant 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 simultaneous kidney transplantation. Because of their long history of parenteral nutrition (TPN) use, their line access tends to be limited and line infections need to be checked.
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 their liver becomes more cirrhotic than regular cirrhosis patients, as portal flow is decreased due to short gut syndrome. Therefore, we treat these patients carefully once they develop ascites and portal hypertension.
Group 3 is made up of essentially the same as patients who undergo (isolated) liver transplantation. Liver/intestine or full multivisceral transplantation is needed because of difficulty securing inflow to the liver (portal vein flow). Therefore, preoperative evaluation and preparation of patients in this group is the same as that for liver transplant patients.
Indications and Contraindications for Visceral Transplantation
Visceral transplantation is indicated for the patients with (1) irreversible and permanent intestinal failure, and (2) presence or onset of life-threatening complications from TPN.
The onset of liver disease or central venous catheter-related complications such as recurrent or potentially fatal sepsis/fungemia and loss of venous access sites are life-threatening complications from TPN, as well as Medicare-approved criteria for visceral transplantation. Preemptive visceral transplantation (before the patient develops TPN-related complications) is still a controversial issue, as it has not been approved by Medicare or most insurance carriers [1, 2]. In addition to the indications above, patients with liver cirrhosis and mesoportal thrombosis (Group 3) are indicated for liver/intestine or full multivisceral transplantation.
Contraindications to visceral transplantation are similar to those for transplantation of other solid organs due to malignancy, severe systemic disease, etc. They may be even more absolute because of the considerable morbidity and mortality following this procedure. Thus, patients with multiple severe congenital anomalies, recent extra-abdominal malignancy, or severe neurologic disability are not appropriate candidates for transplantation. Recent line infections could be a frequent dilemma for visceral transplant patients. However, the patient can undergo transplantation if a line infection is treated at least for a few days, and the patient is not bacteremic at the time of the procedure. Multisystem autoimmune diseases such as scleroderma and severe immune deficiencies are also relative contraindications to visceral transplantation [1–3].
Pretransplantation Recipient Evaluations
Patients frequently suffer subclinical cerebrovascular events, especially in the setting of hypotension, due to sepsis and ischemic bowel or systemic atherosclerosis. Therefore, our program performs a routine head computerized tomography (CT) scan at the time of outpatient evaluation. Anti-epilepsy drugs need to be checked prior to transplantation since many of them interact with tacrolimus (Prograf). Pretransplant consultation with the neurology service and switching anti-seizure medication to levetiracetam (Keppra) should be considered.
Psychiatric/Social Support Evaluation
Many Group 1 and 2 patients have received numerous surgeries. Some of them undergo 20–30 surgeries prior to coming to a transplant center. Many may have depression and anxiety disorders. Evaluation of patients by a designated psychiatrist who is familiar with intestinal failure and transplantation is essential. It is also not uncommon that patients use narcotics regularly for chronic abdominal pain and have high narcotic tolerance, factors which are extremely challenging in the perioperative setting. Preoperative evaluation by a chronic pain specialist to reduce narcotic use using alternative techniques is important. We prefer transdermal pain management while patients are on the waiting list. This facilitates establishment of a perioperative game plan.