The immunocompromised adult patient and surgery

First Composite Woman-to-Woman Facial Transplantation in Turkey: Challenges and Lessons to Be Learned

ABSTRACT

After the first face transplantation from woman to woman we performed in our clinic, it was aimed to eliminate the lack of knowledge about the subject in the literature by transferring our experiences and long-term results to the problems we had with the patient. A 20-year-old patient underwent partial osteomyocutaneous facial transplant (22nd facial transplant), which included 2 functional units of the face. The patient had no major problems in the early period and had a good aesthetic appearance. In the postoperative period, the patient ended her social isolation and adopted the transplanted face.In the late period, secondary surgical interventions, management of the problems caused by immunosuppression, and the patient's living in a remote location to our clinic were the difficulties encountered. Six revision surgeries were performed after the transplantation. Due to immunosuppression, opportunistic infections and metabolic problems required intermittent hospitalization. The patient died at the end of 56 months because of complications secondary to immunosuppression.A successful transplant involves the management of long-term problems rather than a successful tissue transfer in the early period. In today's conditions, long-term success can be achieved with a good patient compliance, as well as each team member should take an active role in the team at the transplantation centers. More case series are needed to adapt the standard treatment and follow-up protocols for solid organ transplantations for composite tissue allotransplantations. This will be possible by sharing the results and experiences transparently in the centers where face transplantation is performed worldwide.

Acute Abdominal Complications in Deeply Neutropenic Onco-Hematology Patients: A Retrospective Series of 105 Cases

BACKGROUND

Acute abdominal complications (AAC) in patients with deep neutropenia (DN) is challenging to manage because of the expected influence of AAC on oncological prognosis and higher surgical complication rate in a period of DN. In practice, these parameters are difficult to appreciate. This study reported our experience in managing these patients.

METHODS

All consecutive patients treated in our tertiary care cancer center between 2010 and 2020 who developed AAC in the context of a DN were retrospectively analyzed. AAC was defined as an infection (intra-abdominal, perineal, or cutaneous), bowel obstruction, or intra-abdominal hemorrhage.

FINDINGS

Among 105 patients, 18 (17%) required emergent surgery (group 1), 34 patients had a complication requiring surgical oversight (group 2), and 53 patients had a non-surgical etiology (group 3). Fifteen patients underwent surgery in the group 1, three in group 2, and one in group 3. Overall, 28 patients died during hospitalization. Mortality was statistically different between the groups (p = 0·01), with a higher rate in group 1 (n = 9/18, 50%) than in group 2 (n = 11/34, 32%) and group 3 (n = 8/53, 15%). All groups together had a median overall survival (OS) of 14 months and disease-free survival (DFS) of 10 months. OS was not comparable between the groups, and the median length of survival in group 1 was 6 months versus 8 months in group 2 and 23 months in group 3. In group 1, five patients (5/18, 28%) did not relapse at the end of the follow-up compared to 13 in group 2 (13/34, 38%) and 25 in group 3 (25/53, 47%). After discharge, OS and DFS were similar between the groups.

INTERPRETATION

The advent of an AAC necessitating surgery in the context of DN is a deadly event associated with a 50% mortality; nonetheless, in case of unpostponable emergencies, surgery can provide long-term survival in selected patients.

Anesthetic Considerations for Cesarean Delivery After Uterine Transplant

Infertility has many etiologies and can have devastating consequences for young couples attempting to bring children into the world. Uterine factor for infertility is related to either uterine agenesis (Mayer-Rokitansky-Küster-Hauser [MRKH] syndrome), unexpected hysterectomy, or presence of a nonfunctioning uterus. In this review, a patient with MRKH syndrome underwent donor uterus transplantation at the Cleveland Clinic, conceived, and delivered the first healthy baby in the United States and the second worldwide. Additionally, we review the pertinent literature on anesthesia problems. Donor-related uterine transplant is a recent medical innovation requiring multidisciplinary expertise. In patients who deliver successfully, according to the current literature, the transplanted uterus can be used for one more pregnancy only if the mother so desires, otherwise cesarean hysterectomy (C-Hyst) should be performed. In the observed case, C-Hyst was performed because the patient developed placenta accreta and the couple desired no further pregnancy. In summary, with our limited data, careful management of these patients is required to ensure the best outcome for the mother and the newborn fetus.

[Immunosuppression, Surgery, Complication?]

Immunosuppression, Surgery, Complication? Abstract. Surgical conditions sometimes pose major diagnostic and therapeutic challenges for immunosuppressed patients. Especially in patients suffering from diseases with potential septic emergencies or postoperative complications, the indication for elective surgery should be discussed at an early stage. This is best done across disciplines, involving all experts and the patient.

Intraoperative Acute Respiratory Failure in an Immunocompromised Patient with Human Metapneumovirus

Patient: Male, 31

Final Diagnosis: Pneumonia from Human Metapneumovirus pulmonary infection

Symptoms: Cough • fatigue

Medication: —

Clinical Procedure: Hernia repair

Specialty: Anesthesiology

Is Aesthetic Surgery Safe in the Solid Organ Transplant Patient? An International Survey and Review

BACKGROUND

Improved immunosuppression and lifespans have afforded solid organ transplant (SOT) recipients the opportunity to seek aesthetic surgery.

OBJECTIVES

To determine current trends in the provision of aesthetic in the SOT patient population, we polled the international plastic surgery community. We specifically sought to evaluate their experiences with this patient population, as well as to perform a review of the literature to provide updated guidelines for practitioners who may consider performing surgery in the SOT patient population.

METHODS

A web-based survey was sent to national and international colleagues to query the experiences and complication rates of performing aesthetic surgery in this patient population.

RESULTS

Thirty percent of the 1308 respondents performed surgery in SOT patients. Three hundred and forty practitioners performed 552 procedures with a 4.3% complication rate. Over 68% of all procedures were performed on kidney transplant recipients.

CONCLUSIONS

SOT patients can safely undergo elective aesthetic procedures. We recommend working closely with the medical team to assure the best outcomes.

Facial transplantation: the first 9 years

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Patients with immunodeficiency

Patients presenting in an immunocompromised state merit special consideration when being evaluated for fitness to undergo surgery. A variety of immunodeficient conditions and their respective therapies, including human immunodeficiency virus, cancer, and transplantation, exert numerous systemic effects that may lead to multiorgan dysfunction. Understanding the potential impact of these disease manifestations, and their proper evaluation, is essential in achieving optimal perioperative outcomes for these patients.

Copper and anesthesia: clinical relevance and management of copper related disorders

Recent research has implicated abnormal copper homeostasis in the underlying pathophysiology of several clinically important disorders, some of which may be encountered by the anesthetist in daily clinical practice. The purpose of this narrative review is to summarize the physiology and pharmacology of copper, the clinical implications of abnormal copper metabolism, and the subsequent influence of altered copper homeostasis on anesthetic management.

Hemostatic challenges in patients with chronic immune thrombocytopenia treated with eltrombopag

Chronic immune thrombocytopenia (ITP) is an autoimmune disease that results in chronically low platelet counts. Treatment guidelines recommend a platelet count of at least 50 000/µl before minor surgery and at least 80 000/µl before major surgery. This retrospective analysis explored invasive non-dental procedures associated with the risk of bleeding (hemostatic challenges) among patients with chronic ITP in five phase 2/phase 3 studies of the thrombopoietin-receptor agonist, eltrombopag. Data collection for patients who underwent hemostatic challenges included demographics, study medication, timing of the procedure, platelet counts at last assessment before and first assessment after the procedure, supplemental ITP treatment, and bleeding events. Among 494 patients who participated in the studies, 87 hemostatic challenges were recorded. Median platelet counts before 44 major procedures in 32 patients were 100 000/µl and 18 500/µl among patients who received eltrombopag and placebo, respectively; before 43 minor procedures in 38 patients, median platelet counts were 82 000/µl and 20 000/µl among patients who received eltrombopag and placebo, respectively. A minority of patients required supplemental ITP treatment. Only 2 of 87 hemostatic challenges were associated with bleeding events; both patients received eltrombopag and pre-procedural platelet counts were 83 000/µl and 2000/µl. Although the number of patients who did not undergo procedures due to thrombocytopenia was not captured, these data suggest a majority of patients with chronic ITP who receive eltrombopag and experience increases in platelet counts meet current pre-procedural platelet count recommendations. The potential role of eltrombopag in supporting preparation of chronic ITP patients for surgical procedures still needs to be clinically established.

Preoperative assesment of the immunocompromised patient

In some surgical patients immunosuppression is easily apparent and directly caused by known underlying disease or treatment. In others, although induced by the underlying disease, immunosuppression may be less obvious. Perioperative management of immunocompromised patient is mostly directed by the fact that immunosuppression itself does not cause pathology, but does leave the patient prone to infection. Immunodeficiency can be broadly characterized as congenital (primary) or acquired (secondary). The majority of immune deficiencies that are of interest to the anaesthetist are acquired. They can be present both in children and adults, in a huge variety of patients that are presented preoperatively. Most of them do not require different than usual perioperative anaesthetic management. However, in some of them specific aspects of treatment should be considered, such as HIV infected, cancer, transplant patients, and those scheduled for organ transplantation.

[Perioperative management of long-term medication]

Anesthesiologists and surgeons are increasingly faced with patients who are under long-term medication. Some of these drugs can interact with anaesthetics or anaesthesia and/or surgical interventions. As a result, patients may experience complications such as bleeding, ischemia, infection or severe circulatory reactions. On the other hand, perioperative discontinuation of medication is often more dangerous. The proportion of outpatient operations has increased dramatically in recent years and will probably continue to increase. Since the implementation of DRGs (pending in Switzerland, introduced in Germany for some time), the patient enters the hospital the day before operation. This means that the referring physician as well as anesthesiologists and surgeons at an early stage must deal with issues of perioperative pharmacotherapy. This review article is about the management of the major drug classes during the perioperative period. In addition to cardiac and centrally acting drugs and drugs that act on hemostasis and the endocrine system, special cases such as immunosuppressants and herbal remedies are mentioned.