The Preoperative Evaluation of the Transplanted Patient for Nontransplant Surgery

Total joint arthroplasty following solid organ transplants: complications and mid-term outcomes

PURPOSE

Survival after solid organ transplant (SOT) is improving, and demand for total joint arthroplasty (TJA) among SOT recipients is rising. Outcomes including revision, periprosthetic joint infection, and survivorship based on SOT type are variable. We sought to compare peri-operative complications, implant survivorship, and mortality for patients undergoing TJA following SOT.

METHODS

A retrospective review of the institutional database for primary TJA among SOT recipients from 2000 to 2020 was performed. Revisions, conversion TJA, and patients with multiple organ transplants were excluded. Patients were stratified by transplant organ. Transfusions, 90-day readmissions and emergency department (ED) visits, revisions, and mortality were compared using descriptive statistics and Cox proportional hazard ratios.

RESULTS

A total of 119 total hip arthroplasties (THA) and 63 total knee arthroplasties (TKA) in SOT recipients were studied. Most common SOT was renal (39%), then lung (27%), liver (24%), and heart (10%). TKA postoperative transfusion rates varied by organ (p = 0.037; [heart 0%, liver 9.5%, renal 24.0%, lung 50.0%]). Implant survivorship was 95.6% at one year (95% CI 90.3-98.1) and 92.1% at four years (83.9-96.3). Mortality was 2.9% at one year (95% CI 1.1-7.4) and 23.2% at four years (95% CI 16.1-32.3). After adjusting for procedure, duration from transplant to TJA, age, and Elixhauser Index, lung recipients had higher mortality versus heart (RR 4.39 [95% CI 1.64-15.38]; p = 0.002), kidney (7.98 [3.04-24.61]; p < 0.001), and liver (7.98 [3.04-24.61; p < 0.001) patients.

CONCLUSION

TJA after SOT yields acceptable peri-operative outcomes and implant survivorship, but mortality risk is substantial, especially among lung transplant recipients.

Renal Transplantation Is Associated with Increased Complications Following Spinal Fusion Operations: Analysis of a National Database

BACKGROUND

Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed.

METHODS

The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts.

RESULTS

Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P < 0.001; 58% male vs. 45.5% male, P < 0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P < 0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P < 0.001; 13.6% vs. 6.2%, P < 0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P < 0.001), lower routine discharge (odds ratio = 0.57, 95% confidence interval 0.48-0.69, P < 0.001), and higher discharge to alternative care facilities (odds ratio = 1.91, 95% confidence interval 1.57-2.33, P < 0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P < 0.001).

CONCLUSIONS

History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

Acute Care Surgery for Transplant Recipients: A National Survey of Surgeon Perspectives and Practices

BACKGROUND

Transplant recipients are living longer than ever before, and occasionally require acute care surgery for nontransplant-related issues. We hypothesized that while both acute care surgeons (ACS) and transplant surgeons would feel comfortable operating on this unique patient population, both would believe transplant centers provide superior care.

METHODS

To characterize surgeon perspectives, we conducted a national survey of ACS and transplant surgeons. Surgeon- and center-specific demographics were collected; surgeon preferences were compared using χ2, Fisher's exact, and Kruskal-Wallis tests.

RESULTS

We obtained 230 responses from ACS and 204 from transplant surgeons. ACS and transplant surgeons believed care is better at transplant centers (78% and 100%), and transplant recipients requiring acute care surgery should be transferred to a transplant center (80.2% and 87.2%). ACS felt comfortable operating (97.5%) and performing laparoscopy (94.0%) on transplant recipients. ACS cited transplant medication use as the most important underlying cause of increased surgical complications for transplant recipients. Transplant surgeons felt it was their responsibility to perform acute care surgery on transplant recipients (67.3%), but less so if patient underwent transplant at a different institution (26.5%). Transplant surgeons cited poor transplanted organ resiliency as the most important underlying cause of increased surgical complications for transplant recipients.

CONCLUSIONS

ACS and transplant surgeons feel comfortable performing laparoscopic and open acute care surgery on transplant recipients, and recommend treating transplant recipients at transplant centers, despite the lack of supportive evidence. Elucidating common goals allows surgeons to provide optimal care for this unique patient population.

Perioperative management of renal transplant patients undergoing total joint arthroplasty

The success of renal transplantation depends on lifelong immunosuppression. This can lead to a high incidence of avascular necrosis of major joints in the body for which arthroplasty is the treatment of choice. The risk of surgical complications is high in these patients, and there is no current set of cohesive perioperative management guidelines. In this review, we discuss the perioperative management of renal transplant patients undergoing elective total joint arthroplasty.

Outcomes Following Colorectal Resection in Kidney Transplant Recipients

BACKGROUND

Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population.

METHODS

We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors.

RESULTS

In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p < 0.001; adjusted odds ratio [aOR] _2.683.59_4.81) as were overall complications (38.5 vs 31.5%, p = 0.001; aOR _1.081.30_1.56). LOS was significantly longer (10 vs 7 days, p < 0.001; ratio _1.421.53_1.65) and cost was significantly greater ($23,056 vs $14,139, p < 0.001; ratio _1.421.54_1.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p = 0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type.

CONCLUSIONS

KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

Complications, length of stay, and cost of cholecystectomy in kidney transplant recipients

We hypothesized that cholecystectomy may be riskier for kidney transplant recipients (KTR) given their lifelong immunosuppression, physiologic impact of renal failure, and increased risk of gallstone and biliary disease. Using NIS, we compared mortality, morbidity, length of stay and cost in KTR vs non-KTR following cholecystectomy in the US from 2000 to 2011, adjusting for patient and hospital level factors, including transplant center status. Mortality was higher (OR 2.4), morbidity was higher (OR 1.3), LOS was longer (ratio 1.2), and costs were greater (ratio 1.1) for KTR compared to non-KTR following cholecystectomy. While it is clear that KTR are a high risk group following cholecystectomy, the cause of this increased risk requires further investigation.

Surgical approach, cost, and complications of appendectomy in kidney transplant recipients

Kidney transplant recipients (KTRs) have greater morbidity and length of stay (LOS) following certain surgical procedures than non-KTR. Given that appendectomy is one of the most common surgical procedures, we investigated differences in outcomes between 1336 KTR and 2 640 247 non-KTR postappendectomy at transplant and nontransplant centers in the United States from 2000 to 2011, using NIS data and adjusting for patient-level and hospital-level factors. Postoperative complications were identified using ICD-9 codes. Among KTR, there were no post-appendectomy in-hospital deaths, compared to a 0.2% in non-KTR (P = .5). Overall complications were similar among KTR and non-KTR (17.0% vs 11.6%; aOR:_0.77 1.12_1.61 ). LOS and costs were greater for KTR compared to non-KTR (LOS ratio _1.19 1.31_1.45 ; cost ratio _1.11 1.17_1.26 ). Only 44.8% of KTR had laparoscopic approach compared to 54.5% of non-KTR, but had similar complication rates (10.6 vs 8.7%, P = .5). When treated at transplant centers, KTR had similar complications (aOR _0.44 0.79_1.43 ), but longer LOS (ratio _1.21 1.37_1.55 ) and greater hospital-associated costs (ratio _1.19 1.29_1.41 ) than non-KTR. Conversely, at nontransplant centers, KTR and non-KTR had similar complications (aOR _0.75 1.23_2.0 ), LOS (ratio _0.84 0.96_1.09 ), and cost (ratio _0.93 1.01_1.10 ). Contrary to other procedures, KTR did not constitute a high-risk group for patients undergoing appendectomy.

Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care

Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.

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.

Hysterectomy and perioperative morbidity in women who have undergone renal transplantation

OBJECTIVE

The purpose of this study was to compare complications from vaginal hysterectomy with abdominal hysterectomy in renal transplant recipients.

STUDY DESIGN

Women who underwent renal transplantation then hysterectomy from 1966-2008 at Mayo Clinic, Rochester, MN, were identified. Data were collected about preoperative, intraoperative, and postoperative events. Main outcome measure was loss of allograft function; secondary outcomes included types of complications and treatment methods.

RESULTS

Of 58 women with renal transplants, 42 women (72.4%) underwent abdominal hysterectomy. The most common indication for hysterectomy was menorrhagia (n = 20; 34.5%). Overall, 24 women (41.4%) had complications, the most common of which were infection (n = 15) and transfusion (n = 8). Women who underwent abdominal hysterectomy were no more likely to have perioperative complications than were women who underwent vaginal hysterectomy (odds ratio, 1.25; 95% confidence interval, 0.38-4.08).

CONCLUSION

Although patients with renal transplants had perioperative complications, none of these complications led to renal graft loss. Hysterectomy can be considered in these patients when accompanied by diligent postoperative care.

The new face of transplant surgery: a survey on cosmetic surgery in transplant recipients

BACKGROUND

Transplant surgery has undergone tremendous advances within the last decade. Improvements in surgical techniques, availability of potent immunosuppressive medications, and utilization of more sophisticated post-transplant immunosuppression protocols have revolutionized the field. These developments have resulted in increased allograft survival, prolonged longevity, and improved quality of life in transplant organ recipients. Elimination of steroids in many postoperative immunosuppressive regimens has tremendously impacted the quality of life and physical appearance of these patients. They are living longer and more normal lives than previously considered possible. As a testament to the success of transplantation surgery, many transplant patients are now seeking aesthetic surgery.

METHODS

A survey was sent to ASPS members asking about their experience with transplant patients undergoing aesthetic procedures.

RESULTS

Of the 789 (18%) plastic surgeons who responded, 201 (25%) have performed aesthetic surgery on transplant recipients. A total of 278 patients underwent 292 surgical aesthetic procedures and 64 patients underwent 94 nonsurgical aesthetic procedures. The incidence of reported perioperative complications was 3.4%. There were very few additional precautions taken with these patients relative to the general population. With the exception of obtaining medical clearance, these additional precautions were inconsistent among plastic surgeons.

CONCLUSION

Cosmetic surgery in transplant recipients is being successfully practiced in the USA. Surgical and nonsurgical aesthetic procedures are being performed safely in organ transplant recipients without a significant increase in the incidence or degree of complications. If certain precautions are undertaken, these patients may expect a degree of success comparable to that of the rest of the population.