Surgery in the Transplanted Patient
13 Surgical Considerations in Solid-Organ Transplant Recipients
Pasithorn A. Suwanabol, MD, Joshua D. Mezrich, MD
In 2008, over 27,000 patients received solid-organ transplants in
the United States alone.1 Advances in the management and the
surgical techniques of solid-organ transplantation have led to a
growing number of patients living long term with transplanted
organs. In fact, the 5-year survival of living donor renal
transplant and liver transplant has been reported at 91% and 79%,
respectively.1 As a result, general surgeons have a greater
likelihood of encountering a posttransplant patient now than ever
Despite commonly held concerns, a large number of studies have
demonstrated that immunosuppression is not a contradiction to
surgery and good outcomes can be expected in the majority of
patients.2–7 Additionally, abdominal surgery in transplanted
patients is not infrequent, with reports of up to 10% of renal
transplant patients experiencing a severe gastrointestinal (GI)
complication within 10 years8 and 24% of liver transplant patients
having another surgical procedure within 10 years.9
The extensive medication list of transplant recipients frequently
seems complicated to caregivers with limited experience, often
causing hesitation in evaluating these patients as surgical
candidates. Additionally, it can be a challenging task to determine
whether the benefits of the procedure outweigh the risks in this
special population of patients. In general, as long as the surgeon
adheres to basic surgical principles with frequent reevaluation and
a low threshold for operative intervention, the disease processes
should be manageable, with good outcomes.
It should be emphasized that these patients often present with
surgical diseases in a manner unlike their immunocompetent
counterparts and need aggressive intervention to achieve cures.
Additionally, an appreciation for the balance between preventing
graft rejection and infection or malignancy is essential.
This chapter focuses on special considerations in the solid-organ
abdominal transplant patient. The goal of this chapter is to provide
information for the practicing surgeon who is not at a transplant
center to help decide when to perform an intervention or operation,
how to modify standard procedures, and when to consider transfer to
a transplant center if possible. It cannot be stressed enough that
surgical intervention in these patients ideally should be carried
out by the original transplant team. However, because the unstable
or noncompliant patient is a reality, knowledge of perioperative
management of transplant patients is critical for all nontransplant
Discharge from the hospital is often met with anxiety in both the
recent transplant recipient and his or her family members and can be
minimized by assurance and education. The transplant patient should
have been counseled in medications, including the doses, functions,
side effects and potential drug interactions, and recognition of
signs and symptoms of rejection and infection. Therefore, patient
participation should not be underestimated.
An extensive and expensive workup is unnecessary for minor
ambulatory surgery in this population as there is a small
complication rate and a low risk of compromising graft function.9
The surgeon should remember that the workup should focus more on the
indicated procedure rather than the patient's immune status.9,10
Nevertheless, a thorough preoperative evaluation and understanding
of the special considerations in this population are necessary to
reduce risk.11 There is typically no need to change medications
around a minor procedure, except in select cases [see:Management of
Immunosuppression during the Perioperative Period, below].
When planning a major surgical procedure, it is essential for the
surgeon to have knowledge of the patient's graft function. This will
aid the surgeon in optimizing perioperative management of fluid and
electrolyte status, medications, blood pressure, and ventilation as
well as anticipating immediate postoperative care.12 Consideration
of transplant patients undergoing major surgery should follow the
algorithm shown in Figure 1. Patients should provide a thorough
history of symptoms related to their graft. For example, renal
transplant patients vary in their ability to concentrate urine, and
to avoid further graft dysfunction, it is critical to provide
adequate hydration and careful monitoring of serum electrolytes.
Liver transplant recipients should be asked about jaundice,
pruritus, change in the color of urine or stool, and fluid
Renal transplant patients often have associated multiorgan disease
as a result of their primary condition (i.e., diabetes mellitus,
hypertension) and should be evaluated for symptoms of underlying
disease on a physical examination. Liver transplant recipients
should be evaluated for underlying liver dysfunction: asterixis,
ascites, and edema. As with renal and liver transplant recipients,
pancreas transplant recipients should have a thorough physical
examination with particular attention to the abdomen.
In most cases, standard laboratory values are adequate. For
instance, in renal transplant recipients, an assessment of
creatinine, urine protein/creatinine ratio, and glomerular
filtration rate (GFR) may suffice. In liver transplant patients,
assessment of coagulation and liver function tests (LFTs) may be
adequate. In general, bilirubin and synthetic function becomes
normal within 3 months following transplantation, and trends in LFTs
should be monitored for abnormalities. Pancreas transplant
recipients should have serum amylase and lipase, urine amylase (for
bladder-drained transplants), and glucose levels monitored.
Additionally, as the nutritional status of any patient is critical
to decrease the risk of infection and improve wound healing, it is
especially important in this particular patient population.9,11–15
Whenever possible, appropriate specialists (i.e., nephrologists,
hepatologists) should follow the patient in the perioperative
Figure 1 Algorithm for Transplant Patients
As in any surgical procedure, it is essential to know the patient's
anatomy and examine previous operative notes if at all possible [see
Table 1for a summary of common locations and procedures for each
transplant]. This will allow consideration of altered anatomy that
can lead to unexpected complications. For instance, in patients who
have had kidney transplants, the location of the organ, particularly
the ureter, is crucial to avoid injury. A previously transplanted
ureter looks remarkably like an adhesion even to the trained eye,
and many have been divided during uncomplicated lysis of adhesions.
This is particularly likely if the kidney was placed through a
midline incision and the surgeon does not know on which side the
graft was placed.
In patients who have undergone a pancreas transplant, one must
consider if a Roux-en-Y reconstruction for drainage of the duodenum
was used (or if the pancreas was bladder drained, although this is
far less common in recently transplanted pancreata) or if the vein
drains via the superior mesenteric vein or the iliac vein in the
recipient. Likewise for the liver, knowledge of any vascular
reconstructions is critical.
Diagnostic and Radiologic Considerations
Although the physical examination is critical in the evaluation of
any surgical patient, caution must be exercised in the transplant
patient, particularly those patients who have been on
immunosuppression for many years. It is not unheard of to explore a
patient with a near-normal examination and be surprised to find an
abdomen full of succus. For this reason, we are aggressive in
obtaining abdominal imaging in the majority of transplant patients
who are being evaluated for an intra-abdominal process.
Consideration should be made for diagnostic sampling of any fluid
collections or free intra-abdominal fluid that is not expected to
rule out surgical causes. Fluid is typically sent for Gram stain and
culture, bilirubin, amylase, creatinine, and any other biochemical
marker that is relevant to the situation. In general, it is
acceptable to follow patients conservatively if that is the judgment
of the caregiver, but frequent reassessments are necessary. If the
patient does not improve quickly, consideration should be made for
aggressive intervention or at least reimaging.
When it comes to choosing radiologic imaging, similar algorithms
should be used, as in the nontransplant patient. As in their
immunocompetent counterparts, immunocompromised patients may undergo
ultrasonography to evaluate the biliary tree, kidneys or ureters,
and the female reproductive organs. Computed tomography (CT) is the
best tool for assessment of intra-abdominal fluid.16
Transplanted patients being evaluated for trauma should be assessed
as any other trauma patient.10,17 Kidney transplant patients often
have creatinine levels that run higher than those in the
nontransplant patient, with values in the range of 2 mg/dL or above
even with stable function. Appropriate hydration decreases the risk
of nephrotoxicity similar to that of nontransplant patients,17 and
standard bicarbonate protocols are similarly helpful. If CT is
warranted for safe management of the trauma, it should be conducted.
It may be useful to hold the calcineurin inhibitor (cyclosporine or
tacrolimus) for a few days following the contrast load as these
drugs are nephrotoxic. Holding a calcineurin inhibitor for a few
days in the setting of a trauma typically is safe. Depending on the
patient, extra steroids (such as the equivalent of 10 to 30 mg of
prednisone per day) can be considered during this period, although,
again, if use is limited to a few days, it is probably unnecessary.
Ideally, this would be done in consultation with an appropriate
specialist or transplant center.
Since the introduction of minimally invasive techniques, transplant
surgeons have been active participants in its use, from
ultrasound-guided biopsy to laparoscopic donor nephrectomy. As in
immunocompetent patients, the use of minimally invasive techniques
in immunocompromised patients is safe and provides the same
benefits, such as decreased hospital stay and narcotic use, as well
as com parable or even improved complication rates.18–21 A skilled
laparoscopic surgeon should always offer the immuno compromised
patient the laparoscopic alternative when available and feasible.
During any reoperation following a kidney transplantation, one
should always be thinking of the ureter. If one does come across and
divide the ureter unexpectedly, the most likely repair will be a
ureteroureterostomy, using the patient's native ureter and sewing it
end to end over a stent after spatulation. Most commonly, this does
not require a native nephrectomy even if the patient's native kidney
makes urine, although, in occasional cases, hydronephrosis can
follow, requiring a native nephrectomy at a later time point.
As a general rule, similar principles of surgical technique should
hold with the transplant patient. Additionally, any procedure that
is reasonable in the nontransplant patient can be used in the
transplant patient. We do caution the practitioner who has not had a
lot of experience with transplant patients that the long-term
immunosuppressed patient in particular certainly has an increased
risk of poor healing or wound or anastomotic dehiscence. Moreover,
the patient will not always show the signs of sepsis that are
commonly noted when this happens. Note that there is no real
definition of “long term,” and this is an anecdotal observation. In
general, those patients who have been immunosuppressed for a decade
or more seem to be at higher risk for complications related to
healing. Therefore, any transplant patient who simply does not
progress and heal in a fashion that seems reasonable should be
considered for a complication, and aggressive radiologic assessment
Antibiotics and Pain Medicine in the Perioperative Period
It is well established that immunocompromised patients encounter
many more infections than their immunocompetent counterparts, in
particular rare fungal, bacterial, and viral infections.10,15,22–28
Fifty to 70% of transplant patients have at least one episode of
bacterial infection, and 30 to 60% have at least one serious viral
infection.10,29 In general, posttransplant patients have a
predictable infectious course: within the first posttransplant
month, infections are comparable to those of their immunocompetent
counterparts and are usually bacterial in nature; in months 1
through 6, patients are at risk for opportunistic infections,
including Pneumocystis carinii, Listeria monocytogenes, and
Aspergillus species; more than 6 months posttransplantation, two
thirds of patients suffering from an infection will develop a
community-acquired respiratory virus, whereas the remainder will
develop chronic viral infections (such as hepatitis B and C
viruses). A group at particular risk are those who received
excessive amounts of immunosuppression as a result of early
rejection or delayed graft function, causing the greatest risk of
infection from opportunistic pathogens such as Cryptococcus
neoformans, P. carinii, and L. monocytogenes.30,31 Other viruses
that are quite well known to transplant physicians are
cytomegalovirus and BK virus, which can cause nonspecific symptoms
such as fevers or diarrhea but can also cause graft dysfunction or
loss of a graft. Certainly, any transplant patient who is suffering
from more than an easily diagnosable and treatable urinary tract
infection, pneumonia, or line infection should undergo workup for
these pathogens, and consideration should be given to transferring
to a transplant center.
There is no evidence of prolonged perioperative antibiotic (greater
than 24 hours) use despite the widespread use of prophylactic
antibiotics in a patient's medication regimen. This is attributable
to an increased risk of viral and fungal infections in addition to
superinfection with resistant bacteria and/or Clostridium
difficile.11,32 Surgical prophylaxis should include therapies
against skin flora such as staphylococci and streptococci and, in
renal transplant patients, the inclusion of therapies against urine
species such as Escherichia coli, Klebsiella, and Proteus. In
suspected infection, empirical therapy should be guided by the
suspected anatomic site and organism, previous antibiotic therapy,
renal and hepatic function, and immunosuppression status. Continued
therapy after identification of an organism should be as specific as
possible with consideration of renal and hepatic function.
Postoperatively, consideration of hepatic and renal function is
necessary when choosing medications such as narcotics and
antihypertensives. For example, in patients with suboptimal liver
function, morphine, meperidine, or propoxyphene for pain management
and clonidine or nifedipine for hypertension are preferred.9
Management of Immunosuppression during the Perioperative Period
Immunosuppression in the solid-organ transplant patient often
includes several agents with different mechanisms to use lower doses
and decrease potential toxicity.31 Additionally, in the late
postoperative period (2 to 6 months), immunosuppression is usually
decreased as the allograft is typically functioning well and rates
of rejection are highest in the first 6 months, with decreasing
incidence thereafter. When considering elective procedures, it may
make sense to delay them for up to 6 months after transplantation or
at least the point where they are down to their baseline maintenance
immunosuppression. This, of course, has to be balanced with the
urgency or risk of delaying the surgical procedure.
Immunosuppression is associated with an increased susceptibility to
infection and poor wound healing.10,33 However, a balance between
preventing graft rejection and anticipating the patient's response
to surgical stress must be appreciated. If the procedure is unable
to be performed by the original transplant team, the surgeon should
not hesitate to consult a transplant service for immunosuppressive
Although historically there has been concern over a
immunocompromised patient's ability to undergo surgical procedure, a
number of studies demonstrate that these patients are able to
undergo a variety of procedures with complication rates similar to
those of their immunocompetent counterparts34–37 and without an
increased risk of wound healing problems.9,38,39 In general,
immunosuppression is not altered during the perioperative period
unless the patient is demonstrating significant infection or sepsis.
It should be given at the same schedule and dose as the patient's
home regimen.9 If the patient is unable to take anything orally,
azathioprine and mycophenolate mofetil (MMF) can be safely withheld
for 2 to 3 days. Intravenous cyclosporine can be used at one third
the total daily oral dose over 4 to 8 hours. Until the patient is
able to tolerate immunosuppression by mouth, immunosuppression
levels should be checked daily, with the goal of having no variation
from baseline greater than 25%.9 There are some exceptions to this,
however. Most transplant surgeons would suggest discontinuing
sirolimus and changing to a calcineurin inhibitor as sirolimus has
been known to impair wound healing.11,40
In our own practice [see Table 2 for a summary of the medicines and
recommended adjustments], for minor procedures, we do not recommend
any change in immunosuppression. Patients can take their medicines
on the morning of surgery and resume them that night or the next
morning, depending on how they are feeling. It is important that
patients stay well hydrated perioperatively as the calcineurin
inhibitors are nephrotoxic, and this is compounded by a prerenal
state. Therefore, we are more aggressive about admitting patients
for a day or two after surgery or at least following their
laboratory results (organ specific labs are drawn as outpatients at
their local clinic/hospital, and results are faxed to the transplant
unit) as outpatients and seeing them more frequently if admission is
not necessary or feasible. For more extensive procedures,
particularly those that will require patients to be nihil per os
(NPO) for a period of time, we typically hold their calcineurin
inhibitor and put them on the equivalent of 20 to 30 mg of
intravenous prednisone per day (we typically use dexamethasone, 2 mg
every 8 to 12 hours IV, until they can return to their home dose).
This obviously depends on what organ they have received, how recent
the transplantation was, and what their rejection history is.
If the patient is well clinically and at high risk for rejection
(young, recent transplant, previous episodes of rejection, African
American, kidney transplant recipient), then con sideration can be
made for using intravenous cyclosporine if the patient is on that
medication or sublingual tacrolimus (typically half the dose of
oral). If this is done, levels should be followed daily until they
return to the patient's normal oral dose and baseline levels have
been achieved. If at all possible, we do recommend at least
discussing the plan with the transplant physician prior to the
surgery and, ideally, having his or her input in the perioperative
period. If the patient is on MMF, we usually continue this drug
intravenously. A well-known side effect of this drug is diarrhea or
other GI symptoms, so if the procedure is a major GI operation, it
may be necessary to hold this until bowel function normalizes.
We would offer caution considering any operation on a patient who is
on sirolimus. This drug has a dramatic effect on wound healing, and,
ideally, we stop this drug 2 months before an elective procedure,
substituting a calcineurin inhibitor if possible. We would prefer
that the patient remain off this drug at least 2 months after the
procedure, assuming that the wound has healed well. For those
patients who have more urgent procedures, we would at least
recommend that sirolimus is held postoperatively for 2 months or
more, again substituting alternative agents. All of these decisions
should be made in concert with the transplant physicians.
A common concern for nontransplant practitioners is the use of
stress-dose steroids in the transplant patient population. Although
patients on immunosuppressive medications may have abnormalities of
the pituitary-adrenal axis, there is no evidence to support the use
of increased steroids in the perioperative period.9,33,41 In fact,
the use of high-dose steroids promotes poor wound healing, causing
both slower healing and decreased strength of the wound.9,10 This
effect has been offset by the administration of vitamin A
supplementation.10,42 Stress-dose steroids may be indicated when a
patient demonstrates adrenocortical insufficiency, as evidenced by
clinical symptoms of weakness, nausea, vomiting, and fever.2 To
reiterate, the use of stress-dose steroids is not supported or
advocated prophylactically in any procedure. It may be reasonable to
consider stress-dose steroids in the septic patient or those
patients undergoing major surgery with unexplained hypotension or
other signs of adrenocortical insufficiency but otherwise may not be
Fortunately, the complication rate for elective procedures in this
patient population is similar to that of immunocompetent patients.
However, emergent procedures are associated with increased morbidity
and length of hospital stay.9 Most authors would advocate an
aggressive approach to this group of patients, with surgical
revision early if possible.11 It is crucial to remember that
transplant patients can have very subtle findings even with major
postsurgical complications or infections. As a general rule, any
patient who is not progressing as expected should undergo aggressive
workup for complications, including liberal use of imaging and
diagnostic tapping or reoperation in response to unexpected fluid
collections. All fevers should be worked up aggressively either for
preexisting infections or peri- or postsurgically acquired
Follow-up for the immunocomprised patient after surgery should
proceed in the same manner as performed in an immunocompetent
patient. Generally, patients are seen 2 weeks after discharge
depending on the hospital course and condition of the wound.
Patients are continued on their home immunosuppression, and, as
stated previously, unless there is a specific reason, antibiotics
are not extended. In our practice, wounds are left covered for 48
hours after surgery, and staples are typically removed 3 weeks after
surgery to account for slow healing. Obviously, clinical assessment
of wounds may override these recommendations. Levels of calcineurin
agents (cyclosporine or tacrolimus) should be followed closely for a
few weeks after surgery until the preoperative therapeutic range is
achieved. It is common for people to have either high or low levels
after surgery, particularly until bowel function has returned to
normal. There is a risk that rejection can occur in the
postoperative period if levels are too low, and if a patient is
having difficulty getting the level up quickly, extra steroids (or
another agent) may be required for a few weeks while the level is
returning to baseline.
When to Consider Transfer to a Transplant Center
The decision on when to transfer a patient to a transplant center
will depend on many factors, including geography, comfort level of
the caregivers, desires of the patient, size of the procedure, organ
that was transplanted, and postoperative course. Many procedures can
be conducted safely on transplant patients without specialized care
from a transplant center. However, some patients are reluctant to
have anyone other than their transplant physicians treat them once
they have received a transplant, and some transplant physicians
likewise will agree with that. Ideally, a discussion will take place
with both the patient and the transplant physician prior to the
procedure to make a plan. If a surgeon is comfortable performing a
procedure or operation, the same attention to good technique will
apply to these patients. All postoperative complaints or findings
should be evaluated very carefully, and if at any point a patient is
not progressing appropriately, contact should be made with the
transplant center with consideration of transfer. A transplant
physician or specialist with some comfort in transplant medications
or infections should be consulted if at all possible. Discussions
with transplant physicians or pharmacists regarding medications and
any alterations in them should be conducted daily if possible.
Although the occurrence of acute appendicitis in the general
population is widespread, its frequency in transplant recipients is
quite rare, with a reported rate of 0.2% in liver, heart, kidney,
and pancreas recipients.43–46 Nevertheless, given the rising number
of transplant recipients, knowledge of the management of this
disease in this patient population is important.
In the past, appendectomies in conjunction with a pancreas
transplant were routine to prevent misdiagnosis of transplant
pancreatitis. However, the low incidence and reliability of modern
imaging in visualizing acute appendicitis no longer make this
current practice at most institutions.
Ultimately, transplant recipients found to have acute appendicitis
should be managed similarly to nontransplant patients with the use
of laparoscopy based on surgeon preference. As with any
intra-abdominal pathology in a transplant recipient, clinical signs
can be subtle. Therefore, imaging is crucial in securing the
Our institution is aggressive about proceeding with operative
management in patients with acute appendicitis. If management of
nontransplant patients includes consideration of percutaneous drain
placement and interval appendectomy in perforated and walled-off
appendicitis, the same can be considered in the transplant patient.
These patients do require close monitoring with serial examinations
and reimaging. It cannot be stressed enough that the signs and
symptoms of progression can be subtle. A low threshold to abandon
conservative management in favor of operative intervention should be
considered in patients who do not rapidly improve.
SMALL BOWEL OBSTRUCTION
As a result of medical immunosuppression, transplant recipients
rarely develop extensive adhesions causing small bowel obstruction.
However, it has been hypothesized that transplant and nontransplant
patients develop small bowel obstruction similarly, mainly the
formation of adhesions following intra-abdominal surgery.
Additionally, there have been reports of small bowel obstruction
secondary to internal hernias in pancreas transplant
recipients.47,48 The increased risk of malignancy in this patient
population should also make the surgeon suspicious of a malignant
As in nontransplant patients, obstruction can be fatal and should be
managed similiarly. Conservative management with nasogastric tube
decompression, hydration, and close monitoring is appropriate. If
the patient does not improve quickly, operative management is
PEPTIC ULCER DISEASE
Prior to the advent of histamine2 blockers, mortality from peptic
ulcer disease in this patient population was as high as 40%49,50 and
was even reported to be approximately 4% only a few years ago.51 The
cause of peptic ulcer disease in this patient population is
multifactorial. There have been reports of up to 62% of living donor
liver recipients52,53 and approximately 30% of renal transplant
recipients with Helicobacter pylori colonization.8,51,53,54
Additionally, high-dose steroids used to treat rejection have been
found to be ulcerogenic,55 and MMF has been found to cause ulcer
perforation or bleeding in 3 to 8% of patients within 6 months.56
Transplant patients are typically placed on prophylactic medications
in the perioperative period to prevent the development of peptic
ulcer disease. Fortunately, in our practice, we have rarely had to
operate on this as in our nontransplant patient population. Surgical
management, when necessary, should be no different than in the
BILIARY TRACT PATHOLOGY
Cyclosporine therapy has been associated with biliary calculous
disease and primary choledocholithiasis.10 However, studies have
demonstrated the safety of cholecystectomy following transplantation
despite previously held beliefs regarding immunosuppression and
Biliary tract pathology is common in liver transplant recipients,
with an incidence of 10 to 30% and the majority seen within the
first 6 months posttransplantation.57 Most commonly, anastomatic
stricture of the bile duct following duct to duct reconstruction
occurs, resulting in patients who present with symptoms of
cholangitis. Elevated bilirubin, fevers, and sepsis warrant urgent
endoscopic cholangiopancreatography and broad-spectrum antibiotics.
Because of the tenuous condition of these patients, transfer to a
transplant center is highly recommended.
Diverticulitis in the transplant patient population is higher (1%
versus 0.02%)58 and more aggressive59 than in the general
population. In a study comparing immunosuppressed and
immunocompetent patients with acute diverticulitis, immunosuppressed
patients were found to have an increased risk of free perforation
(43% versus 14%) and postoperative mortality (39% versus 2%).60
Therefore, patients are typically offered surgical intervention
following a single episode of uncomplicated diverticulitis if it is
safe and once the acute episode resolves.61 Although there is a
paucity of data to support this in the literature, the risk of
complications from recurrent episodes and difficulty in diagnosing
these patients until they progress to a later stage of disease may
be an incentive to intervene earlier than in nontransplant patients.
Acute episodes of diverticulitis are managed conservatively with
broad-spectrum antibiotics and percutaneous drain placement.
However, frequent reassessment and reimaging are critical. Interval
surgical intervention should always be considered if the patient
does not progress. In our practice, we have been cautious in
performing a primary anastomosis in acute complicated diverticulitis
in the sigmoid region, particularly in patients on long-term
immunosuppression. We favor reestablishing continuity 3 to 6 months
later. Of note, great caution should be taken with patients on
sirolimus at the time of presentation. These patients are
notoriously poor at healing, and strong consideration should be
given for diverting these patients in the acute setting.
Clinicians should have an appreciation for the increased risk of
cancer associated with immunosuppression. Although the exact risk
remains controversial, the incidence of malignancy in transplant
recipients is increasing, and there are estimates that after 10
years of chronic immunosuppression, the incidence of malignancy is
20%.62 The risk of malignancy can vary based on the medication and
type of cancer and is believed to be closely associated with overall
exposure to immunosuppression.62
In general, solid-organ tumors of the GI tract have an approximately
1.25 to 5 times and lymphomas a 10 times greater incidence in
transplant patients.63 In solid-organ transplant recipients,
nonmelanotic skin cancers are extremely common,64,65 with transplant
patients at a 65-fold increased risk of developing squamous cell
carcinoma.66 For this reason, all patients should be followed by a
As with nontransplant patients, transplant patients with solid
tumors should be followed under the same oncologic principles.
Multidisciplinary teams including transplant physicians,
oncologists, and surgeons are necessary for the care of these
A special note should be made regarding posttransplantation
lymphoproliferative disorder (PTLD). PTLD is the second most common
malignancy seen in renal transplant patients67 and the most common
malignancy in liver transplant patients.68 It can have variable
presentations, including abdominal pain, small bowel obstruction,
weight loss, and GI bleed. The presence of masses on a CT scan is
suggestive of PTLD, with 25% involving the small bowel and 6%
involving the colon.69 PTLD may cause bowel obstruction,
necessitating emergent surgery. Interestingly, simply reducing
immunosuppression can sometimes cause eradication of disease.
Additionally, as the majority of cases are B cell in nature and
associated with Epstein-Barr virus, B cell–directed therapies such
as anti-cd20 antibody rituximab, may eliminate the disease.
Consequently, patients with PTLD should be managed at a transplant
center where graft loss or mortality can be minimized by the
modification of immunosuppression and other therapies.
Immunosuppressants often have GI effects that modify symptoms and
therefore the presentation of GI diseases.49 It is quite common for
transplant patients to develop diarrhea, sometimes severe episodes.
This can sometimes be related to transplant medications, and a
careful drug history should be the initial step in evaluating a
transplant patient with diarrhea. For example, up to 50% of patients
on MMF develop GI complaints.70 Ruling out other causes,
particularly infections, is important and can be challenging.
Infectious processes often seen in the transplant population include
C. difficile superinfection, cytomegalovirus colitis, more common GI
viruses, and opportunistic infections. The initial workup should be
no different from that for the nontransplant patient but may
ultimately require colonscopy and biopsy to rule out the above.
General surgeons can certainly have some level of comfort with the
knowledge that with careful attention to medications and symptoms,
general principles will hold true with transplant patients. Minor
procedures can usually be conducted without much modification, and
more major procedures may require some adjustment of medication
regimen. The most important point is to watch these patients closely
as their physical examination, including vital signs and laboratory
studies, can be misleading, and frequent reassessment with imaging
may be necessary. If a patient does not proceed along the expected
recovery, attention must be given to a possible complication. Most
transplant centers have a program for following up with their
patients and a contact to call for questions about their care and
organ function. It is always recommended to communicate with a
program. Consideration for transfer to a transplant center may be
appropriate in complicated cases or in the setting of complications.
Financial Disclosures: None Reported
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7. Merrell SW, Ames SA, Nelson EW, et al. Major abdominal
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