Cholecystectomy for Acute Cholecystitis After Renal Transplantation

Incidence and Mortality of Emergency General Surgery Conditions Among Solid Organ Transplant Recipients in Ontario, Canada: A Population-based Analysis

BACKGROUND

Emergency general surgery (EGS) conditions and their outcomes are perceived to be disproportionately high among solid organ transplant recipients (SOTRs). However, this has not been adequately investigated at a population level. We characterized the incidence and mortality of EGS conditions among SOTRs compared with nontransplant patients.

METHODS

Data were collected through linked administrative population-based databases in Ontario, Canada. We included all adult SOTRs (kidney, liver, heart, and lung) who underwent transplantation between 2002 and 2017. We then identified posttransplantation emergency department visits for EGS conditions (appendicitis, cholecystitis, choledocolithiasis, perforated diverticulitis, incarcerated/strangulated hernias, small bowel obstruction, and perforated peptic ulcer). Age-, sex-, and year-standardized incidence rate ratios (SIRRs) were generated. Logistic regression models were used to evaluate association between transplantation status and 30 d mortality after adjusting for demographics, year, and comorbidities.

RESULTS

Ten thousand seventy-three SOTRs and 12 608 135 persons were analyzed. SOTRs developed 881 EGS conditions (non-SOTRs: 552 194 events). The incidence of all EGS conditions among SOTR was significantly higher compared with the nontransplant patients [SIRR 3.56 (95% confidence interval [CI] 3.32-3.82)], even among those with high Aggregated Diagnosis Groups scores ( > 10) [SIRR 2.76 (95% CI 2.53-3.00)]. SOTRs were 1.4 times more likely to die at 30 d [adjusted odds ratio 1.44 (95% CI 1.08-1.91)] after an EGS event compared with nontransplant patients, predominantly amongst lung transplant recipients [adjusted odds ratio 3.28 (95% CI 1.72-6.24)].

CONCLUSIONS

The incidence of EGS conditions is significantly higher in SOTRs even after stratifying by comorbidity burden. This is of particular importance as SOTRs also have a higher likelihood of death after an EGS condition, especially lung transplant recipients.

Cholecystectomy-Associated Complications in Kidney Transplant Recipients Compared With the General Population

Cholelithiasis is one of the most prevalent diseases in the general population. Among kidney transplant (KT) recipients, atypical clinical presentation may delay the diagnosis and proper treatment. This single-center retrospective cohort study compared cholelithiasis clinical presentation and cholecystectomy-associated complications in 230 KT recipients and in 172 members of the general population. KT recipients had a higher proportion of men, comorbidities, biliary pancreatitis, choledocholithiasis, and acute cholecystitis clinical presentations than the general population. KT recipients presented higher American Society of Anesthesiologists scores and higher rates of emergency surgeries (15.7% vs 9.9%, P = .091), conversion (5.7% vs 1.2%, P = .019), drainage (7.8% vs 2.3%, P = .016), postoperative complications (10% vs 4.7%, P = .047), and longer hospital length of stay (1 vs 1 days, interquartile range, 2 vs 0 days; P < .001). There were 5 deaths, all of which occurred in KT recipients. History of diabetes mellitus, renal function, and surgical conversion were independent risk factors associated with postoperative complications. Male sex and level of renal function were independent risk factors associated with postoperative acute cholecystitis. KT was an independent risk factor associated with postoperative choledocholithiasis (adjusted odds ratio, 5.89; 95% confidence interval, 3.03-15.66) and pancreatitis (adjusted odds ratio, 6.89; 95% confidence interval, 2.99-11.61). In conclusion, KT recipients with cholelithiasis have an increased risk for clinical and surgical complications compared with the general population.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Kidney and pancreas transplant recipients undergoing cholecystectomy experience superior outcomes in transplant centers

BACKGROUND

This retrospective analysis aims to identify differences in surgical outcomes between pancreas and/or kidney transplant recipients and the general population undergoing cholecystectomy.

METHODS

Multivariate logistic regression and linear regression tests computed odds ratios (OR) and coefficients of the linear regression by analyzing weighted data from the NIS database between 2005 and 2014 to identify differences in mortality, morbidity, length of stay (LOS) and costs amongst KTx, PTx, PKTx, and non-Tx undergoing cholecystectomy in all centers and transplant centers.

RESULTS

Overall 6007 KTx, 164 PTx, 535 PKTx, and 4,207,241 non-Tx met the inclusion criteria. Mortality from cholecystectomy was 1.0%. Transplant recipients did not experience a significant increase in mortality. However KTx and PTx suffered increased morbidity risks (KTx OR1.244 p < 0.01; PTx OR2.165 p < 0.01) compared to non-Tx. However transplant recipients did not incur an increased morbidity risk in transplant centers.

CONCLUSION

Transplant recipients undergoing cholecystectomy should be counseled about their increased complication risks. Surgeons should consider transferring KTx and PTx to transplant centers for their cholecystectomy procedure to mitigate these risks.

Minimally Invasive Surgery Is Feasible in Patients with Liver and Kidney Transplantation

Background

Minimally invasive surgery (MIS) has rapidly advanced, but its use in transplant patients has lagged. We share our experience of MIS for patients after kidney and liver transplantation and compare our results with similar studies in the literature.

Material/Methods

This study included 14 MIS (12 laparoscopic, 2 transvaginal) procedures for 13 transplant cases (6 liver and 7 kidney) done from May 2006 to May 2018. Gastrointestinal surgery was performed in 6 cases: appendectomy performed 8 months after liver transplant and 16 months after kidney transplant in 2 cases, radical right hemi-colectomy performed 6 weeks after liver transplant in 1 case; exploration for chylous ascites 6 months after liver transplant in 1 case, sleeve gastrectomy performed 3 years after kidney transplant in 1 case, and partial hepatectomy performed 12 years after kidney transplant in 1 case. For urological problems, 2 patients received ipsilateral right-side nephroureterectomy performed 10 and 12 years after kidney transplant, and 1 patient received contralateral left-side nephroureterectomy performed 12 years after kidney transplant. The 2 liver transplant patients with huge incisional hernias received repair approximately 3 and 2 years after liver transplant. Three patients underwent gynecological surgery: 2 transvaginal for pelvic floor reconstruction in 1 patient with liver transplant and 1 hysterectomy in a kidney transplant patient, and 1 laparoscopic-assisted hysterectomy in a kidney transplant patient. We retrospectively analyzed the clinical presentation, operative findings, operation time, postoperative complications, and length of stay.

Results

The postoperative course was uneventful, with early resumption of oral intake, including immunosuppressants administered the same as in the non-transplant patients. All surgical procedures in these transplant patients were achieved without conversion, showed stable kidney and liver function, had better surgical outcomes in comparison with traditional surgery, and most of them were discharged within 1 week.

Conclusions

Laparoscopic and non-laparoscopic MIS surgery are feasible and safe for abdominal organ transplant patients and are helpful for timely intervention in cases with acute abdomen. No adjustment of immunosuppressant is usually needed, as oral intake can be resumed very soon after surgery.

Deceased Donor Renal Transplantation Combined with Bilateral Nephrectomy in a Patient with Tuberous Sclerosis and Renal Failure

Introduction

A 27-year-old female patient with known tuberous sclerosis complex (TSC), polycystic kidneys with multiple large bilateral angiomyolipomas, and failing renal functions with prehemodialysis values (urea: 19 mmol/L; creatinine: 317 μmol/L; CKD-EPI 0,27) was admitted to our department for pre-renal transplant evaluation. The patient was placed on the transplant waiting list as the living donor did not pass pretransplant workup and was subsequently contraindicated. Patient was placed on the “cadaverous kidney transplant waiting list”.

Method

Computed tomography angiography revealed symptomatic PSA in the right kidney angiomyolipoma (AML). The patient underwent urgent transarterial embolisation of the PSA's feeding vessel in the right kidney AML. Based on the “kidney transplant waiting list” order patient underwent a bilateral nephrectomy combined with transperitoneal renal allotransplantation of a cadaverous kidney graft through midline laparotomy, appendectomy, and cholecystectomy.

Results

Postoperative period was complicated by delayed graft function caused by acute tubular necrosis requiring postoperative hemodialysis. The patient was discharged on the 17th postoperative day with a good renal graft function. Patient's follow-up is currently 23 months with good graft function (urea: 9 mmol/L; creatinine: 100 μmol/L).

Conclusion

Renal transplantation combined with radical nephrectomy provides a definitive treatment for TSC renal manifestations.

Gallbladder Pathologies in Kidney Transplant Recipients: Single-Center Experience and a Review of the Literature

Background

In patients with end-stage renal disease, cholelithiasis is observed with an increased frequency. In transplant recipients, symptoms might be obscured, which may delay the diagnosis and lead to complications. The aim of our study was to evaluate the frequency of gallbladder pathologies in kidney transplant recipients (KTRs) in the Caucasian population, and to discuss the potential benefits of prophylactic cholecystectomy before kidney transplantation (KT).

Material/Methods

Data from 434 patients who underwent KT was analyzed. Demographic data along with gallbladder status were collected from the pre-transplantation charts. We compared our results to data from the general Polish population.

Results

In our analyzed group of KTRs, there were 284 men and 150 women. Complete data, including abdominal ultrasound description, were available in 412 cases. In this group, 36 patients (8.74%) underwent cholecystectomy before KT. Other gallbladder pathologies (gallstones and polyps) were found in 41 patients (9.95%) at pre-transplantation evaluation. The incidence of gallbladder pathologies in KTRs, being mostly cholelithiasis, was higher than in the general Polish population.

Conclusions

In specific age subgroups of KTRs, the frequency of gallbladder pathologies was higher than in the general population. Prophylactic cholecystectomy may potentially offer benefits in these subgroups of patients.