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VCUDEATH AND COMPLICATIONS CONFERENCE
Introduction
Complication Readmission, delayed diagnosis of colon
perforation Procedure
Hartmann’s procedure Primary Diagnosis
ESRD s/p living donor kidney transplant
Clinical History 58 yo man with DM1, and ESRD s/p living donor kidney
transplant 2/21. Readmitted on 4/1 for syncope. Pt states that he got lightheaded when he got up to go to the restroom after eating dinner. He passed out and hit his head on the floor. PMH: HTN, DM1, ESRD s/p LDKT, hypothyroid, HLD, CAD,
diverticulosis on colonoscopy 12/2011. PSH: LDKT Meds: amlodipine, carvedilol, insulin pump, esomeprazole,
levothyroxine, prednisone, cellcept, tacrolimus, senna, SOC: 36 pack year tob, quit 2 years ago Allergic to PCN
Hospital Course BP 132/70, HR 84, afebrile Phys exam:
Alert, oriented, comfortable Normal respirations, CTAB NSR, Not tachycardic, no diaphoresis Abdomen soft, nondistended, mild ttp bilateral lower
quadrants WBC 11.6, hgb 10.8, electrolytes normal
Syncope workup Orthostatic hypotension, 30mm Hg difference in BP On further discussion c/o crampy abdominal pain Acute series
Hospital Course
4/1/12
Hospital Course
4/1/12
Hospital Course
2/21/12
Hospital Course
Pt continued to be orthostatic, afebrile, tolerated clears and full liquid diet, +flatus, no BM
Continued intermittent complaint of abdominal pain
WBC 12.8, 12.6 CT abdomen obtained on 4/3
CT scan
CT scan
CT scan
CT scan
Hospital Course
Taken to OR that night Perforated sigmoid colon with many
diverticula Sigmoid colectomy, Hartman’s pouch, end
colostomy Subsequent improvement in BP,
orthostasis, WBC, abdominal pain Uneventful recovery, discharged on POD
#7
Analysis of Complication
• Was the complication potentially avoidable?• Yes, could have avoided transplantation and
immunosuppression; could have removed the sigmoid prior to transplant; could have diagnosed the problem sooner
• Would avoiding the complication change the outcome for the patient?– Yes. Avoid syncope/fall/readmission, avoid ostomy; less
pain, shorter hospital stay
• What factors contributed the complication?– Presence of sigmoid diverticula, immunosuppression, diet
Complicated Diverticulitis in the Transplant Patient Complicated Diverticulitis: diverticular
disease associated with abscess, phlegmon, fistula, stricture, bowel obx, peritonitis.
Immunocompromised patients: Atypical signs/symptoms More likely to have free perforation Less likely to respond to conservative
management Higher postoperative risk of complications and
death
Possible contributing factors: History of diverticulosis/diverticulitis Immunosuppression, especially high
dose steroids Infection (CMV, mucormycosis) Polycystic kidney disease Age over 50 yo
Retrospective review of 875 renal transplant patients 1986-2004 8 patients with colon perforation (0.9%)
Methods: analyzed age, gender, steroid dosage, time
interval from transplantation, clinical presentation, delay between symptom onset and surgery, surgical procedure, graft/patient outcomes
Results
Mean age: 58.5 Presentation: fever, abdominal pain,
localized or diffuse peritonitis, leukocytosis in 7 of 8 patients
All c/o constipation prior to presentation Steroid dose:
3 pts were on steroid-free immunosuppression 5 on steroids, 2 pts were on steroid dose
>20mg Mean 4.1 year interval between transplant
and perforation 2 patients within 1 month of transplant 6 between 1 year and 15 years
Procedures, outcomes
7 of 8 patients taken to the OR within 48 hrs of onset Hartmann’s procedure: 5 of 8 cases
1 patient underwent ostomy closure within 6 months 3 patients refused ostomy takedown
Resection with primary anastomosis: 2 cases No fecal contamination present No complications
Primary repair of perforation: 1 case Mortality: 12.5% (one patient) Outcome: at 6.1 year median follow up, 6
surviving patients (75%) surviving, 5 functioning grafts
Conclusions
Aggressive diagnostic and treatment approach
Hartmann’s procedure Primary anastomosis with or without
protective ileostomy may be used in selected patients
Steroid sparing immunosuppressive regimen
Prevent constipation
Retrospective review:1,137 renal transplant patients 1.1% (13 pts) with complicated
diverticulitis 25 days to 14 yrs after transplant
Atypical presentation (2 asymptomatic)
From asymptomatic pneumoperitoneum (2 patients) to generalized peritonitis
Complicated Diverticulitis Following Renal TransplantationLederman, et al, Department of Surgery, Albany Medical College, Albany, New York Diseases of the Colon Rectum, May 1998
Associated factorsPKD etiology of renal failure (46% of pts)
Reported elsewhere, no clear explanation
Cyclosporin Age over 50Diverticulosis pre transplant
Operative intervention: 10 sigmoidectomy, end colostomy +/- mucus
fistula 1 primary anastomosis 1 primary with diverting colostomy 1 primary diversion with later resection and
anastomosis Outcomes
6 pts had colostomy reversal within one year One death (MI POD#6) All survivors had graft function at 5 years
Conclusions
High index of suspicion Immunosuppressed with mild abdominal
pain, no pertionitis PKD Known diverticulosis
Early operative intervention Sigmoid colectomy with end colostomy
Summary of Conclusions/ Recommendations: Prevention: steroid sparing
immunosuppressive regimen, fiber diet, prevent constipation
High index of suspicion for intra-abdominal catastrophe in spite of benign exam
Treatment: aggressive diagnostic and treatment approach, early CT scan, early surgical intervention, decrease immunosuppression, broad spectrum antibiotic coverage, evaluate for infectious etiology
Hartman’s procedure preferred, especially if stool spillage
Learning Points
Have an elevated level of concern for abdominal pain in immunosuppressed patients, early CT scan. Do not just watch clinically.
Recognize Morgagni hernia. Surgical management is best for
diverticular disease in immunosuppressed patients, especially if any spillage.
Hinchey
Stage 1: small, confined pericolic or mesenteric abscess
Stage 2: larger abscess, often confined to pelvis
Stage 3: perforated diverticulitis, ruptured abscess, purulent peritonitis
Stage 4: ruptured diverticulitis with fecal contamination of the peritoneal cavity
Helderman JH: Colonic screening prior to renal transplantation and its impact on post-transplant colonic complications. Clin Transplant 6:91–96, 1992 Review of 1186 renal transplants
pretransplantation colonic screening of pts >50yo was ineffective in predicting posttransplantation colonic complications
20 cases of diverticular disease identified among older patients
>25% associated with adult polycystic disease. No pretransplantation colectomy No posttransplantation symptomatic colon disease Recommendation: abandon pretransplantation
colonic screening in asymptomatic patients >50 yr of age.
Screening should be done selectively in certain transplant candidates
Pts with PKD, with documented active diverticulitis, symptomts suggestive of diverticular disease
Recommended