Transplant Surgery

Question 1

Delayed graft function is associated w/

Answer 1

Reduced graft function/survival, & increased risk of rejection

Question 2

Can you match A to B donor-recipient blood group for transplant?

Answer 2

Yes. B/c A has two subtypes: A1 & A2 which differ in the amount of A antigen produced on the surface of the cell. A2 has low amounts of antigen so you can offer A2 to O or A2 to B donations

Question 3

What malignancies increase post solid organ transplantation?

Answer 3

Squamous cell carcinoma
Cervical cancer
Post-transplant lymphoproliferative disorder

Question 4

What has been shown to have some efficacy in restoring wound healing function in pts w/ chronic steroid usage?

Answer 4

Vitamin A supplementation

Question 5

In pts w/ kidney-pancreas transplants, prolonged hyper-insulinemia can be an independent risk factor for which conditions?

Answer 5

Enhanced atherosclerosis –> ischemic heart disease

elevated insulin levels are associated with elevated plasma triglycerids, LDL and HDL levels

Question 6

Presentation of post-transplant lymphoproliferative disorder (PTLD)?

Answer 6

Abdominal pain + small bowel mass on CT scan +/- GI bleeding (most common)

Could also present as lymphadenopathy & malaise/headaches

Question 7

What does persistent coagulopathy, prolonged cholestasis, poor bile production, and significant ascites post-liver transplant signify?

Answer 7

Small for size graft syndrome = partial liver graft is unable to meet the functional demand of the recipient ==> EARLY GRAFT DYSFUNCTION

Question 8

What can a persistent leak post-op in liver transplant pt indicate?

Answer 8

Hepatic artery compromise (thrombosis or stenosis) ==> donor graft provides blood flow to bile duct so leak or stricture/stenosis can occur w/ ischemic changes

Question 9

Why do you avoid meperidine/demerol in the post-op period of kidney transplant pts?

Answer 9

Metabolites from meperidine are renally excreted and can rise to toxic levels in pts w/ allograft early non-function

Toxicity can lead to seizures

Question 10

What’s the advantage of living donor vs deceased donor transplantation?

Answer 10

Improved long-term graft survival

Question 11

When should you consider a donor liver biopsy?

Answer 11

Obese patients w/ BMI greater than or equal to 37

Steatosis is suspected

Question 12

What are the signs and symptoms of a renal vein thrombosis post renal transplant?

Answer 12

Abrupt pain & drop in UOP + bloody urine
Renal U/S will show thrombosis

Need to return to OR

Question 13

What are the signs and symptoms of PTLD (post-transplant lymphoproliferative disorder)?

Answer 13

Appears like acute EBV infection - fever, malaise, sweats, cervical lymphadenopathy, enlarged tonsils

Diffuse lymphadenopathy or disseminated organ involvement + small bowel transplant

Question 14

What is the role of the IgA antibodies?

Answer 14

Found on mucosal surfaces (gut, resp tract) & has secretory form

Found in large quantities in breast milk ==> provides passive immunity to infants w/ developing immune system

Question 15

What are the risks with trying to biopsy a liver lesion at the dome of segment 7? posterior segment 5? caudate?

Answer 15

Segment 7 - risk of iatrogenic lung puncture & pneumothorax

Segment 5 & caudate - both are close to the IVC

Question 16

What is the ideal segment of the liver to biopsy?

Answer 16

Segment 6 as there are no major vascular or biliary structures in that area

Question 17

What’s the pathognomonic CT enhancement pattern of hepatic hemangiomas?

Answer 17

Hypodense in precontrast

Peripheral nodular enhancement on arterial phase

Peripheral to central filling on venous phase…delayed washout

Question 18

What is Kesselbach-Merrit Syndrome? Sxs?

Answer 18

This is an associated consumptive coagulopathy with hepatic hemangioma’s

Pain, compressive sxs, hemorrhage, inflammation, coagulopathy

Question 19

Describe the impact of chronic rejection in heart & kidney transplants

Answer 19

Obliterative fibrosis of vessels w/n the graft

Lesions resembling atherosclerosis w/ collagen deposition lead to endothelial injury and intimal thickening

Question 20

What is Budd-Chiari syndrome?

Answer 20

BCS - constellation of signs/sxs caused by hepatic vein obstruction.

Sxs: Ascites (MC), liver failure, profound coma, sepsis, hepatorenal syndrome

Often 2/2

Question 21

At what size cutoff should you treat on asymptomatic hepatic adenomas?

Answer 21

4 cm or greater due to the risk of spontaneous rupture & malignant degeneration

Hepatic adenomas grow in high estrogen states, such as OCP usage & pregnancy

Question 22

What are the radiographic features for a hepatic focal nodular hyperplasia (FNH)?

Answer 22

CENTRAL STELLATE SCAR

Enhancing lesion, well-demarcated border, & central fibrous scar

Question 23

What are the common sites of metastasis for melanoma?

Answer 23

Commonly will go to lymph nodes and subcutaneous tissues

Can also got lungs, viscera, brain, or liver (though not common)

Question 24

What is the trade off to improving cold ischemia time with UW solution in Liver transplantation?

Answer 24

While you can increase preservation times to > 12 hrs it increases incidence of biliary tract complications.