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