ORGAN TRANSPLANT

• Renal transplant• Liver transplant• Pancreatic transplant• Bowel transplant

Types of Transplant

• Heterotopic or Orthotopic

different same

• Autograft: same being• Isograft/Syngenetic graft: identical twins• Allograft/homograft: same species• Xenograft/heterograft: between species

Transplantable Organs/Tissues

• Liver• Kidney• Pancreas• Heart • Lung• Intestine• Face• Bone Marrow• Cornea• Blood

Renal transplant

Renal TransplantIndications

1. Glomerulonephritis2. Diabetic neuropathy3. Hypertensive nephropathy4. Renal vascular disease5. Polycystic disease6. Pyelonephritis7. Obstructive uropathy8. Systemic lupus

erythematous9. Analgesic nephropathy

Recipient evaluation and preparation

• Multidisciplinary team including surgeon and physician

• Determine presence of co morbidity

• Malignancy and systemic sepsis• Evaluate against organ specific

criteria for transplantation• Psychological evaluation• Need for preparative surgery• Optimize recipient condition for

surgery

Living Donor Nephrectomy

• Loin incision or midline incision

• Lateral border and upper pole mobilized first

• On left side adrenal and gonadal veins are divided

• Traction of renal artery is avoided

• Ureter mobilization• Diuresis • Laparoscopic nephrectomy

Cadaveric donor• Optimisation of donor • Midline incision• Canulation of aorta• Infusion of cold

preservation solution• Kidneys mobilized• Distal aorta and

venacava are divided• Transfered to cold

solution

The Recipient Operation

Oblique incision-

• Vascular anastomosis –Artery-end to end (internal

iliac) end to side (external

iliac)Renal vein- end to side to

external iliac vein• ureteric anastomosis• ureteroneocystostomy

Vascular Anastomosis

Ureteroneocystostomy

Complications of renal transplant

• Vascular complications; Renal artery,vein thrombosis

• Urological complications; urinary

leaks, ureteric obstruction• lymphocele• Acute tubular necrosis-

reperfusion injury • Infections• Gastointestinal complication• Hyperparathyroidism• Tumors

Ureteric Stones

Clot Auria

Immunosuppresion

• Corticosteroid• Cyclosporin• Tacrolimus• Azathioprine• Mycophenolate mofetil• Antilymphocyte antibodies

Outcome after renal transplantation

• Improves quality and duration of life• Chronic rejection is most common cause of

graft failure• Half life of graft- living donor is longer than

cadaveric grafts• Deceased donor graft-13 yrs• Living unrelated graft -14 yrs • Living haploidentical graft-15 yrs• Living identical sibling graft-27 yrs

LIVER TRANSPLANTATION

Liver TransplantationIndications

• Cirrhosis• Acute fulminant liver failure• Metabolic liver disease• Primary hepatic malignancy

Acute liver failure

Kings college criteria

Acetaminophen induced

pH <7.3

INR >6.5,Cr>3m

g,Encephalop

athy iii,iv

Non Acetaminophen induced

INR>6.5,

Age <10>40Bil>17.5mg,I

NR>3.5Jaundice to

coma.>7Drug

toxicity,nonA –E

hepatiis

Tools Used to Stratify Transplant Recipients

• MELD/PELD= model for end stage liver disease and pediatric end stage liver disease

• MELD:>12y.oCr, Bili, and INR

• PELD:<12 y.o.Alb, BIli, INR, growth failure and age

MELD>15, CTP>9

Donor Assesment

• Respiratory and haemodynamic support

• Serial follow up of liver enzymes• Hepatitis ,transmissible diseases

screening• History of alcohol intake• Marginal and expanded criteria

donor• Donor and recipient matching-

ABO compatibility and size

Deceased Donor Liver Recovery

• Midline incision• Expose IVC ,IMV, infra renal

aorta • Cannulate - Aorta and IMV • Dissection of liver done• Perfusion with cold

preservative solution • Liver removed with celiac

artery, portal vein,CBD,retro hepatic vena cava

Recipient hepatectomy

• Mercedes Benz incision • Ligaments divided • Porta hepatis exposed • Veno-venous bypass• IVC is divided between two

clamp• Liver is explanted

Living Donor Hepatectomy

• Left lobe - children , Right - adults

• Mercedes Benz incision • Liver is mobilized• Right hepatic vein -right

lobe donation ,middle and left for left lobe donation

• Hilar dissection• Vessels occluded-ischemic

plane marked-divided

Liver graft implantation

• Donor suprahepatic IVC • Donor infrahepatic IVC• Portal vein • Hepatic artery• Biliary drainage

Piggyback Liver Transplant

• It is a IVC preserving technique

• Initial steps similar to classic technique

• Hepatic veins divided , stumps joined to form common cloaca-IVC

• Donor infrahepatic IVC is closed with ligatures

• PV, hepatic artery, biliary anastomosis

Pediatric Liver Transplantation

• Major limiting factor –lack of donors

• Transplantation of left lateral segments split from cadaveric donor or living donor is standard practice

• Procedure require precise knowledge of the hepatic anatomy of the donor

Immunosuppressive strategies

• Tripple immunosuppresion-steroid

calcineurin inhibitors

mycophenolate mofetil

• Induction with CNI sparing-in renal dysfunction

(IL-2receptor antibody)

• Autoimmune diseases-lifelong low dose steroid

Complications

• Haemorrhage• Vascular complications-

hepatic artery ,portal vein thrombosis

• Biliary complications-leak,stenosis

• Primary nonfunction• Infections

Outcome after liver transplantation

• Chronic liver disease-best results

• Acute liver failure-higher mortality

• Tumors –recurrence• Hepatitis B,C-graft failure

because of recurrent viral disease

Pancreatic Transplantation

Pancreatic Transplantation• It obviates need of insulin in diabetic

patient

• Reduces the progression of vascular disease retinopathy,nephropathy

• Reserved for patients with type 1 diabetes mellitus (<55yrs)

• For most patients simultaneous kidney transplant is also undertaken(SPKT,PAKT,PTA)

SurgicalTechnique• Transplantation of whole

pancreas is done with segment of duodenum

• SPKT - through midline incision

• Pancreas graft-intraperitoeally on right side in the pelvis, kidney graft on left

• Donor vessel -recipient iliac vessels

• Exocrine drainage (enteric drainage,urinary drainage)

complications

• Vascular thrombosis• Allograft pancreatitis• Fistula and abscess• Urologic complications

Outcome

• Prolong life in diabetic patients

• After SPKT 1 year patient survival rate is >95%

• Most deaths are due to cardiovascular complications or infections

• Results of PTA graft is not as good (1 year graft survival 70%)

Pancreatic islet transplantation

• Islet of langerhans – scattered throughout pancreas

• Transplantation restores normal glucose metabolism

• Problems- isolation ,several donor cells used• Pancreas perfused with collagenase ,density

gradient purification,in vitro culture• Liver infusion-flouroscopic cannulation of PV

Small bowel transplantation

Small Bowel Transplantation

• Intestinal atresia• Necrotising enterocolitis• Volvulus• Mesentric infarction• Crohns disease • Trauma • Desmoid tumours

Bowel transplant

Types• Small bowel with or without

portion of colon• Combined liver- Small bowel

grafts• Multivisceral transplant

• Should be considered for patients in whom long term TPN has failed

Technique

• SMA of graft is anastomosed to recipient aorta(with a aortic patch)

• SMV is anastomosed to IVC or to portal vein

• Proximal end is anastomosed to recipient duodenum or jejunum

• Distal end is anastomosed to side of colon(with a loop ileostomy) or fashioned as end -ileostomy

Outcome

• 1 year graft survival rate is 65%

• 3 year graft survival rate is 45%

• Patient survival is better after isolated small bowel transplantation

Thoracic Organ Transplantation

• Heart tranplantation

Indications• ischaemic heart disease• Valvular heart disease• Cardiomyopathy• Myocarditis• Congenital heart diseaseHeart lung transplantation-pulmonary

vascular disease with heart diseaseLung transplantation-end stage

pulmonary disease

Composite tissue allotransplantation

• Transplantation of multiple tissues of ectodermal and mesodermal origin

• Involves simultaneous transplantation –skin muscle,nerve,bone and tendons

• Donor-brain dead,ABO compatible

• Sequency-bony fixation,arterial revascularisation,vein repair,tendonrepair and nerve repair

New areas of transplantion

• Larynx• Hand• Knee• Abdominal wall• Face• Islet cell transplant

Thank you