Copy of organ transplant 123


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Copy of organ transplant 123

  1. 1. ORGAN TRANSPLANT<br />
  2. 2. Renal transplant<br />Liver transplant<br />Pancreatic transplant<br />Bowel transplant<br />
  3. 3. Types of Transplant<br />Heterotopic or Orthotopic<br /> different same<br />Autograft: same being<br />Isograft/Syngenetic graft: identical twins<br />Allograft/homograft: same species<br />Xenograft/heterograft: between species<br />
  4. 4. Transplantable Organs/Tissues<br />Liver<br />Kidney<br />Pancreas<br />Heart <br />Lung<br />Intestine<br />Face<br />Bone Marrow<br />Cornea<br />Blood <br />
  5. 5. Renal transplant<br />
  6. 6. Renal TransplantIndications<br />Glomerulonephritis<br />Diabetic neuropathy<br />Hypertensive nephropathy<br />Renal vascular disease<br />Polycystic disease<br />Pyelonephritis<br />Obstructive uropathy<br />Systemic lupus erythematous<br />Analgesic nephropathy<br />
  7. 7. Recipient evaluation and preparation<br />Multidisciplinary team including surgeon and physician <br />Determine presence of co morbidity<br />Malignancy and systemic sepsis<br />Evaluate against organ specific criteria for transplantation<br />Psychological evaluation<br />Need for preparative surgery<br />Optimize recipient condition for surgery <br />
  8. 8. Living Donor Nephrectomy<br />Loin incision or midline incision<br />Lateral border and upper pole mobilized first <br />On left side adrenal and gonadal veins are divided <br />Traction of renal artery is avoided <br />Ureter mobilization<br />Diuresis<br />Laparoscopic nephrectomy<br />
  9. 9. Cadaveric donor<br />Optimisation of donor <br />Midline incision<br />Canulation of aorta<br />Infusion of cold preservation solution<br />Kidneys mobilized<br />Distal aorta and venacava are divided<br />Transfered to cold solution<br />
  10. 10. The Recipient Operation<br />Oblique incision- <br />Vascular anastomosis–<br />Artery-end to end (internal iliac)<br /> end to side (external iliac)<br />Renal vein- end to side to external iliac vein<br />uretericanastomosis<br />ureteroneocystostomy<br />
  11. 11. Vascular Anastomosis<br />
  12. 12. Ureteroneocystostomy<br />
  13. 13. Complications of renal transplant<br />Vascular complications; Renal artery,vein thrombosis <br />Urological complications; urinary leaks, ureteric obstruction<br />lymphocele<br />Acute tubular necrosis-reperfusion injury <br />Infections<br />Gastointestinal complication<br />Hyperparathyroidism<br />Tumors<br />
  14. 14. Ureteric Stones<br />
  15. 15. Clot Auria<br />
  16. 16. Immunosuppresion<br />Corticosteroid <br />Cyclosporin<br />Tacrolimus<br />Azathioprine<br />Mycophenolatemofetil<br />Antilymphocyte antibodies<br />
  17. 17. Outcome after renal transplantation<br />Improves quality and duration of life<br />Chronic rejection is most common cause of graft failure<br />Half life of graft- living donor is longer than cadaveric grafts<br />Deceased donor graft-13 yrs<br />Living unrelated graft -14 yrs <br />Living haploidentical graft-15 yrs<br />Living identical sibling graft-27 yrs<br />
  19. 19. Liver TransplantationIndications<br />Cirrhosis<br />Acute fulminant liver failure<br />Metabolic liver disease<br />Primary hepatic malignancy<br />
  20. 20. Acute liver failure<br />
  21. 21. Tools Used to Stratify Transplant Recipients<br />MELD/PELD= model for end stage liver disease and pediatric end stage liver disease<br />MELD:>12y.o<br /> Cr, Bili, and INR<br />PELD:<12 y.o.<br /> Alb, BIli, INR, growth failure and age <br /> MELD>15, CTP>9<br />
  22. 22. Donor Assesment<br />Respiratory and haemodynamic support<br />Serial follow up of liver enzymes<br />Hepatitis ,transmissible diseases screening<br />History of alcohol intake<br />Marginal and expanded criteria donor<br />Donor and recipient matching- ABO compatibility and size<br />
  23. 23. Deceased Donor Liver Recovery<br />Midline incision<br />Expose IVC ,IMV, infra renal aorta <br />Cannulate - Aorta and IMV <br />Dissection of liver done<br />Perfusion with cold preservative solution <br />Liver removed with celiac artery, portal vein,CBD,retro hepatic vena cava<br />
  24. 24. Recipient hepatectomy<br />Mercedes Benz incision <br />Ligaments divided <br />Portahepatis exposed <br />Veno-venous bypass<br /> IVC is divided between two clamp<br /> Liver is explanted <br />
  25. 25. Living Donor Hepatectomy<br />Left lobe - children , Right - adults<br />Mercedes Benz incision <br />Liver is mobilized<br />Right hepatic vein -right lobe donation ,middle and left for left lobe donation<br />Hilar dissection<br />Vessels occluded-ischemic plane marked-divided<br />
  26. 26. Liver graft implantation<br />Donor suprahepatic IVC <br />Donor infrahepatic IVC<br />Portal vein <br />Hepatic artery<br />Biliary drainage <br />
  27. 27. Piggyback Liver Transplant<br />It is a IVC preserving technique<br />Initial steps similar to classic technique<br />Hepatic veins divided , stumps joined to form common cloaca-IVC<br />Donor infrahepatic IVC is closed with ligatures<br />PV, hepatic artery, biliaryanastomosis<br />
  28. 28. Pediatric Liver Transplantation<br />Major limiting factor –lack of donors<br />Transplantation of left lateral segments split from cadaveric donor or living donor is standard practice<br />Procedure require precise knowledge of the hepatic anatomy of the donor<br />
  29. 29. Immunosuppressive strategies<br />Trippleimmunosuppresion-steroid<br />calcineurin inhibitors <br />mycophenolatemofetil<br />Induction with CNI sparing-in renal dysfunction (IL-2receptor antibody)<br />Autoimmune diseases-lifelong low dose steroid<br />
  30. 30. Complications<br />Haemorrhage<br />Vascular complications-hepatic artery ,portal vein thrombosis<br />Biliary complications-leak,stenosis<br />Primary nonfunction<br />Infections<br />
  31. 31. Outcome after liver transplantation<br />Chronic liver disease-best results <br />Acute liver failure-higher mortality<br />Tumors –recurrence<br />Hepatitis B,C-graft failure because of recurrent viral disease<br />
  32. 32. Pancreatic Transplantation<br />
  33. 33. Pancreatic Transplantation<br />It obviates need of insulin in diabetic patient<br />Reduces the progression of vascular disease retinopathy,nephropathy<br />Reserved for patients with type 1 diabetes mellitus (<55yrs)<br />For most patients simultaneous kidney transplant is also undertaken(SPKT,PAKT,PTA)<br />
  34. 34. SurgicalTechnique<br />Transplantation of whole pancreas is done with segment of duodenum<br />SPKT - through midline incision<br />Pancreas graft-intraperitoeally on right side in the pelvis, kidney graft on left<br />Donor vessel -recipient iliac vessels<br />Exocrine drainage (enteric drainage,urinary drainage)<br />
  35. 35. complications<br />Vascular thrombosis<br />Allograft pancreatitis<br />Fistula and abscess<br />Urologic complications<br />
  36. 36. Outcome<br />Prolong life in diabetic patients<br />After SPKT 1 year patient survival rate is >95%<br />Most deaths are due to cardiovascular complications or infections <br />Results of PTA graft is not as good (1 year graft survival 70%) <br />
  37. 37. Pancreatic islet transplantation<br />Islet of langerhans – scattered throughout pancreas<br />Transplantation restores normal glucose metabolism<br />Problems- isolation ,several donor cells used<br />Pancreas perfused with collagenase ,density gradient purification,in vitro culture<br />Liver infusion-flouroscopiccannulation of PV<br />
  38. 38. Small bowel transplantation<br />
  39. 39. Small Bowel Transplantation<br />Intestinal atresia<br />Necrotisingenterocolitis<br />Volvulus<br />Mesentric infarction<br />Crohns disease <br />Trauma <br />Desmoidtumours<br />
  40. 40. Bowel transplant<br />Types<br />Small bowel with or without portion of colon<br />Combined liver- Small bowel grafts<br />Multivisceral transplant <br />Should be considered for patients in whom long term TPN has failed<br />
  41. 41. Technique<br />SMA of graft is anastomosed to recipient aorta(with a aortic patch)<br />SMV is anastomosed to IVC or to portal vein<br />Proximal end is anastomosed to recipient duodenum or jejunum<br />Distal end is anastomosed to side of colon(with a loop ileostomy) or fashioned as end -ileostomy<br />
  42. 42. Outcome<br /> 1 year graft survival rate is 65% <br />3 year graft survival rate is 45%<br />Patient survival is better after isolated small bowel transplantation<br />
  43. 43. Thoracic Organ Transplantation<br />Heart tranplantation<br />Indications<br />ischaemic heart disease<br />Valvular heart disease<br />Cardiomyopathy<br />Myocarditis<br />Congenital heart disease<br />Heart lung transplantation-pulmonary vascular disease with heart disease<br />Lung transplantation-end stage pulmonary disease<br />
  44. 44. Composite tissue allotransplantation<br />Transplantation of multiple tissues of ectodermal and mesodermal origin<br />Involves simultaneous transplantation –skin muscle,nerve,bone and tendons<br />Donor-brain dead,ABO compatible<br />Sequency-bony fixation,arterialrevascularisation,veinrepair,tendonrepair and nerve repair <br />
  45. 45. New areas of transplantion<br />Larynx<br />Hand<br />Knee<br />Abdominal wall<br />Face<br />Islet cell transplant<br />
  46. 46. Thank you<br />