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  • 1. www.acssurgery.com WILEY W. SOUBA, MD,ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor April 2008 BEST SURGICAL THIS MONTH’S UPDATES THINKING 9 CARE IN SPECIAL SITUATIONS and physiologic reserve are of paramount importance in the elderly Radical Resection versus 1 The Elderly Surgical surgical patient. Patient A solid understanding of the Local Excision for Early physiologic changes associated with Sylvia S. Kim, MD, and Michael aging can facilitate preoperative Rectal Cancer E. Zenilman, MD, FACS assessment of the elderly patient’s Julio Garcia-Aguilar, MD, PhD State University of New York functional reserve and thus, University of California, San Downstate College of Medicine ultimately, help ensure a more Francisco accurate assessment of the operative The elderly portion of the U.S. risk and likelihood of potential DOI 10.2310/7800.2008.NCapr population uses a substantial complications. adical resection (RR) of the share of total health care R rectum with total mesorectal excision achieves excellent local resources, and physicians must take into account this Physiologic Changes population’s physiologic changes, control and yields excellent long- assessments that help determine Associated with Aging term survival in patients with early their preoperative candidacy, and hanges in cardiac function are rectal cancer. Unfortunately, RR is associated with an appreciable risk the surgical procedures common to this population. C particularly significant, and cardiac complications remain a of mortality and significant morbid- ity; in many instances, a permanent DOI 10.2310/7800.2008.S09C01 leading cause of perioperative stoma is required. Accordingly, a morbidity and mortality. A 2007 lder persons are the fastest- less extensive procedure that would spare the rectum without compro- O growing demographic group in the United States. It is estimated report from an American College of Cardiology (ACC)/American mising cure would be appealing to Heart Association (AHA) task force many rectal cancer patients. In that by 2020, Americans older than for perioperative cardiovascular theory, full-thickness local excision 65 years will account for more evaluation recognized the utility (LE), carried out by means of either than 20% of the total population. and efficacy of the Revised Cardiac standard transanal technique or By 2030, their numbers will have transanal microscopic microsurgery, doubled to 70 million, one fourth continued on page 4 should accomplish these goals in of whom will be 85 years of age cases where rectal cancer is limited or older. This segment of the U.S. to the bowel wall. At present, however, the role of LE as definitive population uses a substantial share of total health care resources. Aging is a multifactorial process. In This Issue treatment of stage I rectal cancer is The Best Surgical Thinking controversial. In dealing with older patients, Radical Resection versus Local Solid data are available from physiologic factors are undoubtedly Excision for Early Rectal Cancer 1 prospective studies concerning the significant and must always be 9 Care in Special Situations results of RR in patients with rectal taken into account. Additionally, 1 The Elderly Surgical Patient 1 cancer. In contrast, the current data chronologic age alone is a poor 9 Care in Special Situations on LE in this setting derive mostly predictor of performance status 6 Organ Procurement 6 and advanced age is not considered This Month’s Algorithm 9 from retrospective case series, which an acceptable contraindication vary considerably with respect to Management of Diabetic Foot to surgery. Therefore, adequate Ulcers 9 continued on page 2 assessment of functional age
  • 2. 2 What’s New in ACS Surgery • April 2008 www.acssurgery.com BEST SURGICAL THINKING continued from page 1 Owned and published by BC Decker Inc patient selection criteria, preopera- In an effort to extend the potential tive staging, surgical techniques, use benefits of LE to patients with T2 EDITORIAL CHAIR: Wiley W. Souba, MD, SCD, FACS, Columbus, OH of adjuvant therapy, length and tumors without compromising cure, FOUNDING EDITOR: intensity of follow-up, and even end some have proposed administering Douglas W. Wilmore, MD, FACS, Boston points. The limitations of the data adjuvant therapy either after or EDITORIAL BOARD: notwithstanding, the experience before LE. The best available Mitchell P. Fink, md, facs, Pittsburgh Gregory accumulated over the past few J. Jurkovich, md, facs, Seattle Larry R. Kaiser, evidence concerning outcomes after md, facs, Philadelphia William H. Pearce, md, decades clearly indicates that the LE combined with postoperative facs, Chicago John H. Pemberton, md, facs, rate of local recurrence is higher chemoradiation therapy (CRT) Rochester, MN Nathaniel J. Soper, md, facs, Chicago after LE than after RR for tumors comes from two prospective phase II COUNCIL OF FOUNDING EDITORS: that are limited to the submucosa trials. In the Radiation Therapy Murray F. Brennan, md, facs, New York (T1) and that this difference is more Oncology Group (RTOG) study, Laurence Y. Cheung, md, facs, Kansas City apparent in tumors that infiltrate Alden H. Harken, md, facs, San Francisco patients with early rectal cancer James W. Holcroft, md, facs, Sacramento into but not through the muscularis were assigned to one of three Jonathan L. Meakins, md, dsc, facs, Oxford propria (T2). treatment groups after local exci- PUBLISHER: In comparing RR with LE for the sion, in accordance with the final President, Brian C. Decker Vice President, Sales, Rochelle J. Decker treatment of early rectal cancer, the pathology. Patients with T1 tumors, Vice President and Publisher, Liz Pope most relevant end point is survival negative margins, and favorable Managing Editor, Susan Cooper rather than local recurrence. RR Manager, Special Sales, Jennifer Coates histology received no additional Manager, Customer Care and Distribution, Marie carries a higher perioperative therapy after LE; patients with T1 Moore mortality and morbidity than LE tumors and unfavorable histology Rights and Permissions, Paula Mucci Director, Digital Publishing, David Love does, and the outcome measure and patients with T2 tumors Electronic Media Systems Analyst, Jeff Ferguson should incorporate these differences. received postoperative CRT. The Senior Web/IT Developer, Faisal Shah Moreover, although some patients ACS Surgery: Principles & Practice (bound local recurrence rates were corre- volume: ISBN 978-1-55009-399-5; CD-ROM: in whom LE has failed have unre- lated with the T stage: 4% for T1 ISBN 978-1-55009-421-3; quarterly CD ROM: sectable disease at the time when ISSN 1538-3210; online: ISSN 1547-1616) is tumors and 16% for T2 tumors. In their recurrence is diagnosed, a owned and published by BC Decker Inc, 50 King the Cancer and Leukemia Group B St. E., 2nd Floor, PO Box 620, LCD1, Hamilton, number of them present with disease ON L8N 3K7, Canada, Web site: http://www. (CALGB) study, LE was followed by that can still be treated by means of bcdecker.com. © 2008 BC Decker Inc. All rights observation in patients with T1 reserved. No part of this issue may be reproduced salvage RR. by any mechanical, photographic, or electronic tumors and by CRT in patients with Because of issues with sample size process or in the form of a phonographic T2 tumors. The local recurrence recording, nor may it be stored in a retrieval and patient acceptance, a well- rates at 48 months were 7% for T1 system, transmitted, or otherwise copied for designed phase III trial that com- public or private use without written permission tumors and 14% for T2 tumors. of the publisher. pares RR and LE with disease-free The actuarial 6-year disease-free survival as the end point may not be Annual subscription rates in Canada and the feasible. Thus, the best information survival rates were 85% for T1 USA: Quarterly CD-ROM: $209 (individual), $709 (institutional); Online: $189 (individual). currently available comes from tumors and 71% for T2 tumors. Institutional Web site license pricing available on several retrospective reviews of These results were comparable with request. Please e-mail acssurgery@bcdecker.com. the survival data reported for stage I Separate shipping and handling apply. All prices single-institution or population- subject to change without notice and quoted in based case series that evaluated disease by the National Cancer US dollars. Database. Unfortunately, surgical POSTMASTER: Send address changes to BC survival in T1 and T2 rectal cancer Decker Inc, PO Box 1819, Danbury, CT 06813- patients treated with LE or RR. The compliance was very poor in the 9663. results of these series indicated that RTOG study, and almost one third FOR ASSISTANCE WITH YOUR SUBSCRIPTION for patients with T1 rectal cancer, of the patients originally registered Please address all inquiries to Fulfillment Department, RR yielded higher survival rates in the CALGB study were excluded BC Decker Inc, P.O. Box 1819, Danbury, CT 06813- than LE; however, this trend was after surgery because of larger 9663, or call 800-545-0554 or 203-790-2087, fax us at 203-790-2066, or email us at acssurgery@bcdecker. not statistically significant. Only two tumor sizes, questionable resection com. For change of address, please provide both your studies reported on T2 tumors, and margins, or both. new and your old addresses; be sure to notify us at least six weeks before you expect to move to avoid both found survival rates to be Preoperative adjuvant CRT interruptions in your service. significantly higher for patients induces tumor regression in a YOUR FEEDBACK IS WELCOME treated with RR than for those substantial proportion of patients • E-mail: acssurgery@bcdecker.com treated with LE. In the light of these with locally advanced rectal cancer, • Write: BC Decker Inc P.O. Box 620, LCD 1 results, curative LE as the sole form and it achieves better local tumor Hamilton, ON L8N 3K7 of therapy can be recommended control than postoperative CRT Canada (albeit with some reservations) only does. It would therefore seem logical for patients with T1 rectal cancers; to try to take advantage of this patients with T2 tumors should not be treated with LE alone. continued on page 3 www.acssurgery.com
  • 3. www.acssurgery.com What’s New in ACS Surgery 3 BEST SURGICAL THINKING continued from page 2 downstaging effect of neoadjuvant and LE will result in higher rates of CRT in patients with early rectal cancer who may be candidates for tumor control than the combination of LE and postoperative CRT This Month’s CME LE. The results of several retrospec- tive studies and one small prospec- examined in other protocols. In addition, we hypothesize that Chapters tive study suggest that CRT fol- the reduced tumor size and the ACS Surgery offers CME in lowed by LE is comparable to RR downstaging that result from the convenient online format. As alone with respect to local tumor cytoreductive effects of preoperative many as 60 AMA PRA Category control and patient survival. CRT will increase the number of 1 credits can be earned at To explore this treatment strategy, patients who are candidates for this any time during the year. The the American College of Surgeons type of therapy and will reduce the following chapters are available Oncology Group (ACOSOG) has percentage who have positive for CME credit this month: initiated the Z6041 study [see Figure margins after LE. The main limita- 9 Care in Special Situations below], a phase II trial aimed at tions of the Z6041 study are (1) the 1 The Elderly Surgical Patient determining the disease-free survival tumor staging and patient selection rate at 3 years in patients with based on imaging studies and (2) the 9 Care in Special Situations 6 Organ Procurement T2N0 rectal cancer (as staged by potential increase in morbidity endorectal ultrasonography or associated with performing LE in an endorectal coil magnetic resonance irradiated rectum. The study was imaging) after treatment with opened to accrual in June 2006; to tumors of the distal rectum who neoadjuvant CRT and LE. This date, it has accrued 60 out of a total want to avoid a permanent colos- study should also provide valuable sample size of 82 patients. Physi- tomy or the sequelae of a coloanal information about the response rate cians wishing to enter patients into anastomosis. For patients with T2 of early rectal cancer to preoperative the Z6041 trial may contact rectal cancer, RR provides the best CRT, about the potential complica- ACOSOG via the Group’s Web site: chance of cure, and LE as the only tions of LE after CRT, and about www.acosog.org. form of therapy cannot be recom- the impact of CRT and LE on In summary, the role of LE in the mended. Patients seeking an anorectal function and quality of treatment of early rectal cancer alternative to RR should be entered life. We hypothesize that the remains to be determined. LE may into a prospective study such as the combination of neoadjuvant CRT be an option for patients with T1 ACOSOG Z6041 protocol. Z6041 T0-T2 and negative margins: observation Radiation Patients with combined stage I rectal with Proctoscopy/ LOCAL cancer REGISTER capecitabine FOLLOW biopsy EXCISION (uT2uN0) by plus ERUS staging oxaliplatin × 5 weeks T3 or positive margins: radical resection
  • 4. 4 What’s New in ACS Surgery • April 2008 www.acssurgery.com Risk Index (RCRI) and delineated a stepwise approach to perioperative cardiac assessment. The first step is a basic clinical evaluation. The THIS MONTH’S UPDATES continued from page 1 patient is assessed for any active cardiac conditions or clinical risk factors that might have to be treated system. Muscle mass is lost, muscle in that it is a truly multidimensional strength declines, and body fat mass evaluation of the elderly patient. before surgery. Active cardiac increases. To counter this, early In addition to assessing comorbid conditions include unstable coronary ambulation in the postoperative conditions, cognitive ability, mental syndromes, decompensated heart period, with assistance as necessary, function, socioenvironmental failure, significant dysrhythmias, should be encouraged. One factors, and nutrition status, it and severe valvular disease. If any also scrutinizes medications and of these conditions are present, should also take extra care when positioning patients in the OR, functional ability. the surgical procedure should be The CGA may be used both to postponed until further testing ensuring that appropriate padding and joint protection are provided. identify at-risk individuals and to and treatment are complete. If no guide interventions. When evaluated active cardiac conditions demanding as a screening tool in the geriatric immediate attention are present, the Geriatric Assessments community, it has been shown patient’s functional status should be to detect new and unsuspected n 1987, the National Institutes evaluated. Also with aging comes a I of Health (NIH) Consensus Conference on Geriatric Assessment problems in 76% of elderly persons living at home. It has been found to significant decline in respiratory be potentially beneficial in reducing function, and pulmonary Methods for Clinical Decision- the incidence of hospitalization, complications account for nearly making defined the Comprehensive falls, delirium, and readmission 50% of postoperative complications Geriatric Assessment (CGA) as in geriatric medical studies. It in the total population of surgical a “multidisciplinary evaluation is predictive of both morbidity patients. The renal system of the in which the multiple problems and mortality in older patients. elderly population also sees its of older persons are uncovered, In addition to the CGA, various share of morphologic and histologic described, and explained, if additional preoperative assessments changes. These physiologic changes possible, and in which the resources exist to evaluate elderly individuals place elderly surgical patients at and strengths of the person are [see Table 2]. increased risk for dehydration and catalogued, need for services Functional status may be prerenal azotemia. Acute renal assessed, and a coordinated measured in several different ways. failure can increase postoperative care plan developed to focus In geriatric medicine, evaluation of mortality substantially in these interventions on the persons functional status typically includes patients. Fluids and electrolytes problems.” The CGA differs from assessment of the patient’s ability should be carefully monitored, a standard preoperative evaluation to perform activities of daily living exposure to nephrotoxic drugs should be minimized, and oliguria should be addressed promptly and Table 2 Multidisciplinary Workup of Elderly Patients: Elements of Comprehensive Geriatric aggressively. Assessment Gastrointestinal changes Domain Measure associated with aging include Functional status Activities of daily living decreased basal and stimulated Instrumental activities of daily living salivary flow rates (which can lead Karnofsky score Eastern Cooperative Oncology Group grade to impaired swallowing), reduced Timed up and go test mucosal protection of the stomach, Number of falls within past 6 months and prolonged intestinal motility. Comorbidity Cumulative Illness Rating Scale–Geriatrics Clinicians should be aware of Charlson Comorbidity Index Older American Resources and Services Subscale the risk of potentially important cytochrome P-450–mediated Nutrition Mini Nutritional Assessment Body mass index drug interactions, particularly in Percentage of unintentional weight loss within past 6 months the setting of polypharmacy. Cognition Mini-Mental State examination Aging is associated with Blessed Orientation-Memory Concentration Test disruption of thermoregulation. Depression Geriatric Depression Scale Maintaining normothermia Hospital Anxiety and Depression Scale during surgical procedures is of Beck Depression Scale particular importance in elderly Social support RAND Medical Social Support Scale patients. The elderly also see their Medical Outcome Study Social Support Survey Seeman and Berkman Social Ties Score share of structural and functional Polypharmacy changes in the musculoskeletal
  • 5. www.acssurgery.com What’s New in ACS Surgery 5 (ADLs) (personal care tasks) and on a scale of 0 to 100 and includes take into account these potential instrumental activities of daily “emotional” and “tangible” differences in tumor biology seen living (IADLs) (everyday tasks). subscales. Another commonly used in older patients, the common The performance status scores measure of social support is the comorbid conditions, and the commonly used in oncology include Seeman and Berkman Social Ties typical functional impairments when the Eastern Cooperative Oncology Score, which measures social ties in planning treatment, along with the Group (ECOG) grade and the four different areas. understanding that undertreatment Karnofsky score. Both of these The physiologic changes is associated with higher recurrence are essentially global indicators of associated with aging lead to rates and increased mortality. overall functional status. Studies alterations in pharmacokinetics, Lung cancer is the leading cause involving older cancer patients and these alterations, in conjunction of cancer-related death in Western have shown that adding assessment with polypharmacy, leave the older nations. More than 50% of persons of ADLs and IADLs substantially patient susceptible to adverse drug diagnosed with lung cancer are older enhances the functional status interactions. Review of the patient’s than 65 years. For patients with evaluation provided by Karnofsky medication list is an integral early non–small cell lung carcinoma, scores or ECOG grades alone. component of the CGA. surgery affords the best chance of Comorbid conditions are common a cure. Lobectomy is currently the in elderly surgical patients and surgical standard of care for these frequently translate into adverse Special Surgical patients. outcomes. The scoring system that Considerations in the Colorectal cancer is the second is almost universally employed for most common cancer in the United assessing comorbidity in surgical Elderly States, with over 150,000 new patients is the American Society he elderly account for the of Anesthesiologists physical status classification. Additional T majority of cancer patients. Fifty-six percent of all newly cases and 50,000 deaths estimated for 2007. The mainstay of curative treatment for colorectal cancer measures of comorbidity include diagnosed cancers and 70% of is surgery: segmental resection the Cumulative Illness Rating cancer deaths are found within the for colon cancer and additional Scale–Geriatrics and the Charlson group of patients aged 65 years total mesorectal excision for Comorbidity Index. and older. The increased incidence rectal cancer. In selected elderly Impaired nutritional status and prevalence of cancer in older patients, functional outcomes after is highly prevalent among the patients, coupled with the increased low anterior resection may be as elderly. As many as 12% of project longevity within the geriatric good as those in younger patients, men and 8% of women in the population, make cancer treatment with similar subjective findings of healthy geriatric population are in the elderly a common concern. satisfaction with bowel function undernourished. Higher rates of Not surprisingly, cancer treatment and similar objective findings from surgical complications and increased plans employed in elderly patients manometry data. However, there postoperative mortality have been differ from those employed in is a growing body of evidence observed in patients with poor younger patients. Nevertheless, supporting the idea that elderly nutritional status, as determined by surgical intervention is generally patients are capable of tolerating a low body mass index, weight loss, accepted to be part of the standard adjuvant chemotherapy and deriving a low preoperative serum albumin of care for elderly patients with a demonstrable survival benefit level, or a low Mini Nutritional some of the more commonly seen comparable to that observed in Assessment score. cancers. younger patients. Preoperative cognitive dysfunction The incidence of breast cancer is has been associated with increased six times higher in older patients postoperative complications and than in younger ones. Many elderly worse survival in elderly surgical breast cancer patients may be patients. Cognitive ability can be undertreated: studies have shown assessed with the Mini-Mental State that such patients are less likely examination. Depression and the lack of social to undergo radiation treatment, chemotherapy, or axillary Coming in May support are also linked to adverse dissection. However, there is 1 Basic Surgical and Perioperative outcomes in older surgical patients. evidence to suggest that the biologic Considerations A tool that is commonly employed behavior of breast tumors differs 2 Infection Control in Surgical Practice in screening for depression in the in the elderly. Older women with elderly is the Geriatric Depression breast cancer are more likely to have 5 Gastrointestinal Tract and Abdomen Scale. Several tools are available for estrogen receptor–positive tumors 7 Surgical Treatment of Morbid Obesity quantifying social support resources that are amenable to hormonal 6 Vascular System in elderly patients. One such tool is therapy. In addition, they are more 20 Lower-Extremity Amputation for the Medical Outcome Study Social likely to have a lower rate of tumor Ischemia Support Survey, which yields a score cell proliferation. Physicians must
  • 6. 6 What’s New in ACS Surgery • April 2008 www.acssurgery.com 9 CARE IN SPECIAL SITUATIONS Organ Procurement from appropriate resuscitation. Livers from donors with viral 6 Organ Procurement Cadaveric Donors hepatitis or alcoholism can also be successfully used for patient does not become a transplantation if an acceptable Talia B. Baker, MD, FACS, Anton I. Skaro, MD, PhD, FRCSC, A potential donor until all lifesaving efforts have failed. Once • biopsy is performed. When kidney transplantation Paul Alvord, MD, Prosanto Chaudhury, MD, CM, MSc the patient has been declared brain is performed in a sensitized (Oxon), FRCSC dead and the decision has been made recipient, a negative crossmatch to proceed with organ donation, is essential for avoiding Northwestern University Feinberg accelerated rejection. For the management of the donor is redirected School of Medicine, Naval Medical kidney graft itself, anoxia time toward optimizing potentially Center, and McGill University and hypoperfusion time correlate salvageable organs. After a potential Faculty of Medicine with graft dysfunction. Donor- donor has been identified, the donor DOI 10.2310/7800.2008.S09C06 coordinator from the local organ related factors contribute to procurement organization (OPO) native renal disease, which may As a result of organ procurement prevent use of the kidneys for from both cadaveric and obtains a detailed medical and social history. The OPO coordinator transplantation. Biochemical living donors, and even parameters are also important non–heart-beating donors, more then contacts local and regional transplant programs about their indicators of kidney function. patients than ever benefit from If the donor is elderly and has organ transplantation. needs. Sharing of all organs is multiple comorbid conditions, based on the principle that organs mprovements in a renal biopsy is helpful in I immunosuppression, organ preservation, surgical technique, should be offered first to patients in the local area and then to patients determining suitability for transplantation. within a larger geographic region. and recipient management have • The criteria for heart and lung However, specific medical criteria donors are strict. Donors are led to the widespread adoption for prioritizing patients on the of transplantation as a viable usually young, with no cardiac waiting lists for various organs are disease and a normal chest x-ray therapeutic option for end-stage constantly being reevaluated. and electrocardiogram. Donors organ disease. Consequently, are also closely matched to more patients than ever benefit recipients with respect to size. from organ transplantation. Organ Evaluation • Pancreas transplantation is Unfortunately, the rate of organ nce organs are matched to donation has not kept pace with the increase in the number of recipients O specific recipients, the local OPO procurement coordinator arranges not lifesaving, and therefore, pancreas donors tend to be chosen more selectively awaiting transplantation. an operating room time for the than donors of other organs. The relative shortage of organs donor procedure and organizes Clearly, diabetes is an absolute has necessitated an increasing transportation of the participating contraindication to donation. reliance on creative strategies surgical teams. The decision to Less commonly, fibrotic or aimed at broadening or expanding use an organ is ultimately based fatty infiltration resulting from the limits of the donor pool. For on an experienced transplant alcohol use and obesity may instance, organs now are frequently surgeon’s judgment at the time of render pancreata unsuitable for obtained from so-called extended- the procurement. Careful evaluation transplantation. criteria donors (i.e., donors who of the donor, the prospective • Intestinal transplantation are elderly or who have significant recipient’s medical history, and any poses substantial challenges to comorbid conditions) or from non– pertinent laboratory data is essential surgeons because of the problems heart-beating donors. A particularly for ensuring the best outcome. faced by patients with intestinal important strategy for alleviating failure: frequent line infections, • Several biochemical parameters difficult access, and cirrhosis the organ shortage has been the are considered in the evaluation arising from total parenteral broader application of living donor of liver grafts. With ideal donors, nutrition–related liver disease. transplantation. these parameters normally Consequently, intestinal donors This chapter outlines the current include the serum aspartate are chosen very carefully. state of organ procurement from aminotransferase, serum alanine both cadaveric and living donors, aminotransferase, and bilirubin including donor evaluation levels. However, even with Procurement of Cadaveric Organs and various donor procedures. donors in whom the injurious very effort is made to sustain the Cadaveric and living donors are discussed separately because these event leading to death results in abnormal transaminase levels E donor in a normal physiologic state up to the organ procurement two groups differ vastly, both from (which may be reversible), livers procedure. Aggressive monitoring a technical or surgical standpoint suitable for transplantation of blood pressure, arterial and from a medical standpoint. can often be salvaged after oxygenation, central venous
  • 7. www.acssurgery.com What’s New in ACS Surgery 7 pressure, and urine output are key cellular integrity. The impermeants process until the organs are flushed to donor management. Before the and colloids they include prevent with cold preservation solution; procurement procedure, the donor’s cell swelling, which is the major thus, warm ischemia is eliminated chart is carefully reviewed by the mechanism of organ injury. At entirely. However, the ever- transplant surgeon to confirm present, University of Wisconsin increasing disparity between the satisfactory completion of the solution (Belzer solution) is still the number of organs available and declaration of brain death and gold standard for preservation of the the number of patients awaiting the consent for organ donation. kidney, the liver, the pancreas, and transplantation has stimulated In addition, the blood type, the the small bowel. renewed interest in the procurement serologic assays, and the laboratory Static cold storage is the preferred of organs from non–heart-beating test results should be confirmed. organ preservation method in most donors (donation after cardiac There are as many ways to centers. However, every effort death, or DCD). Donation from perform donor operations as there must be made to minimize cold non–heart-beating donors begins are surgeons performing them. In ischemia time so as to maximize after cardiopulmonary function has general, however, regardless of organ function in the recipient. ceased and the prescribed additional which organs are to be procured, Cold ischemia sets the stage for a amount of time (2 to 5 minutes) has the operation includes a preliminary complex cascade of inflammatory passed before death can be declared dissection of the great vessels of the events occurring upon reperfusion and organ retrieval initiated. abdomen and the chest. The aorta Accumulating data suggest that that result in early graft injury and is isolated at preplanned levels to despite the warm ischemia, kidneys, dysfunction. The various organs allow cross-clamping, so that the livers, lungs, whole pancreata, differ in their ability to tolerate cold organs to be removed can be core- and pancreatic islet cells from cooled in situ with intra-aortic ischemia. Kidneys can be preserved for as long as 72 hours—often non–heart-beating donors can be and intraportal infusions, thereby used for transplantation in selected avoiding warm ischemia. This longer when hypothermic machine storage is employed. Pancreas and situations. technique has been adopted as an In a 10-year analysis of DCD international standard. liver grafts may be safely preserved for as long as 20 hours; however, published in 2005, the average The procurement procedure number of organs transplanted begins with a generous incision the risk of primary liver graft from each DCD donor was 2.02, from the sternal notch to pubis nonfunction increases substantially compared with 3.18 from each with an electrocautery device. The when cold ischemic time exceeds brain-dead donor. In terms of long- abdominal and thoracic contents 12 hours. The intestine may be term graft survival, outcomes with are grossly examined and palpated preserved for as long as 12 hours, kidneys from DCD donors appear and a cursory examination of the but it should be implanted as to be equivalent to those with abdominal and thoracic contents soon as possible. Time constraints is made. The organs are evaluated kidneys from brain-dead donors. are more rigid for the heart and for their quality. It is critical that The results of liver transplantation the lungs: these organs should be all occult pathologic conditions be from controlled DCD donors transplanted within 6 hours. fully investigated and that biopsies are not as high as for kidney The cardiac team proceeds first, be obtained when indicated. The transplantation but are encouraging. removing the heart, the lungs, or order in which the steps of the To date, experience with both as expeditiously as possible procurement procedure are done transplantation of whole pancreata while the abdominal organs are varies from surgeon to surgeon, as and islet preparations from DCD covered with ice slush and perfused does the ratio of “warm dissection” donors has been limited. with the preservation solution. to “cold dissection.” The approach Thereafter, the process of removing described here is only one of the the liver and pancreas begins. The many viable methods. last organs to be procured are the Organ Procurement from Often, different teams work at Living Donors kidneys. The two organs may be different paces, on different organs, removed either individually or en iving donor transplantation is not and in different body cavities, and cross-clamping must be coordinated bloc. L a new concept. However, with living donors, even more than with across all of the participating teams. Once the surgeon communicates Organ Procurement after cadaveric donors, good judgment with the other teams to coordinate and a high degree of technical skill the cross-clamping in the chest and Cardiac Death are crucial for successful recipient the abdomen, the surgeon should ince the mid-1970s, when the and donor outcomes. Regardless ensure that adequate amounts of cold preservation solution and S U.S. adopted the legal definition of brain death, the majority of of which organ is considered for donation, donor safety must sterile ice are available to minimize cadaveric organs have been obtained be paramount. Evaluation of a potential injury to the organs during from brain-dead donors. A brain- living donor must be careful and the ischemic time. dead donor is fully supported comprehensive. Practice guideline The preservation solutions are with medication and mechanical recommendations regarding living designed to maintain the organs’ ventilation throughout the donation donors have been outlined by the
  • 8. 8 What’s New in ACS Surgery • April 2008 www.acssurgery.com Live Organ Donor Consensus a current U.S. study document a open approach or laparoscopically. Group. 1-year graft survival rate of 81%, Although open donor nephrectomy Any healthy adult (age >18 years) which is consistent with other has historically been the standard, the can be considered as a potential registry data worldwide. Operative laparoscopic alternative is now the living liver donor. Many programs techniques include open left lateral procedure of choice, particularly for have upper age limits; virtually sectionectomy and open donor right left kidneys. all would be reluctant to consider hepatectomy. One of the major Single-lung transplantation from donors older than 60 years. In impediments to more widespread a living donor has been performed general, liver donation is the most adoption of LDLT has been donor with some success. Procurement of rigorous, including comprehensive morbidity. The application of blood testing, ECG and chest x-ray, minimally invasive techniques to the pancreas and the small intestine imaging studies, liver biopsies in this operation, such as laparoscopic- from living donors has been shown some cases, and a host of additional assisted donor right hepatectomy, to be technically possible; however, tests that may be clinically indicated has the potential to reduce this serious concerns remain about the on an individual basis. Living impediment and thereby broaden adequacy of partial grafts for donor liver transplantation (LDLT) the pool of willing donors. correcting diabetes or short-gut has been performed since the late Kidney donation from a live donor syndrome. Such procedures are 1980s. Preliminary results from may be accomplished either via an currently considered experimental.
  • 9. www.acssurgery.com What’s New in ACS Surgery 9 This Month’s Algorithm Management of Diabetic Foot Ulcers A lower-extremity ulcer presents a unique window into a patient’s health. The term ulcer implies a nonhealing wound, meaning that an ulcer is most likely to be present in a patient with an underlying pathophysiologic derangement. There is no standard protocol that encompasses the care of all diabetic foot ulcers. Treatment of such wounds must be individualized, which is why it is best undertaken in a multidisciplinary fashion. The following are the general steps that should be taken to address the major causative variables, though, as noted, their relative importance will vary from patient to patient Patient has possible diabetic foot ulcer Establish diagnosis of diabetic neuropathic foot ulcer. Evaluate for significant arterial disease (ABI, PtcO2, TBI, Doppler duplex examination, arteriography, MRA). Establish presence or absence of comorbid conditions (e.g., diabetes, venous disease, renal failure), and address these conditions when possible. Perform revascularization when it is warranted and possible [see Figure 8]. Offloading Evaluation of neuropathy Optimization of perfusion Care of wound Gold standard is total Apply 10 g of pressure with Ensure adequate hydration, Choose dressings so as to contact cast. a Semmes-Weinstein 5.07 control pain, keep limb warm, ensure moist healing. Promote Consider also custom or monofilament to assess control edema, and provide autolytic debridement. off-the-shelf orthotics, neuropathy. Improvement supplemental O2. Debride callus, biofilm, and cutouts, crutches, wheel- may be noted after glycemic Consider hyperbaric oxygen necrotic tissue (this often must chair, or bed rest. control has been achieved or only after revascularization be done sequentially). revascularization performed. or if PtcO2 > 10 mm Hg with If wound bed is otherwise patient breathing 100% O2. prepared and healing is stalled or slow, consider growth factors or biologic dressings. Administer NPWT as appropriate. Control of bioburden Assessment of biomechanical derangements Optimization of systemic Surgical treatment Give systemic antibiotics if patient has advancing erythema, sepsis, Perform physical examination, parameters or gangrene. and obtain x-rays. Ensure vascular supply is sufficient for healing. Evaluate for osteomyelitis Refer patient to orthopedic or Obtain glycemic control, (especially if ulcer is tender or if podiatric specialist as necessary and encourage smoking Options include capsule or bone is exposed). Obtain (e.g., for Achilles tendon lengthening, cessation. • Grafts • Flaps deep cultures to guide therapy. Charcot foot reconstruction, removal Provide patient education • Amputation (with goal of Remove biofilm. of bony prominences). and initiate preventive preserving as much ambulatory measures as appropriate. capacity as possible)