1. VCU Death and Complications Conference

2. Introduction Complication Procedure Primary Diagnosis
Readmission, delayed diagnosis of colon perforation
Procedure
Hartmann’s procedure
Primary Diagnosis
ESRD s/p living donor kidney transplant
Give a synopsis of each case to start the presentation.

3. 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
Prednisone 15mg

4. 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
Initial workup included orthostatic blood pressures, drug levels, held BP meds, carotid doppler, EKG, cardiac enzymes, chest xray, c spine xray, kidney US.
The pt mentioned crampy abdominal pain that started after eating the hamburger and fries the previous night. No N/V. No fevers. Last BM was two days ago. Pt passing gas.
Acute series was ordered.

5. Hospital Course
4/1/12
  Indication: Status post kidney transplant T12, elevated white count and abdominal pain with cramping. Assess.   The chest x-ray shows normal size heart with mild tortuosity of aorta. There is subsegmental atelectasis in the right lung base.   There are multiple mild moderately dilated small bowel loops in the abdomen with mild dilatation of the cecum. The remainder the colon is relatively decompressed with stool in the descending colon.
Is no evidence of free air. There are mild degenerative changes lumbar spine.   Conclusions: 1. Mildly dilated small bowel loops. May be seen with early partial obstruction or postop ileus. Followup recommended No evidence of free air or organomegaly. 2. Postoperative changes from renal transplant left iliac fossa

6. Hospital Course
4/1/12
Indication: Status post kidney transplant T12, elevated white count and abdominal pain with cramping. Assess.   The chest x-ray shows normal size heart with mild tortuosity of aorta. There is subsegmental atelectasis in the right lung base.   There are multiple mild moderately dilated small bowel loops in the abdomen with mild dilatation of the cecum. The remainder the colon is relatively decompressed with stool in the descending colon.
Is no evidence of free air. There are mild degenerative changes lumbar spine.   Conclusions: 1. Mildly dilated small bowel loops. May be seen with early partial obstruction or postop ileus. Followup recommended No evidence of free air or organomegaly. 2. Postoperative changes from renal transplant left iliac fossa

8. Hospital Course
2/21/12
CXR from 2/21: Persistent opacity noted at the right cardiophrenic angle consistent with fat within morganii hernia, better delineated on abdominal CT dated 9/27/11  

9. 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

10. CT scan
1. Status post left lower quadrant renal transplant with nephroureteral stent in place. No evidence of hydronephrosis or perinephric fluid. 2. Free intraperitoneal air and multiple collections of free intraperitoneal fluid, findings consistent with bowel perforation. A collection of free air and fluid in the left lower quadrant medial to the transplant kidney, measuring 5.1 cm AP x 5.6 cm transverse, with tract extending inferiorly and medially to the distal sigmoid colon. Additional free air is seen underneath the anterior abdominal wall, adjacent to the liver and extending into the patient's known fat-containi ng morganii hernia. This is likely related to diverticulitis as there are numerous diverticula in this region and there is adjacent fat stranding. Iatrogenic perforation is not excluded. 3. Stable low-attenuation lesions in the liver, consistent with cysts. 4. Bilateral renal atrophy with stable hypoattenuating renal lesions, incompletely characterized on this noncontrast study. Large cyst lower pole left kidney. 5. Small hiatal hernia. No evidence of bowel obstruction. 6. Interval development of trace bilateral pleural effusions. 7. Remainder stable.

11. CT scan

12. CT scan

13. CT scan

14. 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

15. 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
Error in diagnosis
Error in judgment
Error in technique
Nature of disease
Systems error

16. 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

17. Possible contributing factors:
History of diverticulosis/diverticulitis
Immunosuppression, especially high dose steroids
Infection (CMV, mucormycosis)
Polycystic kidney disease
Age over 50 yo
BASED ON MANY SMALL STUDIES LITTLE DEFINITIVE EVIDENCE

18. 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
University of Parma, in parma italy

19. 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

20. 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

21. 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

22. Retrospective review:1,137 renal transplant patients
Complicated Diverticulitis Following Renal Transplantation Lederman, et al, Department of Surgery, Albany Medical College, Albany, New York Diseases of the Colon Rectum, May 1998
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: free perforation, abscess, phlegmon, fistula (stricture disease, bowel obstruction, peritonitis)
PKD: 5.6 % of PKD patients end up with perfed diverticulitis
27 year review
Almost half the pts in this study had PKD
The addition of cyclosporin reduced colon perf rates in half, though not SS
The first 388 patients ( ) received prednisone
and azathioprine, with cyclosporine added to the
immunosuppressive regimen for the subsequent 823 recipients
( ).
Clinical presentation was highly variable, ranging from
asymptomatic pneumoperitoneum (2 patients) to generalized
peritonitis.
Patients with polycystic kidney disease as the
cause of renal failure had a significantly higher rate of
complicated diverticulitis.
Neither
treatment with cyclosporine nor donor source had a significant
effect on the rate of diverticular complications
Complicated diverticulitis following renal transplantation is rare, and the clinical presentation
may be atypical in the immunosuppressed transplant recipient.
pretransplant screening and prophylactic
sigmoid resection in this high-risk population deserve consideration and further study

23. Associated factors PKD etiology of renal failure (46% of pts)
Reported elsewhere, no clear explanation
Cyclosporin
Age over 50
Diverticulosis pre transplant
Small patient volume, most of these numbers did not approach significance
The addition of cyclosporin reduced colon perf rates in half, though not SS

24. 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
Graft survival in all pts except for one who died post op day 6 of an MI

25. Conclusions High index of suspicion Early operative intervention
Immunosuppressed with mild abdominal pain, no pertionitis
PKD
Known diverticulosis
Early operative intervention
Sigmoid colectomy with end colostomy

26. 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

27. 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.

28. 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
Stage 1 or 2 risk of death is less than 5%
Stage 3: 13%
Stage 4: 43%
Stage 1 or 2: may be drained
Stage 3 or 4: Indications for emergent surgery: generalized peritonitis, uncontrolled sepsis, uncontained visceral perforation, large/undrainabel abscess, lack of improvement or deterioration within 3 days of medical management

29. 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
Gastrointestinal Complications of Transplant Immunosuppression. Helderman,JH. Jnl Am Soc Nephrol 13: 277–287, 2002
performed at Vanderbilt University