Perioperative and Surgical Management of the Transplant Recipient
Core concepts
Understand the surgical anatomy and anastomoses for kidney, liver, heart, lung, and pancreas transplants, and the immediate postoperative complications each predisposes to: vascular thrombosis, anastomotic bleeding, biliary or ureteral leaks and strictures, and primary graft dysfunction. Know immediate postoperative monitoring: hemodynamics, urine output, drain output, liver enzymes, and imaging. Learn anesthesia considerations including fluid management, pulmonary vascular resistance in right heart failure, and reperfusion syndrome in liver transplantation. Understand immediate immunosuppression induction and when to hold or adjust it for infection or bleeding.
Traps
Questions mix early versus late complications: vascular thrombosis is early, anastomotic stricture often later. Another trap is attributing oliguria after kidney transplant solely to rejection when hypovolemia, ureteral obstruction, or vascular compromise are more urgent possibilities. In liver transplant, watch for reperfusion syndrome with hypotension, hyperkalemia, and arrhythmia. Do not forget that primary graft dysfunction presents immediately, not weeks later.
Worked example
A kidney recipient has falling urine output and rising creatinine on postoperative day one. Rule of thumb: assess volume status and bladder catheter patency, obtain Doppler ultrasound for vascular flow and hydronephrosis, and only then consider rejection; a fluid challenge may correct the problem before any biopsy.
Study strategy
For each organ, list the top three early surgical complications and the first test you would order.