J Gastrointest Surg (2014) 18:1299–1305 DOI 10.1007/s11605-014-2534-0
ORIGINAL ARTICLE
Colorectal Surgery After Kidney Transplantation: Characteristics of Early vs. Late Posttransplant Interventions Janet T. Lee & Ty B. Dunn & Anne-Marie Sirany & Genevieve B. Melton & Robert D. Madoff & Mary R. Kwaan
Received: 23 June 2013 / Accepted: 2 May 2014 / Published online: 17 May 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background The majority of colorectal complications after kidney transplantation reportedly occur 0.99 >0.99 0.99 >0.99 >0.99 0.59 0.72 0.56 0.06 0.14
Received intraoperative blood transfusion Received lasix/diuresis postoperatively
7 (78) 7 (78)
11 (31) 13 (36)
0.02 0.06
Overall, there were five perioperative deaths (11 %). Perioperative mortality was higher in the 1-year group (33 vs. 6 %, p=0.05). Two of the deaths in the 0.99 0.10 >0.99 >0.99 0.48 0.02 0.58 0.70 0.01 0.19
J Gastrointest Surg (2014) 18:1299–1305
complications related to combination of the transplant procedure and a prothrombotic state. The other perioperative mortality in the 1-year group, one patient death was related to overwhelming Aspergillus sepsis and postoperative ischemic colitis secondary to a previous abdominal aortic aneurysm repair. An additional perioperative death occurred that was attributed to complications from a perforated viscus, severe sepsis, and a massive postoperative bleed. After comparison of only emergency cases in the two groups, differences in postoperative LOS, perioperative mortality, prolonged intubation, and blood transfusions were no longer significant (Table 4). Among all emergency cases, the perioperative mortality was 19 %, and overall complication rate was 62 %. The perioperative mortality of elective colon and rectal surgeries in our series was low at 4 % with an overall complication rate of 21 %. Malignancy Thirteen patients in the study cohort (29 %) developed gastrointestinal malignancies that required operation with an overall incidence of 0.5 % for the entire kidney transplantation cohort during the study period. Of the patients in our study cohort, ten (24 %) patients had colorectal cancer, two (24 %) had lymphoma, and one (2 %) had anal cancer. All malignancies presented remote from transplantation (range 1.2–37 years, median 9 years). There were no perioperative deaths among patients undergoing surgery for colorectal cancer, although two patients (20 %) developed major complications postoperatively. One patient experienced an anastomotic leak and accompanying sepsis, while the other patient developed an intra-abdominal abscess and acute renal failure but did not require hemodialysis.
Discussion In examining the relationship between graft age and surgical outcomes after colon and rectal surgery, we found that the majority of surgeries occurred several years after transplantation. This is in contrast to existing literature that emphasizes the high incidence of colonic complications in the first year posttransplant. Despite a significantly higher percentage of emergency cases in the 1year group, the complication rates were not significantly different between the groups in our study. The small sample size of our study, however, may have limited the ability to detect a difference in complication rates between groups. In the 0.99
3 (33) 2 (22) 2 (22) 326 (447)
3 (43) 1 (8) 5 (42) 160 (149)
>0.99 0.57 0.64 0.31
under age 65, however, may no longer be included in a Medicare sample. In conclusion, kidney transplant recipients undergoing colon and rectal surgery in the early posttransplant period (1 year). The 1-year group, likely due to more emergency cases in this group. Despite the higher incidence of emergency surgery, patients with grafts 1 year. Our study finds that a difference in mortality is seen between the two groups without a difference in complication rates to explain the higher mortality in the early posttransplantation group. A larger sample could further clarify whether a statistically significant difference exists in complication rates. Further delineation of risk factors and the relationship of graft age and surgical outcomes for kidney transplant recipients may help guide prognosis and treatment selection for patients with conditions that place them at risk for future emergent intervention.
Sources of Support None
References 1. Carson SD, Krom RAF, Uchida K, Yokota K, West JC, Weil JC. Colon perforation after kidney transplantation. Ann Surg 1978; 188: 109-113. 2. Sawyerr OI, Garvin PJ, Codd JE, Graff RJ, Newton WT, Willman VL. Colorectal complications of renal allograft transplantation. Arch Surg 1978;113:84-86. 3. Meyers WC, Harris M, Stein S. Alimentary tract complications after renal transplantation. Ann Surg 1979;190:535-542. 4. Bardaxoglou E, Maddern G, Ruso L, et al. Gastrointestinal surgical emergencies following kidney transplantation. Transpl Int:1993;6:148.
J Gastrointest Surg (2014) 18:1299–1305 5. Church JM, Fazio VW, Braun WE, et al. Perforation of the colon in renal homograft recipients. A report of 11 cases and review of the literature. Ann Surg 1986;203:69-76. 6. Galbraith P, Bagg MN, Schabel SI, Rajagopalan PR. Diverticular complications of renal failure. Gastrointest Radiol 1990;15:259-262. 7. Lao A, Bach D. Colonic complications in renal transplant recipients. Dis Colon Rectum 1988;31:130-133. 8. Stelzner M, Vlahakos DV, Milford EL, et al. Colonic perforations after renal transplantation. J Am Coll Surg 1997;184:63. 9. Reshef A, Stocchi L, Kiran RP, et al. Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients vs. immunocompetent patients. Colorectal Dis 2012;14:1546-52. 10. Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic dis 1987;40:373-83. 11. Dindo D, Demartines N, Clavien P. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213. 12. Johnson EE, Leverson GE, Pirsch JD, Heise CP. A 30-year analysis of colorectal adenocarcinoma in transplant recipients and proposal for altered screening. J Gastroinstet Surg 2007;11:272-279.
1305 13. Papaconstantinous HT, Sklow B, Hanaway MJ. Characteristics and survival patterns of solid organ transplant patients developing de novo colon and rectal cancer. Dis Col Rectum 2004;47:18981903. 14. Miao Y, Everly JJ, Gross TG. De novo cancers arising in organ transplant recipients are associated with a diverse outcomes compared with the general population. Transplantation 2009;87:13471359. 15. Birkeland SA, Lokkegaard H, Storm HH. Cancer risk in patients on dialysis and after renal transplantation. Lancet 2000; 355: 1886–7. 16. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009 Nov; 9(Suppl 3):S1-155. 17. Krysa J, Patel V, Tayler J, Williams AB, Carapeti E, George ML. Outcome of patients on renal replacement therapy after colorectal surgery. Dis Col Rectum 2008;51:961-965. 18. Transplant in the U.S. by Region. U.S. Department of Health & Human Services: Health Resource and Services Administration, 2011. OPTN/SRTR 2011 annual data report. http://srtr.transplant. hrsa.gov/annual_reports/2011/default.aspx. Accessed January 3, 2013.
ORIGINAL ARTICLE
Colorectal Surgery After Kidney Transplantation: Characteristics of Early vs. Late Posttransplant Interventions Janet T. Lee & Ty B. Dunn & Anne-Marie Sirany & Genevieve B. Melton & Robert D. Madoff & Mary R. Kwaan
Received: 23 June 2013 / Accepted: 2 May 2014 / Published online: 17 May 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background The majority of colorectal complications after kidney transplantation reportedly occur 0.99 >0.99 0.99 >0.99 >0.99 0.59 0.72 0.56 0.06 0.14
Received intraoperative blood transfusion Received lasix/diuresis postoperatively
7 (78) 7 (78)
11 (31) 13 (36)
0.02 0.06
Overall, there were five perioperative deaths (11 %). Perioperative mortality was higher in the 1-year group (33 vs. 6 %, p=0.05). Two of the deaths in the 0.99 0.10 >0.99 >0.99 0.48 0.02 0.58 0.70 0.01 0.19
J Gastrointest Surg (2014) 18:1299–1305
complications related to combination of the transplant procedure and a prothrombotic state. The other perioperative mortality in the 1-year group, one patient death was related to overwhelming Aspergillus sepsis and postoperative ischemic colitis secondary to a previous abdominal aortic aneurysm repair. An additional perioperative death occurred that was attributed to complications from a perforated viscus, severe sepsis, and a massive postoperative bleed. After comparison of only emergency cases in the two groups, differences in postoperative LOS, perioperative mortality, prolonged intubation, and blood transfusions were no longer significant (Table 4). Among all emergency cases, the perioperative mortality was 19 %, and overall complication rate was 62 %. The perioperative mortality of elective colon and rectal surgeries in our series was low at 4 % with an overall complication rate of 21 %. Malignancy Thirteen patients in the study cohort (29 %) developed gastrointestinal malignancies that required operation with an overall incidence of 0.5 % for the entire kidney transplantation cohort during the study period. Of the patients in our study cohort, ten (24 %) patients had colorectal cancer, two (24 %) had lymphoma, and one (2 %) had anal cancer. All malignancies presented remote from transplantation (range 1.2–37 years, median 9 years). There were no perioperative deaths among patients undergoing surgery for colorectal cancer, although two patients (20 %) developed major complications postoperatively. One patient experienced an anastomotic leak and accompanying sepsis, while the other patient developed an intra-abdominal abscess and acute renal failure but did not require hemodialysis.
Discussion In examining the relationship between graft age and surgical outcomes after colon and rectal surgery, we found that the majority of surgeries occurred several years after transplantation. This is in contrast to existing literature that emphasizes the high incidence of colonic complications in the first year posttransplant. Despite a significantly higher percentage of emergency cases in the 1year group, the complication rates were not significantly different between the groups in our study. The small sample size of our study, however, may have limited the ability to detect a difference in complication rates between groups. In the 0.99
3 (33) 2 (22) 2 (22) 326 (447)
3 (43) 1 (8) 5 (42) 160 (149)
>0.99 0.57 0.64 0.31
under age 65, however, may no longer be included in a Medicare sample. In conclusion, kidney transplant recipients undergoing colon and rectal surgery in the early posttransplant period (1 year). The 1-year group, likely due to more emergency cases in this group. Despite the higher incidence of emergency surgery, patients with grafts 1 year. Our study finds that a difference in mortality is seen between the two groups without a difference in complication rates to explain the higher mortality in the early posttransplantation group. A larger sample could further clarify whether a statistically significant difference exists in complication rates. Further delineation of risk factors and the relationship of graft age and surgical outcomes for kidney transplant recipients may help guide prognosis and treatment selection for patients with conditions that place them at risk for future emergent intervention.
Sources of Support None
References 1. Carson SD, Krom RAF, Uchida K, Yokota K, West JC, Weil JC. Colon perforation after kidney transplantation. Ann Surg 1978; 188: 109-113. 2. Sawyerr OI, Garvin PJ, Codd JE, Graff RJ, Newton WT, Willman VL. Colorectal complications of renal allograft transplantation. Arch Surg 1978;113:84-86. 3. Meyers WC, Harris M, Stein S. Alimentary tract complications after renal transplantation. Ann Surg 1979;190:535-542. 4. Bardaxoglou E, Maddern G, Ruso L, et al. Gastrointestinal surgical emergencies following kidney transplantation. Transpl Int:1993;6:148.
J Gastrointest Surg (2014) 18:1299–1305 5. Church JM, Fazio VW, Braun WE, et al. Perforation of the colon in renal homograft recipients. A report of 11 cases and review of the literature. Ann Surg 1986;203:69-76. 6. Galbraith P, Bagg MN, Schabel SI, Rajagopalan PR. Diverticular complications of renal failure. Gastrointest Radiol 1990;15:259-262. 7. Lao A, Bach D. Colonic complications in renal transplant recipients. Dis Colon Rectum 1988;31:130-133. 8. Stelzner M, Vlahakos DV, Milford EL, et al. Colonic perforations after renal transplantation. J Am Coll Surg 1997;184:63. 9. Reshef A, Stocchi L, Kiran RP, et al. Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients vs. immunocompetent patients. Colorectal Dis 2012;14:1546-52. 10. Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic dis 1987;40:373-83. 11. Dindo D, Demartines N, Clavien P. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213. 12. Johnson EE, Leverson GE, Pirsch JD, Heise CP. A 30-year analysis of colorectal adenocarcinoma in transplant recipients and proposal for altered screening. J Gastroinstet Surg 2007;11:272-279.
1305 13. Papaconstantinous HT, Sklow B, Hanaway MJ. Characteristics and survival patterns of solid organ transplant patients developing de novo colon and rectal cancer. Dis Col Rectum 2004;47:18981903. 14. Miao Y, Everly JJ, Gross TG. De novo cancers arising in organ transplant recipients are associated with a diverse outcomes compared with the general population. Transplantation 2009;87:13471359. 15. Birkeland SA, Lokkegaard H, Storm HH. Cancer risk in patients on dialysis and after renal transplantation. Lancet 2000; 355: 1886–7. 16. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009 Nov; 9(Suppl 3):S1-155. 17. Krysa J, Patel V, Tayler J, Williams AB, Carapeti E, George ML. Outcome of patients on renal replacement therapy after colorectal surgery. Dis Col Rectum 2008;51:961-965. 18. Transplant in the U.S. by Region. U.S. Department of Health & Human Services: Health Resource and Services Administration, 2011. OPTN/SRTR 2011 annual data report. http://srtr.transplant. hrsa.gov/annual_reports/2011/default.aspx. Accessed January 3, 2013.
