Tissue Transfer in Transplant Patients--An Article Review

This is an important topic, as the number of transplant patients continues to grow. These patients are not exempt from problems (trauma, cancer resection, etc) that are best treated with tissue transfer.

Background: Traditionally, organ transplantation has been synonymous with patients with poor prognosis and outcome. Surgeons felt that the risks posed by immunosuppressive drugs outweighed the benefits of non-life-threatening procedures. With the enormous advances in the field of organ transplantation, a growing number of transplant patients present for a variety of surgical procedures. The objective of this report was to study the surgical outcome of organ transplantation patients who required reconstructive surgery using free tissue transfer.

The article is a multiple academic centers (5), retrospective patient (19) chart review. The fact that it is retrospective and that there are only 19 patients are weaknesses, but you have to start somewhere. I applaud them for this beginning. The Five academic centers that participated in the study are: Louisiana State University Health Sciences Center, Eastern Virginia Medical School, University of California, Los Angeles Medical Center, Harvard Medical School, and Tulane Health Sciences Center.

The study group included organ transplant patients who underwent elective microvascular free flap procedures. Cause of organ failure, medications, reconstruction site, flap choice, days hospitalized, complications, and outcome were examined. Delayed wound healing is defined as a wound that should have healed within 6 to 8 weeks after surgery but did not. Statistical analysis using sample t testing was performed.

Nineteen transplant patients required free flaps. Flap sites included nine lower extremity, five head and neck, three breast, and two upper extremity sites. ....... Transplant drugs being used by patients at the time of free flap surgery included cyclosporine, azathioprine, FK506, and prednisone. All free flaps survived. In our series, there were no episodes of acute rejection in the immediate postoperative period. None of the patients required changes in their immunosuppression regimen in the preoperative setting. All transplanted organs continued to function normally after flap surgery. Postoperative complications were observed in eight of 19 cases. They included partial skin graft loss, suture line dehiscence, intraoperative arterial thrombosis, and hematoma formation. Delayed wound healing was observed in two of 19 cases. In case 3, the patient with delayed wound healing was on immunosuppressive agents and insulin dependent. In case 10, the patient was on immunosuppressive agents and the recipient surgical site had been previously irradiated. In case 4, the patient had an uneventful post-free flap experience; however, a nonhealing infected foot ulcer redeveloped 6 years after surgery at the free flap recipient site. Forefoot amputation was eventually performed. Follow-up time in all cases was greater than 12 months.

The majority of transplant medications (Table 2) can cause both hypertension and thrombocytopenia, which may increase the risk of hematoma; however, this was not observed in our study. Decreased platelet activation may actually have beneficial effects. In our series, patients were not noted to have excessive bleeding or clotting dysfunction. Meticulous hemostasis and blood pressure control is warranted in any surgical procedure.

Preoperative medical evaluation and surgical planning are crucial to the outcome of a successful operation. The various disciplines (e.g., plastic surgery, transplant surgeon, internist) must maintain an open dialogue to meet the needs of the patient. It is of paramount importance that the organ transplant patient seeking any elective plastic surgery procedure have optimization of the underlying medical problem.

In addition, these patients often have other comorbid diseases such as hypertension, peripheral vascular disease, diabetes mellitus, and coronary artery disease that may adversely affect the surgical outcome. Therefore, we recommend that the patient be managed on the surgical transplant team with plastic surgery and various medical consultants available to follow the patient in the perioperative setting. This ensures that the patient continues to have careful optimal transplant organ and flap monitoring.

Part of Table 2

	Effect on Blood Pressure	Effect on Clotting	Effect on Wound Healing
Antilymphocytes ATGAM (polyclonal) Thymoglobulin Basiliximab (humanized anti-CD25 monoclonal antibody)	HTN hypotension HTN HTN	Decreased platelets, hemolysis Decreased platelets Decreased platelets	Not proven
Antimetabolites Azathioprine (imuran-1960's) Mycophenolate mofetil	HTN, hypotension (rapid IV push)	Decreased platelets Decreased platelets	Impaired Impaired
Glucocorticoids Prednisone	HTN		Impaired
Calcineurin inhibitors Cyclosporin (neoral or sandimmune) FK506	HTN HTN	Decreased platelets Decreased platelets	Not proven Not proven
Newer Drugs Sirolimus (rapamune) Mycophenolate sodium	HTN No Effect	Decreased platelets Decreased platelets	Delayed or prolonged Unknown

There results would tend to show that if a transplant patient needs a a microvascular free flap, then will careful planning and a co-operative team approach it can be successfully done.

REFERENCE

Microvascular Free Tissue Transfer in Organ Transplantation Patients: Is It Safe?; Journal of Plastic and Reconstructive Surgery, Vol 121, No 6, pp 1986-1992; Anh B. Lee, M.D.; Charles L. Dupin, M.D.; Lawrence Colen, M.D.; Neil F. Jones, M.D.; James W. May, M.D.; Ernest S. Chiu, M.D.