Abdominal operations after lung transplantation. Indications and outcome.

OBJECTIVE: To assess the outcomes of abdominal operations in patients with lung transplants and identify adverse risk factors. DESIGN: Matched cohort study. SETTING: University referral center. PARTICIPANTS: Twelve lung transplant recipients who required abdominal operations (hereafter referred to as case patients) and 12 age-, sex-, and pulmonary diagnosis-matched lung transplant recipients who had not undergone an abdominal procedure (hereafter referred to as control patients). INTERVENTIONS: Elective abdominal operations including laparoscopic cholecystectomies (n = 5), laparoscopic repair of a colovaginal fistula (n = 1), and open colectomy for a benign colovesical fistula (n = 1) and urgent operations including bowel resections (n = 3), subtotal pancreatectomy (n = 1), and hepatorrhaphy for an iatrogenic liver injury (n = 1). MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: Abdominal operations were performed in 12 (11%) of the patients undergoing lung transplantation at the university referral center since 1987, with an associated mortality rate of 25%. Morbidity and mortality rates of electively performed procedures were 28% and 14%, respectively. An urgent indication for abdominal procedure was associated with 100% morbidity and 40% mortality. Compared with a matched group of 12 control patients, the long-term survival of the case patients was reduced (18% vs 64% at 4 years). Case patients undergoing an abdominal procedure in the posttransplantation period tended to have a higher prevalence of previous rejection (67% vs 25%), a higher perioperative steroid dosage (53 mg/d vs 36 mg/d), and a significantly lower posttransplantational forced expiratory volume in 1 second (FEV1, 1.23 L vs 1.91 L; P < .05). CONCLUSIONS: Elective abdominal operations are relatively safe in properly prepared lung transplant recipients. However, laparotomy for urgent surgical conditions is associated with increased morbidity and mortality rates caused in part by the magnitude of the abdominal operation and influenced by the status of the lung transplant as manifested by previous rejection episodes, perioperative steroid dosages, and FEV1 values.

Upper gastrointestinal bleeding following major surgical procedures: prevalence, etiology, and outcome.

With continuing improvements in the medical therapy of peptic ulcer disease, the incidence of primary upper gastrointestinal bleeding (UGIB) has markedly declined. Nonetheless, in a subset of surgical patients, secondary UGIB following a major operation may still be a source of substantial morbidity. To further elucidate this problem, we reviewed 103 cases of overt UGIB following all major surgical procedures conducted in two hospitals between July 1982 and June 1994. The prevalence of postoperative UGIB during this period was 0.39%. The mean interval between initial operation and UGIB was 16 days (range 1-55 days) and there was a high incidence of associated sepsis (26%). The source of bleeding was defined endoscopically in all cases and included gastritis (69.9%), solitary ulcers (17.5%), and other causes (12.6%). Postoperative UGIB (nonvariceal) was most commonly seen following portacaval shunting operations but mortality rates were highest in patients who developed UGIB after cardiovascular operations. We conclude that: (1) postoperative UGIB has become a relatively uncommon but still formidable clinical problem; (2) erosive gastritis continues to be the major source of UGIB but acute ulcers, varices, and other causes contribute to the total; and (3) postoperative UGIB is most likely to be fatal in cardiovascular patients and those who develop concurrent sepsis and/or multiorgan failure.