1. www.acssurgery.com
WILEY W. SOUBA, MD,ScD, FACS, Editorial Chair DOUGLAS W. WILMORE, MD, FACS, Founding Editor April 2008
BEST SURGICAL THIS MONTH’S UPDATES
THINKING 9 CARE IN SPECIAL SITUATIONS and physiologic reserve are of
paramount importance in the elderly
Radical Resection versus 1 The Elderly Surgical surgical patient.
Patient A solid understanding of the
Local Excision for Early physiologic changes associated with
Sylvia S. Kim, MD, and Michael aging can facilitate preoperative
Rectal Cancer E. Zenilman, MD, FACS assessment of the elderly patient’s
Julio Garcia-Aguilar, MD, PhD State University of New York functional reserve and thus,
University of California, San Downstate College of Medicine ultimately, help ensure a more
Francisco accurate assessment of the operative
The elderly portion of the U.S. risk and likelihood of potential
DOI 10.2310/7800.2008.NCapr population uses a substantial complications.
adical resection (RR) of the share of total health care
R rectum with total mesorectal
excision achieves excellent local
resources, and physicians
must take into account this Physiologic Changes
population’s physiologic changes,
control and yields excellent long-
assessments that help determine
Associated with Aging
term survival in patients with early
their preoperative candidacy, and hanges in cardiac function are
rectal cancer. Unfortunately, RR is
associated with an appreciable risk the surgical procedures common
to this population.
C particularly significant, and
cardiac complications remain a
of mortality and significant morbid-
ity; in many instances, a permanent DOI 10.2310/7800.2008.S09C01 leading cause of perioperative
stoma is required. Accordingly, a morbidity and mortality. A 2007
lder persons are the fastest-
less extensive procedure that would
spare the rectum without compro- O growing demographic group in
the United States. It is estimated
report from an American College
of Cardiology (ACC)/American
mising cure would be appealing to Heart Association (AHA) task force
many rectal cancer patients. In that by 2020, Americans older than for perioperative cardiovascular
theory, full-thickness local excision 65 years will account for more evaluation recognized the utility
(LE), carried out by means of either than 20% of the total population. and efficacy of the Revised Cardiac
standard transanal technique or By 2030, their numbers will have
transanal microscopic microsurgery, doubled to 70 million, one fourth continued on page 4
should accomplish these goals in of whom will be 85 years of age
cases where rectal cancer is limited or older. This segment of the U.S.
to the bowel wall. At present,
however, the role of LE as definitive
population uses a substantial share
of total health care resources.
Aging is a multifactorial process.
In This Issue
treatment of stage I rectal cancer is The Best Surgical Thinking
controversial. In dealing with older patients,
Radical Resection versus Local
Solid data are available from physiologic factors are undoubtedly Excision for Early Rectal Cancer 1
prospective studies concerning the significant and must always be
9 Care in Special Situations
results of RR in patients with rectal taken into account. Additionally, 1 The Elderly Surgical Patient 1
cancer. In contrast, the current data chronologic age alone is a poor 9 Care in Special Situations
on LE in this setting derive mostly predictor of performance status 6 Organ Procurement 6
and advanced age is not considered This Month’s Algorithm 9
from retrospective case series, which
an acceptable contraindication
vary considerably with respect to Management of Diabetic Foot
to surgery. Therefore, adequate Ulcers 9
continued on page 2 assessment of functional age

2. 2 What’s New in ACS Surgery • April 2008 www.acssurgery.com
BEST SURGICAL THINKING
continued from page 1
Owned and published by
BC Decker Inc
patient selection criteria, preopera- In an effort to extend the potential
tive staging, surgical techniques, use benefits of LE to patients with T2 EDITORIAL CHAIR:
Wiley W. Souba, MD, SCD, FACS, Columbus, OH
of adjuvant therapy, length and tumors without compromising cure,
FOUNDING EDITOR:
intensity of follow-up, and even end some have proposed administering Douglas W. Wilmore, MD, FACS, Boston
points. The limitations of the data adjuvant therapy either after or EDITORIAL BOARD:
notwithstanding, the experience before LE. The best available Mitchell P. Fink, md, facs, Pittsburgh Gregory
accumulated over the past few J. Jurkovich, md, facs, Seattle Larry R. Kaiser,
evidence concerning outcomes after md, facs, Philadelphia William H. Pearce, md,
decades clearly indicates that the LE combined with postoperative facs, Chicago John H. Pemberton, md, facs,
rate of local recurrence is higher chemoradiation therapy (CRT) Rochester, MN Nathaniel J. Soper, md, facs,
Chicago
after LE than after RR for tumors comes from two prospective phase II
COUNCIL OF FOUNDING EDITORS:
that are limited to the submucosa trials. In the Radiation Therapy Murray F. Brennan, md, facs, New York
(T1) and that this difference is more Oncology Group (RTOG) study, Laurence Y. Cheung, md, facs, Kansas City
apparent in tumors that infiltrate Alden H. Harken, md, facs, San Francisco
patients with early rectal cancer James W. Holcroft, md, facs, Sacramento
into but not through the muscularis were assigned to one of three Jonathan L. Meakins, md, dsc, facs, Oxford
propria (T2). treatment groups after local exci- PUBLISHER:
In comparing RR with LE for the sion, in accordance with the final President, Brian C. Decker
Vice President, Sales, Rochelle J. Decker
treatment of early rectal cancer, the pathology. Patients with T1 tumors, Vice President and Publisher, Liz Pope
most relevant end point is survival negative margins, and favorable Managing Editor, Susan Cooper
rather than local recurrence. RR Manager, Special Sales, Jennifer Coates
histology received no additional Manager, Customer Care and Distribution, Marie
carries a higher perioperative therapy after LE; patients with T1 Moore
mortality and morbidity than LE tumors and unfavorable histology
Rights and Permissions, Paula Mucci
Director, Digital Publishing, David Love
does, and the outcome measure and patients with T2 tumors Electronic Media Systems Analyst, Jeff Ferguson
should incorporate these differences. received postoperative CRT. The
Senior Web/IT Developer, Faisal Shah
Moreover, although some patients ACS Surgery: Principles & Practice (bound
local recurrence rates were corre- volume: ISBN 978-1-55009-399-5; CD-ROM:
in whom LE has failed have unre-
lated with the T stage: 4% for T1 ISBN 978-1-55009-421-3; quarterly CD ROM:
sectable disease at the time when ISSN 1538-3210; online: ISSN 1547-1616) is
tumors and 16% for T2 tumors. In
their recurrence is diagnosed, a owned and published by BC Decker Inc, 50 King
the Cancer and Leukemia Group B St. E., 2nd Floor, PO Box 620, LCD1, Hamilton,
number of them present with disease ON L8N 3K7, Canada, Web site: http://www.
(CALGB) study, LE was followed by
that can still be treated by means of bcdecker.com. © 2008 BC Decker Inc. All rights
observation in patients with T1 reserved. No part of this issue may be reproduced
salvage RR. by any mechanical, photographic, or electronic
tumors and by CRT in patients with
Because of issues with sample size process or in the form of a phonographic
T2 tumors. The local recurrence recording, nor may it be stored in a retrieval
and patient acceptance, a well-
rates at 48 months were 7% for T1 system, transmitted, or otherwise copied for
designed phase III trial that com- public or private use without written permission
tumors and 14% for T2 tumors. of the publisher.
pares RR and LE with disease-free
The actuarial 6-year disease-free
survival as the end point may not be Annual subscription rates in Canada and the
feasible. Thus, the best information survival rates were 85% for T1 USA: Quarterly CD-ROM: $209 (individual),
$709 (institutional); Online: $189 (individual).
currently available comes from tumors and 71% for T2 tumors. Institutional Web site license pricing available on
several retrospective reviews of These results were comparable with request. Please e-mail acssurgery@bcdecker.com.
the survival data reported for stage I Separate shipping and handling apply. All prices
single-institution or population- subject to change without notice and quoted in
based case series that evaluated disease by the National Cancer US dollars.
Database. Unfortunately, surgical POSTMASTER: Send address changes to BC
survival in T1 and T2 rectal cancer Decker Inc, PO Box 1819, Danbury, CT 06813-
patients treated with LE or RR. The compliance was very poor in the 9663.
results of these series indicated that RTOG study, and almost one third FOR ASSISTANCE WITH YOUR SUBSCRIPTION
for patients with T1 rectal cancer, of the patients originally registered
Please address all inquiries to Fulfillment Department,
RR yielded higher survival rates in the CALGB study were excluded BC Decker Inc, P.O. Box 1819, Danbury, CT 06813-
than LE; however, this trend was after surgery because of larger 9663, or call 800-545-0554 or 203-790-2087, fax us
at 203-790-2066, or email us at acssurgery@bcdecker.
not statistically significant. Only two tumor sizes, questionable resection com. For change of address, please provide both your
studies reported on T2 tumors, and margins, or both. new and your old addresses; be sure to notify us at
least six weeks before you expect to move to avoid
both found survival rates to be Preoperative adjuvant CRT interruptions in your service.
significantly higher for patients induces tumor regression in a
YOUR FEEDBACK IS WELCOME
treated with RR than for those substantial proportion of patients • E-mail: acssurgery@bcdecker.com
treated with LE. In the light of these with locally advanced rectal cancer, • Write: BC Decker Inc
P.O. Box 620, LCD 1
results, curative LE as the sole form and it achieves better local tumor Hamilton, ON L8N 3K7
of therapy can be recommended control than postoperative CRT Canada
(albeit with some reservations) only does. It would therefore seem logical
for patients with T1 rectal cancers; to try to take advantage of this
patients with T2 tumors should not
be treated with LE alone. continued on page 3 www.acssurgery.com

3. www.acssurgery.com What’s New in ACS Surgery 3
BEST SURGICAL THINKING
continued from page 2
downstaging effect of neoadjuvant and LE will result in higher rates of
CRT in patients with early rectal
cancer who may be candidates for
tumor control than the combination
of LE and postoperative CRT This Month’s CME
LE. The results of several retrospec-
tive studies and one small prospec-
examined in other protocols. In
addition, we hypothesize that Chapters
tive study suggest that CRT fol- the reduced tumor size and the ACS Surgery offers CME in
lowed by LE is comparable to RR downstaging that result from the convenient online format. As
alone with respect to local tumor cytoreductive effects of preoperative many as 60 AMA PRA Category
control and patient survival. CRT will increase the number of 1 credits can be earned at
To explore this treatment strategy, patients who are candidates for this any time during the year. The
the American College of Surgeons type of therapy and will reduce the following chapters are available
Oncology Group (ACOSOG) has percentage who have positive for CME credit this month:
initiated the Z6041 study [see Figure margins after LE. The main limita-
9 Care in Special Situations
below], a phase II trial aimed at tions of the Z6041 study are (1) the
1 The Elderly Surgical Patient
determining the disease-free survival tumor staging and patient selection
rate at 3 years in patients with based on imaging studies and (2) the 9 Care in Special Situations
6 Organ Procurement
T2N0 rectal cancer (as staged by potential increase in morbidity
endorectal ultrasonography or associated with performing LE in an
endorectal coil magnetic resonance irradiated rectum. The study was
imaging) after treatment with opened to accrual in June 2006; to tumors of the distal rectum who
neoadjuvant CRT and LE. This date, it has accrued 60 out of a total want to avoid a permanent colos-
study should also provide valuable sample size of 82 patients. Physi- tomy or the sequelae of a coloanal
information about the response rate cians wishing to enter patients into anastomosis. For patients with T2
of early rectal cancer to preoperative the Z6041 trial may contact rectal cancer, RR provides the best
CRT, about the potential complica- ACOSOG via the Group’s Web site: chance of cure, and LE as the only
tions of LE after CRT, and about www.acosog.org. form of therapy cannot be recom-
the impact of CRT and LE on In summary, the role of LE in the mended. Patients seeking an
anorectal function and quality of treatment of early rectal cancer alternative to RR should be entered
life. We hypothesize that the remains to be determined. LE may into a prospective study such as the
combination of neoadjuvant CRT be an option for patients with T1 ACOSOG Z6041 protocol.
Z6041
T0-T2 and
negative margins:
observation
Radiation
Patients with combined
stage I rectal with
Proctoscopy/ LOCAL
cancer REGISTER capecitabine FOLLOW
biopsy EXCISION
(uT2uN0) by plus
ERUS staging oxaliplatin ×
5 weeks
T3 or positive
margins: radical
resection

4. 4 What’s New in ACS Surgery • April 2008 www.acssurgery.com
Risk Index (RCRI) and delineated a
stepwise approach to perioperative
cardiac assessment. The first step
is a basic clinical evaluation. The
THIS MONTH’S UPDATES
continued from page 1
patient is assessed for any active
cardiac conditions or clinical risk
factors that might have to be treated system. Muscle mass is lost, muscle in that it is a truly multidimensional
strength declines, and body fat mass evaluation of the elderly patient.
before surgery. Active cardiac
increases. To counter this, early In addition to assessing comorbid
conditions include unstable coronary
ambulation in the postoperative conditions, cognitive ability, mental
syndromes, decompensated heart
period, with assistance as necessary, function, socioenvironmental
failure, significant dysrhythmias,
should be encouraged. One factors, and nutrition status, it
and severe valvular disease. If any also scrutinizes medications and
of these conditions are present, should also take extra care when
positioning patients in the OR, functional ability.
the surgical procedure should be The CGA may be used both to
postponed until further testing ensuring that appropriate padding
and joint protection are provided. identify at-risk individuals and to
and treatment are complete. If no guide interventions. When evaluated
active cardiac conditions demanding as a screening tool in the geriatric
immediate attention are present, the Geriatric Assessments community, it has been shown
patient’s functional status should be to detect new and unsuspected
n 1987, the National Institutes
evaluated.
Also with aging comes a I of Health (NIH) Consensus
Conference on Geriatric Assessment
problems in 76% of elderly persons
living at home. It has been found to
significant decline in respiratory be potentially beneficial in reducing
function, and pulmonary Methods for Clinical Decision- the incidence of hospitalization,
complications account for nearly making defined the Comprehensive falls, delirium, and readmission
50% of postoperative complications Geriatric Assessment (CGA) as in geriatric medical studies. It
in the total population of surgical a “multidisciplinary evaluation is predictive of both morbidity
patients. The renal system of the in which the multiple problems and mortality in older patients.
elderly population also sees its of older persons are uncovered, In addition to the CGA, various
share of morphologic and histologic described, and explained, if additional preoperative assessments
changes. These physiologic changes possible, and in which the resources exist to evaluate elderly individuals
place elderly surgical patients at and strengths of the person are [see Table 2].
increased risk for dehydration and catalogued, need for services Functional status may be
prerenal azotemia. Acute renal assessed, and a coordinated measured in several different ways.
failure can increase postoperative care plan developed to focus In geriatric medicine, evaluation of
mortality substantially in these interventions on the persons functional status typically includes
patients. Fluids and electrolytes problems.” The CGA differs from assessment of the patient’s ability
should be carefully monitored, a standard preoperative evaluation to perform activities of daily living
exposure to nephrotoxic drugs
should be minimized, and oliguria
should be addressed promptly and Table 2 Multidisciplinary Workup of Elderly Patients: Elements of Comprehensive Geriatric
aggressively. Assessment
Gastrointestinal changes Domain Measure
associated with aging include Functional status Activities of daily living
decreased basal and stimulated Instrumental activities of daily living
salivary flow rates (which can lead Karnofsky score
Eastern Cooperative Oncology Group grade
to impaired swallowing), reduced Timed up and go test
mucosal protection of the stomach, Number of falls within past 6 months
and prolonged intestinal motility. Comorbidity Cumulative Illness Rating Scale–Geriatrics
Clinicians should be aware of Charlson Comorbidity Index
Older American Resources and Services Subscale
the risk of potentially important
cytochrome P-450–mediated Nutrition Mini Nutritional Assessment
Body mass index
drug interactions, particularly in Percentage of unintentional weight loss within past 6 months
the setting of polypharmacy. Cognition Mini-Mental State examination
Aging is associated with Blessed Orientation-Memory Concentration Test
disruption of thermoregulation. Depression Geriatric Depression Scale
Maintaining normothermia Hospital Anxiety and Depression Scale
during surgical procedures is of Beck Depression Scale
particular importance in elderly Social support RAND Medical Social Support Scale
patients. The elderly also see their Medical Outcome Study Social Support Survey
Seeman and Berkman Social Ties Score
share of structural and functional
Polypharmacy
changes in the musculoskeletal

5. www.acssurgery.com What’s New in ACS Surgery 5
(ADLs) (personal care tasks) and on a scale of 0 to 100 and includes take into account these potential
instrumental activities of daily “emotional” and “tangible” differences in tumor biology seen
living (IADLs) (everyday tasks). subscales. Another commonly used in older patients, the common
The performance status scores measure of social support is the comorbid conditions, and the
commonly used in oncology include Seeman and Berkman Social Ties typical functional impairments when
the Eastern Cooperative Oncology Score, which measures social ties in planning treatment, along with the
Group (ECOG) grade and the four different areas. understanding that undertreatment
Karnofsky score. Both of these The physiologic changes is associated with higher recurrence
are essentially global indicators of associated with aging lead to rates and increased mortality.
overall functional status. Studies alterations in pharmacokinetics, Lung cancer is the leading cause
involving older cancer patients and these alterations, in conjunction of cancer-related death in Western
have shown that adding assessment with polypharmacy, leave the older nations. More than 50% of persons
of ADLs and IADLs substantially patient susceptible to adverse drug diagnosed with lung cancer are older
enhances the functional status interactions. Review of the patient’s than 65 years. For patients with
evaluation provided by Karnofsky medication list is an integral early non–small cell lung carcinoma,
scores or ECOG grades alone. component of the CGA. surgery affords the best chance of
Comorbid conditions are common a cure. Lobectomy is currently the
in elderly surgical patients and surgical standard of care for these
frequently translate into adverse Special Surgical patients.
outcomes. The scoring system that Considerations in the Colorectal cancer is the second
is almost universally employed for most common cancer in the United
assessing comorbidity in surgical
Elderly
States, with over 150,000 new
patients is the American Society he elderly account for the
of Anesthesiologists physical
status classification. Additional
T majority of cancer patients.
Fifty-six percent of all newly
cases and 50,000 deaths estimated
for 2007. The mainstay of curative
treatment for colorectal cancer
measures of comorbidity include diagnosed cancers and 70% of is surgery: segmental resection
the Cumulative Illness Rating cancer deaths are found within the for colon cancer and additional
Scale–Geriatrics and the Charlson group of patients aged 65 years total mesorectal excision for
Comorbidity Index. and older. The increased incidence rectal cancer. In selected elderly
Impaired nutritional status and prevalence of cancer in older patients, functional outcomes after
is highly prevalent among the patients, coupled with the increased low anterior resection may be as
elderly. As many as 12% of project longevity within the geriatric good as those in younger patients,
men and 8% of women in the population, make cancer treatment with similar subjective findings of
healthy geriatric population are in the elderly a common concern. satisfaction with bowel function
undernourished. Higher rates of Not surprisingly, cancer treatment and similar objective findings from
surgical complications and increased plans employed in elderly patients manometry data. However, there
postoperative mortality have been differ from those employed in is a growing body of evidence
observed in patients with poor younger patients. Nevertheless, supporting the idea that elderly
nutritional status, as determined by surgical intervention is generally patients are capable of tolerating
a low body mass index, weight loss, accepted to be part of the standard adjuvant chemotherapy and deriving
a low preoperative serum albumin of care for elderly patients with a demonstrable survival benefit
level, or a low Mini Nutritional some of the more commonly seen comparable to that observed in
Assessment score. cancers. younger patients.
Preoperative cognitive dysfunction The incidence of breast cancer is
has been associated with increased six times higher in older patients
postoperative complications and than in younger ones. Many elderly
worse survival in elderly surgical breast cancer patients may be
patients. Cognitive ability can be undertreated: studies have shown
assessed with the Mini-Mental State that such patients are less likely
examination.
Depression and the lack of social
to undergo radiation treatment,
chemotherapy, or axillary Coming in May
support are also linked to adverse dissection. However, there is
1 Basic Surgical and Perioperative
outcomes in older surgical patients. evidence to suggest that the biologic Considerations
A tool that is commonly employed behavior of breast tumors differs 2 Infection Control in Surgical Practice
in screening for depression in the in the elderly. Older women with
elderly is the Geriatric Depression breast cancer are more likely to have 5 Gastrointestinal Tract and Abdomen
Scale. Several tools are available for estrogen receptor–positive tumors 7 Surgical Treatment of Morbid Obesity
quantifying social support resources that are amenable to hormonal 6 Vascular System
in elderly patients. One such tool is therapy. In addition, they are more 20 Lower-Extremity Amputation for
the Medical Outcome Study Social likely to have a lower rate of tumor Ischemia
Support Survey, which yields a score cell proliferation. Physicians must

6. 6 What’s New in ACS Surgery • April 2008 www.acssurgery.com
9 CARE IN SPECIAL SITUATIONS Organ Procurement from appropriate resuscitation.
Livers from donors with viral
6 Organ Procurement Cadaveric Donors hepatitis or alcoholism can
also be successfully used for
patient does not become a transplantation if an acceptable
Talia B. Baker, MD, FACS, Anton
I. Skaro, MD, PhD, FRCSC, A potential donor until all
lifesaving efforts have failed. Once •
biopsy is performed.
When kidney transplantation
Paul Alvord, MD, Prosanto
Chaudhury, MD, CM, MSc the patient has been declared brain is performed in a sensitized
(Oxon), FRCSC dead and the decision has been made recipient, a negative crossmatch
to proceed with organ donation, is essential for avoiding
Northwestern University Feinberg accelerated rejection. For the
management of the donor is redirected
School of Medicine, Naval Medical kidney graft itself, anoxia time
toward optimizing potentially
Center, and McGill University and hypoperfusion time correlate
salvageable organs. After a potential
Faculty of Medicine with graft dysfunction. Donor-
donor has been identified, the donor
DOI 10.2310/7800.2008.S09C06 coordinator from the local organ related factors contribute to
procurement organization (OPO) native renal disease, which may
As a result of organ procurement prevent use of the kidneys for
from both cadaveric and obtains a detailed medical and social
history. The OPO coordinator transplantation. Biochemical
living donors, and even parameters are also important
non–heart-beating donors, more then contacts local and regional
transplant programs about their indicators of kidney function.
patients than ever benefit from If the donor is elderly and has
organ transplantation. needs. Sharing of all organs is
multiple comorbid conditions,
based on the principle that organs
mprovements in a renal biopsy is helpful in
I immunosuppression, organ
preservation, surgical technique,
should be offered first to patients in
the local area and then to patients
determining suitability for
transplantation.
within a larger geographic region.
and recipient management have • The criteria for heart and lung
However, specific medical criteria donors are strict. Donors are
led to the widespread adoption for prioritizing patients on the
of transplantation as a viable usually young, with no cardiac
waiting lists for various organs are disease and a normal chest x-ray
therapeutic option for end-stage constantly being reevaluated. and electrocardiogram. Donors
organ disease. Consequently,
are also closely matched to
more patients than ever benefit recipients with respect to size.
from organ transplantation.
Organ Evaluation
• Pancreas transplantation is
Unfortunately, the rate of organ nce organs are matched to
donation has not kept pace with the
increase in the number of recipients
O specific recipients, the local OPO
procurement coordinator arranges
not lifesaving, and therefore,
pancreas donors tend to
be chosen more selectively
awaiting transplantation. an operating room time for the than donors of other organs.
The relative shortage of organs donor procedure and organizes Clearly, diabetes is an absolute
has necessitated an increasing transportation of the participating contraindication to donation.
reliance on creative strategies surgical teams. The decision to Less commonly, fibrotic or
aimed at broadening or expanding use an organ is ultimately based fatty infiltration resulting from
the limits of the donor pool. For on an experienced transplant alcohol use and obesity may
instance, organs now are frequently surgeon’s judgment at the time of render pancreata unsuitable for
obtained from so-called extended- the procurement. Careful evaluation transplantation.
criteria donors (i.e., donors who of the donor, the prospective • Intestinal transplantation
are elderly or who have significant recipient’s medical history, and any poses substantial challenges to
comorbid conditions) or from non– pertinent laboratory data is essential surgeons because of the problems
heart-beating donors. A particularly for ensuring the best outcome. faced by patients with intestinal
important strategy for alleviating failure: frequent line infections,
• Several biochemical parameters difficult access, and cirrhosis
the organ shortage has been the are considered in the evaluation arising from total parenteral
broader application of living donor of liver grafts. With ideal donors, nutrition–related liver disease.
transplantation. these parameters normally Consequently, intestinal donors
This chapter outlines the current include the serum aspartate are chosen very carefully.
state of organ procurement from aminotransferase, serum alanine
both cadaveric and living donors, aminotransferase, and bilirubin
including donor evaluation levels. However, even with Procurement of Cadaveric Organs
and various donor procedures. donors in whom the injurious very effort is made to sustain the
Cadaveric and living donors are
discussed separately because these
event leading to death results in
abnormal transaminase levels
E donor in a normal physiologic
state up to the organ procurement
two groups differ vastly, both from (which may be reversible), livers procedure. Aggressive monitoring
a technical or surgical standpoint suitable for transplantation of blood pressure, arterial
and from a medical standpoint. can often be salvaged after oxygenation, central venous

7. www.acssurgery.com What’s New in ACS Surgery 7
pressure, and urine output are key cellular integrity. The impermeants process until the organs are flushed
to donor management. Before the and colloids they include prevent with cold preservation solution;
procurement procedure, the donor’s cell swelling, which is the major thus, warm ischemia is eliminated
chart is carefully reviewed by the mechanism of organ injury. At entirely. However, the ever-
transplant surgeon to confirm present, University of Wisconsin increasing disparity between the
satisfactory completion of the solution (Belzer solution) is still the number of organs available and
declaration of brain death and gold standard for preservation of the the number of patients awaiting
the consent for organ donation. kidney, the liver, the pancreas, and transplantation has stimulated
In addition, the blood type, the the small bowel. renewed interest in the procurement
serologic assays, and the laboratory Static cold storage is the preferred of organs from non–heart-beating
test results should be confirmed. organ preservation method in most donors (donation after cardiac
There are as many ways to centers. However, every effort death, or DCD). Donation from
perform donor operations as there must be made to minimize cold non–heart-beating donors begins
are surgeons performing them. In ischemia time so as to maximize after cardiopulmonary function has
general, however, regardless of organ function in the recipient. ceased and the prescribed additional
which organs are to be procured, Cold ischemia sets the stage for a amount of time (2 to 5 minutes) has
the operation includes a preliminary complex cascade of inflammatory passed before death can be declared
dissection of the great vessels of the events occurring upon reperfusion and organ retrieval initiated.
abdomen and the chest. The aorta Accumulating data suggest that
that result in early graft injury and
is isolated at preplanned levels to despite the warm ischemia, kidneys,
dysfunction. The various organs
allow cross-clamping, so that the livers, lungs, whole pancreata,
differ in their ability to tolerate cold
organs to be removed can be core- and pancreatic islet cells from
cooled in situ with intra-aortic ischemia. Kidneys can be preserved
for as long as 72 hours—often non–heart-beating donors can be
and intraportal infusions, thereby used for transplantation in selected
avoiding warm ischemia. This longer when hypothermic machine
storage is employed. Pancreas and situations.
technique has been adopted as an In a 10-year analysis of DCD
international standard. liver grafts may be safely preserved
for as long as 20 hours; however, published in 2005, the average
The procurement procedure number of organs transplanted
begins with a generous incision the risk of primary liver graft
from each DCD donor was 2.02,
from the sternal notch to pubis nonfunction increases substantially
compared with 3.18 from each
with an electrocautery device. The when cold ischemic time exceeds
brain-dead donor. In terms of long-
abdominal and thoracic contents 12 hours. The intestine may be
term graft survival, outcomes with
are grossly examined and palpated preserved for as long as 12 hours,
kidneys from DCD donors appear
and a cursory examination of the but it should be implanted as
to be equivalent to those with
abdominal and thoracic contents soon as possible. Time constraints
is made. The organs are evaluated kidneys from brain-dead donors.
are more rigid for the heart and
for their quality. It is critical that The results of liver transplantation
the lungs: these organs should be
all occult pathologic conditions be from controlled DCD donors
transplanted within 6 hours.
fully investigated and that biopsies are not as high as for kidney
The cardiac team proceeds first,
be obtained when indicated. The transplantation but are encouraging.
removing the heart, the lungs, or
order in which the steps of the To date, experience with
both as expeditiously as possible
procurement procedure are done transplantation of whole pancreata
while the abdominal organs are
varies from surgeon to surgeon, as and islet preparations from DCD
covered with ice slush and perfused
does the ratio of “warm dissection” donors has been limited.
with the preservation solution.
to “cold dissection.” The approach Thereafter, the process of removing
described here is only one of the the liver and pancreas begins. The
many viable methods. last organs to be procured are the
Organ Procurement from
Often, different teams work at Living Donors
kidneys. The two organs may be
different paces, on different organs,
removed either individually or en iving donor transplantation is not
and in different body cavities, and
cross-clamping must be coordinated
bloc. L a new concept. However, with
living donors, even more than with
across all of the participating teams.
Once the surgeon communicates Organ Procurement after cadaveric donors, good judgment
with the other teams to coordinate and a high degree of technical skill
the cross-clamping in the chest and Cardiac Death are crucial for successful recipient
the abdomen, the surgeon should ince the mid-1970s, when the and donor outcomes. Regardless
ensure that adequate amounts of
cold preservation solution and
S U.S. adopted the legal definition
of brain death, the majority of
of which organ is considered
for donation, donor safety must
sterile ice are available to minimize cadaveric organs have been obtained be paramount. Evaluation of a
potential injury to the organs during from brain-dead donors. A brain- living donor must be careful and
the ischemic time. dead donor is fully supported comprehensive. Practice guideline
The preservation solutions are with medication and mechanical recommendations regarding living
designed to maintain the organs’ ventilation throughout the donation donors have been outlined by the

8. 8 What’s New in ACS Surgery • April 2008 www.acssurgery.com
Live Organ Donor Consensus a current U.S. study document a open approach or laparoscopically.
Group. 1-year graft survival rate of 81%, Although open donor nephrectomy
Any healthy adult (age >18 years) which is consistent with other has historically been the standard, the
can be considered as a potential registry data worldwide. Operative laparoscopic alternative is now the
living liver donor. Many programs techniques include open left lateral procedure of choice, particularly for
have upper age limits; virtually sectionectomy and open donor right left kidneys.
all would be reluctant to consider hepatectomy. One of the major Single-lung transplantation from
donors older than 60 years. In impediments to more widespread
a living donor has been performed
general, liver donation is the most adoption of LDLT has been donor
with some success. Procurement of
rigorous, including comprehensive morbidity. The application of
blood testing, ECG and chest x-ray, minimally invasive techniques to the pancreas and the small intestine
imaging studies, liver biopsies in this operation, such as laparoscopic- from living donors has been shown
some cases, and a host of additional assisted donor right hepatectomy, to be technically possible; however,
tests that may be clinically indicated has the potential to reduce this serious concerns remain about the
on an individual basis. Living impediment and thereby broaden adequacy of partial grafts for
donor liver transplantation (LDLT) the pool of willing donors. correcting diabetes or short-gut
has been performed since the late Kidney donation from a live donor syndrome. Such procedures are
1980s. Preliminary results from may be accomplished either via an currently considered experimental.

9. www.acssurgery.com What’s New in ACS Surgery 9
This Month’s Algorithm
Management of Diabetic Foot Ulcers
A lower-extremity ulcer presents a unique window into a patient’s health. The term
ulcer implies a nonhealing wound, meaning that an ulcer is most likely to be present
in a patient with an underlying pathophysiologic derangement. There is no standard
protocol that encompasses the care of all diabetic foot ulcers. Treatment of such wounds
must be individualized, which is why it is best undertaken in a multidisciplinary fashion.
The following are the general steps that should be taken to address the major causative
variables, though, as noted, their relative importance will vary from patient to patient
Patient has possible diabetic foot ulcer
Establish diagnosis of diabetic neuropathic foot ulcer.
Evaluate for significant arterial disease (ABI, PtcO2, TBI,
Doppler duplex examination, arteriography, MRA).
Establish presence or absence of comorbid conditions
(e.g., diabetes, venous disease, renal failure), and address
these conditions when possible.
Perform revascularization when it is warranted and possible
[see Figure 8].
Offloading Evaluation of neuropathy Optimization of perfusion Care of wound
Gold standard is total Apply 10 g of pressure with Ensure adequate hydration, Choose dressings so as to
contact cast. a Semmes-Weinstein 5.07 control pain, keep limb warm, ensure moist healing. Promote
Consider also custom or monofilament to assess control edema, and provide autolytic debridement.
off-the-shelf orthotics, neuropathy. Improvement supplemental O2. Debride callus, biofilm, and
cutouts, crutches, wheel- may be noted after glycemic Consider hyperbaric oxygen necrotic tissue (this often must
chair, or bed rest. control has been achieved or only after revascularization be done sequentially).
revascularization performed. or if PtcO2 > 10 mm Hg with If wound bed is otherwise
patient breathing 100% O2. prepared and healing is stalled
or slow, consider growth factors
or biologic dressings.
Administer NPWT as appropriate.
Control of bioburden Assessment of biomechanical
derangements
Optimization of systemic Surgical treatment
Give systemic antibiotics if patient
has advancing erythema, sepsis, Perform physical examination, parameters
or gangrene. and obtain x-rays. Ensure vascular supply
is sufficient for healing.
Evaluate for osteomyelitis Refer patient to orthopedic or Obtain glycemic control,
(especially if ulcer is tender or if podiatric specialist as necessary and encourage smoking Options include
capsule or bone is exposed). Obtain (e.g., for Achilles tendon lengthening, cessation. • Grafts • Flaps
deep cultures to guide therapy. Charcot foot reconstruction, removal Provide patient education • Amputation (with goal of
Remove biofilm. of bony prominences). and initiate preventive preserving as much ambulatory
measures as appropriate. capacity as possible)