Transplantation Surgery

·         The first liver transplant performed by Dr. Thomas Starzl performed the first operation on March 1, 1963, at the University of Colorado in Denver.

·         In general, all type 1 diabetics who have poorly controlled diabetes despite optimal medical management should be considered for K-P transplantation as long as they are acceptable surgical risks.

·         The first experimental heart-lung transplant: Alexis Carrel, French-born American surgeon, developed the vascular techniques required for heart-lung transplantation and performed the first experimental heart-lung transplant in 1907.

The first successful experimental heart-lung transplant: V.P. Demikhov performed the first successful heart-lung transplant in a dog in 1962.

The surgical strategy required for human heart transplantation: Norman Shumway.

The first human heart transplant: C.N. Bernard performed the first human heart transplant in December, 1967 (in Capetown, South Africa, after visiting Dr. Shumway), although Dr. Shumway set the stage by developing the technique in animals. Shumway and the Stanford group performed the first heart transplant in the United States and accomplished the first successful clinical series.

The first successful heart-lung transplant: Dr. Bruce Reitz at Stanford in 1981 on a 21-year-old woman with pulmonary hypertension secondary to an atrial septal defect.

·         "Domino heart transplant":

The good heart from a heart-lung recipient is transplanted into a patient requiring a heart transplant. Some patients with primary lung dysfunction have secondary irreversible cardiac dysfunction (i.e., Eisenmenger's syndrome); others, however, such as patients with cystic fibrosis, have good cardiac function. Patients with good cardiac function may serve as donors and increase the donor pool.

·         Although heart transplantation has progressed more rapidly, the first lung transplant preceded the first heart transplant.

James Hardy performed the first human lung transplant in 1963; however, more than 20 years passed before lung transplantation was performed routinely in clinical practice (during that 20 year period, only 1 patient did well enough to leave the hospital). This delay was caused by initial graft failure secondary to inadequate organ preservation, long ischemic times, lack of good immunosuppressive agents, and technical difficulties (primarily with the bronchial-not the vascular-anastomoses).

Unlike heart transplants, the diagnosis of rejection in transplanted lungs is imprecise and based on a collection of symptoms and signs. Decreased oxygen saturation, fever, decreased exercise tolerance, and radiologic infiltrate suggest rejection. Sequential quantitative lung perfusion scans that demonstrate a decrease in perfusion are helpful in the diagnosis of rejection after single-lung transplants. Transbronchial biopsy is useful after single- and double-lung transplants.

·         Euro-Collins (EC) solution and University of Wisconsin (UW) solution for lung and crystalloid cardioplegia and UW solution for hearts.

EC solution is a glucose-based solution with an ionic composition that approximates that of the intracellular environment.

UW solution does not contain glucose but does contain the following components not found in EC solution: hydroxy-ethyl starch (prevents expansion of the interstitial space), lactobionate and raffinose (suppress hypothermia-induced cell swelling), glutathione and allopurinol (reduce cytotoxic injury from oxygen free radicals), and adenosine (substrate for adenosine triphosphate formation, vasodilation, and activation of the protective mechanisms of "protective preconditioning").

Two categories exist: intracellular solutions characterized by high K+ and low Na such as Bretschneider (HTK), and extracellular characterized by low to moderate K+ and high Na+ such as St Thomas's cardioplegia solution.

·         Chimerism is leukocyte sharing between the graft and the recipient so that the graft becomes a genetic composite of both donor and recipient.