Principles of Surgery, Companion Handbook - page 63

Principles of Surgery Companion Handbook

FIGURE 10-1 T-cell receptor activation through its interaction with MHC and adhesion molecules and the mechanism of action of selected immunosuppressants. The TCR binds to an MHC molecule (class II is shown). This event is stabilized by an accessory molecule (CD4 or CD8, depending on the MHC class). The costimulatory molecule gp39 upregulates the expression of the APC costimulation molecules B7, shifting the balance of negative regulation by CTLa4 to positive regulation by CD28. This potentiates signal transduction and activation of NF-AT, which in turn induces IL-2 synthesis. IL-2 works in an autocrine loop to force the cell into a division cycle. Cyclosporine (CyA) and tacrolimus (FK506) both block this signal transduction by blocking the calcineurin/calmodulin-potentiating proteins cyclophilin and FK-binding protein, respectively. Rapamycin (RAP) blocks the IL-2 receptor signal transduction by blocking the interaction of RAFT and FK-binding protein.

Books@Ovid
Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook

Principles of Surgery Companion Handbook

FIGURE 10-2 Procurement of the donor liver involves arterial perfusion of UW solution via an aortic cannula with cross-clamping of the supraceliac aorta and concomitant perfusion of the portal vein via a separate cannula. En block procurement with the pancreas, duodenum, and spleen is performed routinely, and the pancreas and liver are then separated on the back table.

Books@Ovid
Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook

Principles of Surgery Companion Handbook

FIGURE 10-3 Conventional orthotopic liver transplantation includes division of the donor hepatic artery, portal vein, common bile duct, and infrahepatic and suprahepatic inferior vena cava with subsequent anastomosis of these from the donor, as shown here. The bile duct anastomosis shown is performed over a T-tube stent. The donor celiac axis is anastomosed end-to-end to the proper hepatic artery or to an arterial graft anastomosed to the recipient aorta.

Books@Ovid
Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook

Principles of Surgery Companion Handbook

FIGURE 10-4 Combined data for U.S. liver transplant centers for the period 1987–1993 on current patient and graft survival rates for adults.

Books@Ovid
Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook

Principles of Surgery Companion Handbook

FIGURE 10-5 Donor cardiac procurement. A. Anticipated lines of transection of the vena cavae, aorta, and pulmonary veins. B. Donor heart excision, beginning with transection of the inferior vena cava (IVC) and pulmonary veins (PV; R = right, L = left, I = inferior, S = superior) and proceeding superiorly before transecting the pulmonary arteries and aorta. RPA = right pulmonary artery; RV = right ventricle; LV = left ventricle; PDA = posterior descending artery. (From: Smith JA, McCarthy PM, et al: The Stanford Manual of Cardiopulmonary Transplantation. Armonk, NY, Futura Publishing, 1996, with permission.)

Books@Ovid
Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook

Principles of Surgery Companion Handbook

FIGURE 10-6 Actuarial survival rates of adult lung transplant recipients (1982–1995). (From: Hosenpud JD, Novick RJ, et al: The registry of the International Society for Heart and Lung Transplantation: Thirteenth official report—1996. J Heart Lung Transplant 15:655–674, 1996, with permission from Mosby–Year Book.)

Books@Ovid
Copyright © 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook