Beyond Immunosuppression: Defining Perioperative Risk in Transplant Patients Undergoing Colorectal and Small Bowel Surgery.

Abstract

Colorectal and small bowel surgery in transplant (TX) recipients presents unique perioperative challenges due to immunosuppression and comorbidities, with poorly defined risks. A retrospective analysis was conducted on 237 TX recipients who underwent colorectal or small bowel surgery at a specialized center between 2008 and 2024. Patient characteristics (transplant type, time since TX, immunosuppression, Charlson Comorbidity Index) and surgical details were analyzed in relation to postoperative outcomes (ICU stay, in-hospital mortality, length of stay, major morbidity [Dindo-Clavien ≥ 3]). Most patients had prior kidney (45.6%) or liver TX (28.3%). The incidence of all adverse endpoints was significantly higher in emergencies as compared to elective surgery (mortality 25.6% vs. 6.2%, morbidity 52.3% vs. 35.4%, LOS 24.9d vs. 15.7d, ICU stay 10.7d vs. 2.9d; all p ≤ 0.001). 14.8% had surgical site infections, 9.7% cardiopulmonary complications. Primary anastomosis was not correlated with worse outcome. Multivariate regression showed emergency surgery (OR 8.48 (2.68-26.8) p = 0.001), colorectal surgery (OR 3.26 (1.54-6.90) p = 0.002) and heart TX (OR 4.35 (1.10-17.23) p = 0.036) as independent risk factors, patients receiving prednisolone had reduced risk (OR 0.28 (0.13-0.60) p = 0.001). Heart TX and emergency surgery correlated with longer ICU stay, hematopoetic stem cell transplantation with longer LOS. TX recipients undergoing colorectal or small bowel surgery face considerable perioperative risks, especially in emergency situations and after heart transplantation. The feasibility of primary anastomosis in selected patients suggests that surgical strategies should be tailored, emphasizing the need for specialized, multidisciplinary care to optimize outcomes in this vulnerable population.