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All right. Um Good evening to everyone that's joined if we just wait another minute or so. Um And then we'll make a start with our webinar. Ok. So I think people are trickling and slows. We will make a start. So, um good evening and thank you to everyone who's joined us and thank you very much to our speakers for this evening. Um So my name is Garima. I'm an ST six in general surgery in the east of England based in Cambridge. Um And I'm also the education lead for the Morning Hand Academy. Um And I'll let my co moderator introduce herself as well. Hi. Uh Good evening everyone. My name is Pfizer and I am the ST four in Yorkshire and I'm also the emergency surgery lead for the morning, an Academy. Ok, great. So this evening, um without much further ado, I'm gonna introduce our first speaker. Uh We've joined today by Mr Sanjay Sanjay Sinha who is a consultant uh transplant surgeon from Oxford. Um And he will be covering some um general surgery for want patients that we all need to know as surgeons. Um And if there's time he will go into some specifics of um died access and kidney transplantation. So over to Mr Singham, if you do have any questions, please put them in the chart and we will do AQ and a session at the end with both speakers. Thanks. I'll, I'll try to work the technology. So wish me luck. Thanks. Can you see my slides? Yes, we can. Fantastic. So, firstly, thank you to the Morning Academy, the A SGP um to Garima and uh and to Pfizer for this kind invite. It's, it's actually a huge pleasure and, and, and a privilege to be talking to young surgeons. So, just a little bit of background about myself. So I'm, I'm an old uh hag at this and uh actually, I must put it out a disclaimer that it was uh Mister K and, and Gma and Pfizer who taught me how to get on to this. Otherwise, this would have been a complete disaster. It just shows because I started surgical training in 1990 I've been a consultant for uh in excess of 20 years in Oxford. Now. Uh that said I would like to share some of uh my experience with regards to kidney pancreas transplant. So, the topic that G gave me was to talk about transplant or general surgery emergencies that you would get in a transplant patient. Now, as you know, um the success of organ donation uh and, and the longevity of transplant organs now means that pretty much each one in this room or this virtual room will come across an organ transplant recipient in a surgical emergency setting. At some point in your career, it might be in your ST five ST six or in your first years as a consultant or maybe just before you retire. But you will definitely come across as I speak. There are more than 60,000 people living in this country with uh with a functioning organ transplant. A and so, you know, it would not be uh a surprise uh uh that you will come across someone who at some stage in their life, either had a kidney transplant, a liver transplant which uh Abdul will uh focus on or a kidney pancreas transplant or one of the other transplants, a cardiothoracic transplant, a lung transplant, a heart transplant. Uh some even have multivisceral transplant, which is essentially the entire abdominal organs or perhaps a hand transplant or, or something similar. And now you might come across a uterine transplant. You probably read uh in the press or came across in the press that we had our first baby born following a successful uterine transplant in Oxford. Um So essentially what I'll try to do in the allotted 20 minutes is, is talk a bit about the types of surgical emergencies that you'll come across. Um point out to you some of the unique considerations in this group of patients who are as you know, immunosuppressed and not really talk too much about the management principles. You probably know much better than I do with regards to general surgical management principles and, and briefly touch on the outcomes in these patients. So just at the outset, can I just say that um there is a lot of meth around transplant, immunosuppressed patients and I've been doing transplants since 1993. Uh And uh they actually do not do any different from your standard patients. It's just that we somehow have a little shudder in our hearts when we come across someone who's got an organ transplant is on immunosuppressive agents. And, and, and we just sort of, um, you know, try to shy away but actually, it's not a lot different. Yeah, the types of surgical emergencies that you'll come across in this group of patients, you know, it's, it's not dissimilar to the kind of emergencies that you come across in the nontransplant group. So the vast majority would be your gallbladder disease. You will come across some gi perforations. I'll briefly touch on the, some, some of the ones which are particular to transplant. You'll come across your patient who is obstructed and, and you will get uh uh the appendicitis, the operation that we all hold our surgical skills on. Uh So within the gallbladder remit, you will get your, uh your entire gamut of presentations, which is acute cholecystitis uh with or without stones. And they could present with an emphysema or one of the other ones, you could get cholecystitis, uh, in the absence of gallstones. You guys know more about it and, and you might get the shriveled up gallbladder, which is also inflamed and needs, uh, needs attention in your acute surgical care gi perforations. The most of them would be diverticular disease related, but you might get the odd peptic ulcer perforation. You might get perforations which are, uh, in the setting of, uh, i inflammatory bowel disease. But the ones which I just wanted you uh to slightly focus on because the others are very familiar uh is, is the last two on this slide. So, as you know, immunosuppressed patients are uh um are on these drugs and 90% of the population is Epstein Barr virus positive and the Epstein Barr virus, if you remember your pathology is, is, is the virus which causes lymphomas. Uh and, and so the transplant patient is not immune to it. And these patients can either present with lymph nodal enlargement in uh your standard lymph nodal stations or in the groin or in the neck, but sometimes within your mesentery and they present as masses which could then present uh with either a perforation or in an obstructive setting. Immunosuppressed patients are also prone and you may be aware of this to opportunistic infections and this could be ac diff related thing or it could be cytomegalovirus related and cytomegalovirus, which is, you know, commonly gives you the kissing disease. Uh is, is much more potent in the transplant setting or in the immunosuppressed patients and can present a range of uh symptoms starting from retinitis to gastritis to colitis. And, and some of these uh may present with perforation, bile obstruction. You would have the standard causes of bile obstruction that you get in the no organ transplant group. The specific ones that I want to point out to you all is um that are a, a vast range of patients with kidney failure may have been on, on peritoneal dialysis before they actually went on to have a transplant. And PD. Uh, I don't know if you are aware of it is essentially a mechanism where you put in fluid with the, with the appropriate concentration and use the, uh, the lining of the bowel and the lining of the peritoneal cavity to do the exchange and, and leach out the creatinine and the urea from, uh, from the blood circulation. And this is a, a reasonably effective form of dialysis and because it's domiciliary and patients can do it at home, they can do it at night. It's, it's a quite a favored form of dialysis and you know, anything that you do to the gut, uh, you have a foreign tube.