Outcome of 118 Pancreas Transplants With Retroperitoneal Portal-Enteric Drainage

Pancreas transplantation with isolated splenic artery blood supply - Single center experience

BACKGROUND

The blood supply of the native pancreas by three arterial lines from the celiac trunk system (splenic artery and common hepatic artery) and the superior mesenteric artery forces surgeons to perform vascular reconstruction to provide sufficient intra-organ blood flow into the graft. The purpose of our study was to assess the possibility of pancreas transplantation with an isolated splenic artery blood supply.

METHODS

From January 2012 to July 2018, simultaneous pancreas-kidney transplantation (SPKT) was performed in 21 patients. Gender: male - 11 (52,4%), female 10 (47,6%). Recipients aged 26 to 54, the median age was 38 [34; 42] years. In 6 (28,6%) recipients, the organ perfusion was carried out through the splenic artery alone; in the rest, it was performed through the splenic and inferior pancreaticoduodenal artery exiting from the superior mesenteric artery of the graft. The transplant function, the quality of carbohydrate metabolism compensation, the objective characteristics of intra-organ blood flow was assessed.

RESULTS

There were no statistically significant differences in the volume blood flow characteristics revealed by CT-perfusion and laboratory data in the study groups.

CONCLUSIONS

Based on the assessment of the function and quality of blood supply to the transplant, the possibility of performing pancreas transplantation with an isolated splenic artery blood supply had been proved.

[Pancreas transplantation with isolated blood supply through the splenic artery]

In multiple organ procurement, taking into consideration certain peculiarities of the vascular architectonics of the celiac trunk or an iatrogenic injury to the superior mesenteric artery, it is impossible to perform standard arterial reconstruction of a pancreas transplant with the use of a Y-shaped vascular allograft. This results in refusal from transplanting a potentially suitable organ. The purpose of our study was to assess the possibility of transplantation of the pancreatoduodenal complex with isolated blood supply via the splenic artery. Between January 2008 and November 2016, transplantation of the pancreas was carried out in a total of 20 patients (9 men and 11 women aged from 26 to 40 years, mean age 37.2±5.6 years). Depending on the number of the major arteries supplying the pancreas, the patients were divided into 2 groups. No statistically significant between-group differences in the parameters of volumetric blood flow determined by means of CT perfusion, in the majority of laboratory findings or therapeutic outcomes were revealed. Based on assessment of the function and quality of pancreatic blood supply, we proved feasibility of transplantation of the pancreatoduodenal complex with isolated blood supply through the splenic artery.

[Pancreas transplantation followed by stumpless duodenal exocrine drainage]

Pancreas transplantation followed by stumpless duodenal exocrine drainage was performed in 2 patients. Primary kidney and pancreas graft function was noted in both cases. Two procedures of pancreas transplantation followed by stumpless duodenal exocrine drainage were carried out for the first time. Perhaps, absent donor duodenal stump has several advantages for the further course of postoperative period that may be confirmed in prospective trials.

Retroperitoneal Pancreas Transplantation With the Use of Duodenal Drainage via "Button Technique": First Clinical Practice (Case Report)

The persistent relative high incidence of duodenum-associated surgical complications significantly reduces pancreas grafts' (PG) and recipients' survival rates. A 31-year-old female patient underwent retroperitoneal pancreas transplantation with the use of PG exocrine drainage into the recipient's duodenum via the "button technique" approach. An uncomplicated postoperative period with satisfactory function of both transplants (pancreas and kidney) was noted. This was the 1st time ever that the transplantation was performed with the use of retroperitoneal placement of the pancreas transplant and duodenal drainage via the "button technique" approach. It is possible that the absence of the duodenal stump in the donor's transplant has a number of benefits in the postoperative period, which can be confirmed during the follow-up observations.

Pancreas transplantation: Advantages of a retroperitoneal graft position

INTRODUCTION

In the 50 years since the first pancreas transplant performed at the University of Minnesota, the surgical techniques employed have undergone many modifications. Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the «native» pancreas. We herein present our experience of a modified technique for pancreatic transplant, with the organ placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodeno-duodenostomy.

METHODS

All pancreas transplantations performed between May 2016 and January 2017 were prospectively entered into our transplant database and retrospectively analyzed.

RESULTS

A total of 10 transplants were performed using the retroperitoneal technique (6 men: median age of 41 years [IQR 36-54]). Median cold ischemia times was 10,30h [IQR 5,30-12,10]. The preservation solution used was Celsior (n=7), IGL-1 (n=2), and UW (n=1). No complications related to the new surgical technique were identified. In one patient, transplantectomy at 12h was performed due to graft thrombosis, probably related to ischemic conditions from a donor with prolonged cardio-respiratory arrest. Another procedure was aborted without completing the graft implant due to an intraoperative immediate arterial thrombosis in a patient with severe iliac atheromatosis. No primary pancreas non-function occurred in the remaining 8patients. The median hospital stay was 13,50 days [IQR 10-27].

CONCLUSIONS

Retroperitoneal graft placement appears feasible with easy access for dissection the vascular site; comfortable technical vascular reconstruction; and a decreased risk of intestinal obstruction by separation of the small bowel from the pancreas graft.

Endoscopic findings following retroperitoneal pancreas transplantation

AIM

An evaluation of the efficacy of endoscopic methods for the diagnosis and correction of surgical and immunological complications after retroperitoneal pancreas transplantation.

MATERIALS AND METHODS

From October 2011 to March 2015, 27 patients underwent simultaneous retroperitoneal pancreas-kidney transplantation (SPKT). Diagnostic oesophagogastroduodenoscopy (EGD) with protocol biopsy of the donor and recipient duodenal mucosa and endoscopic retrograde pancreatography (ERP) were performed to detect possible complications. Endoscopic stenting of the main pancreatic duct with plastic stents and three-stage endoscopic hemostasis were conducted to correct the identified complications.

RESULTS

Endoscopic methods showed high efficiency in the timely diagnosis and adequate correction of complications after retroperitoneal pancreas transplantation.

Multi detector computed tomography (MDCT) for the diagnosis of early complications after pancreas transplantation

PURPOSE

Solitary Pancreas (SPT) and simultaneous kidney-pancreas (SPKT) transplants carry a high risk of surgical complications that may lead to the loss of the pancreas graft and impact later kidney function. The purpose of this study was to investigate the role of MDCT in the diagnosis of early complications and its impact on kidney function.

METHODS

All patients receiving SPT or SPKT over 5 years were retrospectively included. Complications that occurred within the first 15 days were registered and MDCT data analyzed. Data regarding donor, transplant, and recipient characteristics as well as transplantation procedures were analyzed according to the occurrence of early complications. Kidney function at day 3 following MDCT was evaluated.

RESULTS

One hundred and forty-one patients were included (85 men, 56 women; mean age 40.1 years, SD 7.7) with 119 SPKT and 22 SPT. Sixty-four complications were registered in 50 patients. Partial (P-) or complete venous thrombosis (C-VT) occurred in 12.1 % (n = 17), arterial thrombosis (AT) in 1.4 % (n = 2), and hemorrhage in 8.5 % (n = 12) of all patients. For venous thrombosis, the predominant risk factor was body mass index (BMI) for either recipients (P < 0.05) or donors (P < 0.01). Median time for venous thrombosis diagnosis with MDCT was 4 days. Kidney function was not altered following MDCT. Fourteen pancreatectomies were necessary. All patients with C-VT and AT had to undergo graftectomy.

CONCLUSION

Vascular complications occurred early following grafting. Systematic early-enhanced MDCT at day 2-3 should be adequate to detect early thrombosis, especially if risk factors have been identified, without induced kidney function alteration.

Extended pancreas donor program - the EXPAND study rationale and study protocol

BACKGROUND

Simultaneous pancreas kidney transplantation (SPK), pancreas transplantation alone (PTA) or pancreas transplantation after kidney (PAK) are the only curative treatment options for patients with type 1 (juvenile) diabetes mellitus with or without impaired renal function. Unfortunately, transplant waiting lists for this indication are increasing because the current organ acceptability criteria are restrictive; morbidity and mortality significantly increase with time on the waitlist. Currently, only pancreas organs from donors younger than 50 years of age and with a body mass index (BMI) less than 30 are allocated for transplantation in the Eurotransplant (ET) area. To address this issue we designed a study to increase the available donor pool for these patients.

METHODS/DESIGN

This study is a prospective, multicenter (20 German centers), single blinded, non-randomized, two armed trial comparing outcome after SPK, PTA or PAK between organs with the currently allowed donor criteria versus selected organs from donors with extended criteria. Extended donor criteria are defined as organs procured from donors with a BMI of 30 to 34 or a donor age between 50 and 60 years. Immunosuppression is generally standardized using induction therapy with Myfortic, tacrolimus and low dose steroids. In principle, all patients on the waitlist for primary SPK, PTA or PAK are eligible for the clinical trial when they consent to possibly receiving an extended donor criteria organ. Patients receiving an organ meeting the current standard criteria for pancreas allocation (control arm) are compared to those receiving extended criteria organ (study arm); patients are blinded for a follow-up period of one year. The combined primary endpoint is survival of the pancreas allograft and pancreas allograft function after three months, as an early relevant outcome parameter for pancreas transplantation.

DISCUSSION

The EXPAND Study has been initiated to investigate the hypothesis that locally allocated extended criteria organs can be transplanted with similar results compared to the currently allowed standard ET organ allocation. If our study shows a favorable comparison to standard organ allocation criteria, the morbidity and mortality for patients waiting for transplantation could be reduced in the future.

TRIAL REGISTRATION

Trial registered at: NCT01384006.

Intraoperative imaging of pancreas transplant allografts using indocyanine green with laser fluorescence

Vascular thrombosis is a cause of allograft loss after pancreas transplantation. We present the use of intraoperative fluorescence imaging with the SPY imaging device (Novadaq Technologies Inc, Toronto, Canada) in two pancreas transplants as a means to assess potency of the vascular anastomoses. Intravenous indocyanine green 2.5 mg/mL was fluoresced with the device to create the intraoperative video sequences, which were recorded. After 60-day follow-up, real-time SPY imaging on these two pancreas transplants did not demonstrate adverse effects on patients or the transplanted allografts. This method of vascular imaging could prove useful in improving short-term graft survival and possibly lowering the thrombosis rates seen with pancreas transplantation. Long-term correlation studies between intraoperative findings and graft survival must be performed to confirm the utility of this imaging method.

Body mass index and outcomes from pancreatic resection: a review and meta-analysis

INTRODUCTION

There are 1.6 billion adults worldwide who are overweight, with body mass indices (BMI) between 25 and 30, while more than 400 million are obese (BMI >30). Obesity predicts the incidence of and poor outcomes from pancreatic cancer. Obesity has also been linked to surgical complications in pancreatectomy, including increased length of hospital stay, surgical infections, blood loss, and decreased survival. However, BMI's impact on many complications following pancreatectomy remains controversial.

METHODS

We performed a MEDLINE search of all combinations of "BMI" with "pancreatectomy," "pancreatoduodenectomy," or "pancreaticoduodenectomy." From included studies, we created pooled and weighted estimates for quantitative and qualitative outcomes. We used the PRISMA criteria to ensure this project's validity.

RESULTS

Our primary cohort included 2,736 patients with BMI <30, 1,682 with BMI >25, and 546 with BMI between 25 and 30. Most outcomes showed no definitive differences across BMIs. Pancreatic fistula (PF) rates ranged from 4.7% to 31.0%, and four studies found multivariate association between BMI and PF (range odds ratio 1.6-4.2). Pooled analyses of PF by BMI showed significant association (p < 0.05).

CONCLUSION

BMI increases the operative complexity of pancreatectomy. However, with aggressive peri- and post-operative care, increases in BMI-associated morbidity and mortality may be mitigated.

Whole-organ pancreas transplantation at Baylor Regional Transplant Institute: a chance to cure diabetes

The success of pancreas transplantation has improved over the past several decades with advancements in surgical technique, immunosuppressive medicines, and immunologic testing. We retrospectively reviewed our experience with pancreas transplantation from 1995 to 2008. At the Baylor Regional Transplant Program, 151 pancreas transplants were performed in 147 patients: 135 were simultaneous pancreas-kidney transplants, 10 were pancreas transplants after kidney transplants, and 6 were pancreas transplants alone. Follow-up information was available for 138 patients. The 1-year acute cellular rejection rate was 31.6%; the 30-day surgical reexploration rate was 10%; and the technical failure rate was 5.3%. Five-year pancreas graft survival rates were 67% for simultaneous pancreas and kidney transplants and 50% for pancreas transplants after kidney transplants. These outcomes exceed expected results as calculated by the Scientific Registry of Transplant Recipients. In addition, the median time to transplant was 3.8 months, compared with a US median of 14.1 months. Pancreas transplantation is currently the closest thing to a cure for diabetes and should be given as an option for diabetic patients with or without end-stage renal disease.

Complications after pancreas transplantation

PURPOSE OF REVIEW

The history of transplantation of the pancreas, unlike that of transplantation of other abdominal organs, has largely been shaped by the associated surgical complications. After more than three decades of progress, surgical-technical pancreas graft failure rates have decreased to approximately 8%. The most recent developments in this area are systematically reviewed in this article.

RECENT FINDINGS

Vascular graft thrombosis remains, by far, the most common cause of technical graft failure. Recent reports suggested that pancreas preservation with histidine-tryptophan-ketoglutarate solution (HTK) might be a risk factor for reperfusion pancreatitis, graft thrombosis and decreased short- and long-term graft survival. It remains unclear whether these results are, at least in part, related to HTK flush volumes and extended preservation (e.g.,>12 h). For selected thrombosed pancreas grafts, there has been renewed interest in pharmacological, interventional, and surgical salvage. For selected recipients with early pancreas graft thrombosis not amenable to a salvage intervention, transplant pancreatectomy in conjunction with immediate retransplantation has emerged as a viable option. For graft thrombosis prevention, the enhanced backtable pancreas vascular reconstruction techniques (e.g., gastroduodenal artery revascularization) proposed by some authors await more formal study. For prevention of native vascular complications in high-risk recipients, several technical modifications have been reported. Developments with respect to other surgical complications (wound infection, pancreatitis, leak, and bleeding) have been more incremental.

CONCLUSION

Recent evidence underscores the importance of judicious donor and recipient selection and of optimization of preservation and surgical factors for excellent short- and long-term pancreas transplant outcomes.

Retroperitoneal pancreas transplantation with systemic-enteric drainage--case report

Enteric drainage and intraperitoneal graft position is the preferred technique for pancreas transplantation at most transplant centers. The technique of retroperitoneal pancreas transplantation was first described by Boggi et al. [Transplantation,79 (2005), 1137]. In this case report, a modified model of retroperitoneal pancreas transplantation with systemic-enteric drainage is presented. A 48-yr-old patient underwent combined retroperitoneal pancreas and kidney transplantation because of type-I-diabetes, and diabetic nephropathy. At the time of transplantation, the patient had a body mass index of 31 and severe atherosclerosis of the iliac vessels. After mobilization of the colon and mesocolon ascendens, the vessels of the pancreas graft were anastomosed end-to-side to the aorta and to the inferior caval vein of the recipient. For exocrinous drainage, a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the right colon mesentery. The graft was in a retroperitoneal position. The patient was insulin-independent after 48 h, the lipase and amylase levels were within the normal range. The first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed that the technique was safe and had technical advantages when compared with the classic method.

Diabetic gastroparesis-associated bezoar resolution via "cola-lysis"

Phytobezoars associated with diabetic gastroparesis are often sources of diminished quality of life for patients. Poor blood sugar control has been associated with increasing gastroparesis. For recipients of pancreas transplants to correct diabetes, phytobezoar treatment post-transplant can typically be limited to invasive procedures and prokinetic agents. We present the case of an alternative treatment to phytobezoar, cola libation, i.e., "cola-lysis."

Impact of pancreatic venous drainage site on long-term patient and graft outcome in simultaneous pancreas-kidney transplantation

The impact of portal or systemic venous pancreas graft drainage on patient and graft outcome remains controversial. In the present study, the impact of venous drainage type on long-term patient and graft survival is assessed. From July 1996 to December 2002 80 simultaneous pancreas-kidney transplants were enrolled into a prospective study: 44 received a pancreas allograft with portal (P-SPK group) and 36 with systemic venous drainage (S-SPK group). Enteric exocrine drainage was performed in all recipients receiving the same immunosuppressive treatment. At one yr, the patient survival rates were 91.7% and 95.5% both for S-SPK and P-SPK groups, respectively; no significant difference in survival was shown at any time point of the follow-up. The one-, three-, five-, and eight-yr pancreas survival rates were 75%, 60.6%, 56.7%, and 44%, respectively in the S-SPK group compared to 88.6%, 84.1%, 78.4%, and 31.3% in the P-SPK group. The one-, three-, five-, and eight-yr kidney survival rates were 91.7%, 78.15%, 74.1%, and 57.9%, respectively in the S-SPK group compared to 93.2%, 88.6%, 78.4%, and 38.9% in the P-SPK group. Comparing the two groups, no significant difference was shown in the total number of surgical complications as well as in the number of each complication. No significant difference in long-term outcomes between the two groups was shown, even if in S-SPK group a higher incidence of pancreas graft loss has been reported and it was in part correlated to a higher number of graft thromboses.