Compative study of bladder versus enteric drainage in pancreas transplantation

Fluconazole versus micafungin for initial antifungal prophylaxis against Candida in pancreas transplant recipients: a comparative study of two consecutive periods

BACKGROUND

Invasive fungal infection, particularly intraabdominal candidiasis, exerts a negative impact on the outcome of pancreas transplant recipients (PTRs). Optimal antifungal prophylaxis in this context remains unclear.

METHODS

We performed a single-center retrospective study to compare the incidence of invasive candidiasis during the first 6 post-transplant months in a cohort of 218 PTRs over two periods in which different agents for antifungal prophylaxis were used: fluconazole (Fluco-Px) from March 1995 to June 2012, and micafungin followed by fluconazole (Mica-Px) from July 2012 to December 2018.

RESULTS

A total of 152 and 66 PTRs received Fluco-Px and Mica-Px. Mean age was 39.7 ± 7.8 years, 56.4% (123/218) were males and 85.3% (186/218) underwent simultaneous pancreas-kidney transplantation. Invasive candidiasis occurred in 21.7% (33/152) of PTRs under Fluco-Px compared to 24.2% (16/66) of those under Mica-Px (P-value = 0.681). Median time from transplantation to infection was 8 days (interquartile range [IQR]: 6-16) under Fluco-Px versus 6.5 (IQR: 3.3-15.8) under Mica-Px (P-value = 0.623). Non-albicans Candida species comprised 27.5% (11/40) and 25.0% (4/16) of episodes under Fluco-Px and Mica-Px, respectively (P-value = 0.849). Surgical site infection was the most common form in both groups (82.5% [33/40] and 87.5% [14/16]; P-value = 0.954). Multivariable analysis identified cold ischemia time of the pancreas and kidney grafts, surgical reintervention and insulin requirement after transplantation as risks factor for invasive candidiasis.

CONCLUSION

This retrospective study did not reveal a significant benefit from the initial use of micafungin-based antifungal prophylaxis over fluconazole among PTRs in terms of invasive candidiasis.

A case report of percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA) to treat a pancreatic duodenal stump leak after a simultaneous pancreas and kidney transplantation

BACKGROUND

Simultaneous pancreas and kidney transplantation (SPK) is a treatment option for patients with end-stage renal disease due to type 1 diabetes mellitus. We report a patient with a refractory fistula due to leakage from the duodenal stump of the pancreas graft after an SPK with bladder drainage who was successfully treated with a percutaneous direct injection of N-butyl-2-cyanoacrylate (NBCA).

CASE PRESENTATION

A 60-year-old female with a 33-year history of type 1 diabetes mellitus and a 10-year history of renal replacement therapy underwent an SPK in 2015. At the time of transplantation, an abdominal aortic aneurysm with a high risk of rupture was treated by a Y-graft replacement prior to the SPK. Bladder drainage of the pancreas graft was chosen to avoid a vessel graft infection. The patient's postoperative course was uneventful. The patient was discharged on postoperative day 93 with good-functioning pancreas and kidney grafts. One and a half years after the operation, the patient was found to have acute graft pancreatitis and a leak from the duodenal stump of the pancreas graft due to a paralytic neurogenic bladder. The insertion of an indwelling catheter into the bladder and the endoscopic-guided insertion of a catheter into the graft pancreatic duct through the duodenum/bladder anastomosis did not result in the closure of the fistula. Therefore, NBCA was injected at the site of the leak point using CT-guided technique. The fistula was completely closed immediately after the injection, with no recurrences of leaks.

CONCLUSIONS

A percutaneous direct injection of NBCA is one of the treatment options to treat intractable fistulas.

Enteric conversion after bladder-drained pancreas transplantation is not associated with worse allograft survival

In the early experience of pancreas transplantation, bladder drainage was favored, but it often caused urologic, metabolic, and infectious complications that necessitated conversion to enteric drainage. Long-term graft survival after enteric conversion and the impact of time interval from transplantation to enteric conversion on graft survival is poorly understood. We studied all bladder-drained first-time pancreas transplantations performed at the University of Wisconsin from 1985 to 2000. Time to conversion was estimated with the Kaplan-Meier technique, whereas risk factors associated with conversion were estimated via a time-varying Cox proportional hazards model. Of 386 bladder-drained pancreata, 162 (41.9%) eventually required enteric conversion, 29 (17.9%) within the first year. Median time to conversion varied by indication: 0.68 years for surgical, 3.1 years for urologic, and 2.7 years for metabolic disorders. In a time-varying Cox model adjusting for donor and recipient factors, enteric conversion did not affect the risk of pancreas graft loss (hazard ratio [HR] 0.86, P = .26). Kidney survival was not associated with enteric conversion. When necessary due to symptoms or complications, enteric conversion of bladder-drained pancreata is safe and does not affect overall graft survival. This relationship appears to be true no matter when the conversion is performed.

Preneoplastic Lesion in a Pancreas Allograft: Dilemma for the Pancreas Transplant Surgeon

Although the relationship between immunosuppression and cancer risk is well-documented, the association between immunosuppression and the development of preneoplastic lesions (PNL) is less clear. PNLs pose a unique clinical conundrum in the transplanted pancreas because their prevalence in the general population is not infrequent. We present the case of a 58-year-old man with a history of diabetes mellitus type 1 who underwent successful pancreas transplantation with bladder drainage. His kidney function failed 13 years after his transplant and he developed recurrent painful hematuria with symptomatic anemia 2 years after initiating hemodialysis. Upon work-up, he was found to have a 4 cm intraductal papillary mucinous neoplasm in his pancreas allograft. At his enteric conversion, the intraductal papillary mucinous neoplasm was removed through a distal pancreatectomy due to concern for its malignant potential. He recovered well from surgery and continues to be insulin-free. With the rising incidence of PNLs from improved detection and the improved survival of pancreas allografts, the implications of PNLs may be more pronounced in the future. This case raises several important considerations for the pancreas transplant surgeon regarding adequate allograft surveillance protocols, treatment, and follow-up.

Enterovesical Fistula After Enteric Conversion of a Bladder-Drained Pancreatic Allograft: A Case Report

Since the inception of pancreas transplant as a treatment for type 1 diabetes mellitus, there has been considerable debate about the best way to manage exocrine secretions and monitor patients for graft rejection. For patients who undergo bladder exocrine drainage of a pancreatic allograft, a bladder-to-enteric drainage conversion can serve as a rescue procedure in case of anastomotic leaks or other complications. However, this procedure is associated with its own complications, including a rarely described enterovesical fistula. Here we report on a 45-year-old man who underwent a simultaneous kidney and pancreas transplant with bladder drainage to the latter. He developed a pancreatic allograft duodenal leak (duodenal-vesical anastomosis) requiring a bladder-to-enteric drainage conversion. The patient returned 2 weeks after discharge with an enterovesical fistula. He was treated nonsurgically with intravenous antibiotics, bowel rest, and parenteral nutrition, and the fistula successfully closed in approximately 2 weeks. Overall, enterovesical fistula formation is a rare but treatable complication that can occur after a bladder-to-enteric drainage conversion of a pancreatic transplant allograft. It can be managed nonsurgically, which is preferable in these immunocompromised patients.

Surgery of pancreas transplantation

PURPOSE OF REVIEW

The surgical techniques of pancreas transplantation have been evolving and significantly improved over time. This article discusses different current techniques and their modifications.

RECENT FINDING

At this time, the most commonly used technique is systemic venous drainage (for venous outflow) and enteric drainage (for management of exocrine pancreatic secretions). However, new modifications of established techniques such as gastric or duodenal exocrine drainage and venous drainage to the inferior vena cava continue to be introduced.

SUMMARY

This article provides a state-of the-art review of the most prevalent up-to-date surgical techniques as well as a synopsis of their specific risks and benefits. The article also provides the most current registry data regarding utilization of different surgical techniques in the United State and worldwide.

Simultaneous pancreas-kidney transplantation. Experience of the Doce de Octubre Hospital

INTRODUCTION

Simultaneous pancreas-kidney transplantation (SPKT) constitutes the therapy of choice for diabetes type1 or type2 associated with end-stage renal disease, because is the only proven method to restore normo-glicemic control in the diabetic patient.

METHODS

Retrospective and descriptive study of a series of 175 patients who underwent SPKT from March 1995 to April 2016. We analyze donor and recipient characteristics, perioperative variables and immunosuppression, post-transplant morbi-mortality, patient and graft survival, and risk factors related with patient and graft survival.

RESULTS

Median age of the donors was 28years and mean age of recipients was 38.8±7.3years, being 103 males and 72 females. Enteric drainage of the exocrine pancreas was performed in 113 patients and bladder drainage in 62. Regarding post-transplant complications, the overall rate of infections was 70.3%; graft pancreatitis 26.3%; intraabdominal bleeding 17.7%; graft thrombosis 12.6%; and overall pancreas graft rejection 10.9%. The causes of mortality were mainly cardiovascular and infectious complications. Patient survival at 1, 3 and 5-year were 95.4%, 93% and 92.4%, respectively, and pancreas graft survival at 1, 3 and 5-year were 81.6%, 77.9% y 72.3%, respectively.

CONCLUSIONS

In our 20-year experience of simultaneous pancreas-kidney transplantation, the morbidity rate, and 5-year patient and pancreas graft survivals were similar to those previously reported from the international pancreas transplant registries.

Case report: pancreas graft with a duodenal complication rescued using total duodenectomy

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for type 1 diabetics with end-stage renal disease. Recently patients with type 2 diabetes have been considered for transplantation. Despite that the patient and graft survival rates have improved over the past years, it continues to be a procedure with high surgical complication rates. We herein report a case of a pancreatic graft with a duodenal complication rescued using a total duodenectomy, a procedure that is seldom used. A 57-year-old type 2 diabetic underwent a SPK transplantation with systemic-enteric drainage. He was converted to a Roux en Y at day 7 for a small duodenal fistula without peritonitis. At day 13, with good graft function, he presented with gastrointestinal and abdominal bleeding. At laparotomy he had a congestive duodenum with intraluminal bleeding and an anastomotic fistula. We performed a total duodenectomy with enteric drainage. The patient was discharged home on day 39 with a pancreatic fistula on intramuscular Octretotide that lasted for 3 months. He was never readmitted and has good pancreas and kidney function at 16 months of follow-up. We think this is an option to rescue a pancreas graft with duodenal complications in selected cases.

A Simplified Technique of Pancreas Transplantation in a Porcine Model

Background: The incidence of diabetes has been steadily increasing. The only curative option for diabetes is pancreas transplantation (PTx). Porcine models are valuable because of their anatomical and physiological similarities to human beings. Our aim is to introduce a simplified technique of PTx in a porcine model. Methods: In Landrace pigs (n = 32), after median laparotomy, the pancreas was mobilized, and the portal and splenic veins were divided. The proper hepatic and splenic arteries and the bile duct were also prepared, and the duodenal bulb was prepared and stapled. The third portion of the duodenum was freed up to the ligament of Treitz and stapled, and the renal arteries were ligated. After systemic heparinization, the pancreas was perfused through the abdominal aorta with histidine-tryptophan-ketoglutarate solution. The portal and splenic veins were cut for evaluating the sufficiency of perfusion. Whole pancreaticoduodenal graft was procured along with an aortic jump graft containing mesenteric and celiac trunks. In recipients, after total pancreatectomy, the suprarenal inferior vena cava and infrarenal aorta were prepared for vascular anastomosis in an end-to-side manner. After pancreas reperfusion, duodenoduodenostomy was performed in an end-to-side manner. Results: Median cold and warm ischemia times were 10 h (range, 9-14 h) and 50 min (range, 35-80 min), respectively. The hemodynamic status was stable throughout the operation. The median follow-up period was 7 days (range, 4-10). There were no major intra- and postoperative complications. Conclusion: By using an aortic jump graft, there was no need to perform additional arterial reconstruction resulting in a short warm ischemic and operation time. End-to-side portocaval and duodenoduodenal anastomoses make this model of PTx a very feasible method for experimental evaluations.

Surgical Morbidity of Simultaneous Kidney and Pancreas Transplantation: A Single-Centre Experience in the Tacrolimus Era

Introduction. Simultaneous pancreas and kidney (SPK) transplantation is performed to restore normoglycaemia and renal function in patients with Type I diabetes mellitus and end-stage renal failure. We aimed to evaluate the impact of major postoperative complications to patient and graft survival outcomes. Method. Using a prospectively collected database over a 10-year period, major postoperative complications requiring return to operating theatre as well as patient and graft survival outcomes were analysed retrospectively. Results. Between January 2001 and May 2010, 165 patients underwent first-time SPK transplantation. Median age of recipients was 39.8 years (range, 16.9–53.2). Enteric drainage was used in 149 patients, and bladder drainage was used in 16. Median follow-up time was 5.2 years (range 1.1–10.3). Fifty-six patients (34%) returned to operating theatre at least once. Pancreatic allograft loss secondary to vascular thrombosis occurred in 12 patients (7%), and 2 patients (1.2%) required transplant pancreatectomy due to debilitating pancreatic enzyme leaks. At 1 and 5 years, patient survival was 98% and 94%; pancreas graft survival, 86% and 77%; kidney graft survival 96% and 89%, respectively. Conclusion. SPK is a safe and effective treatment for Type I diabetes mellitus and end-stage renal failure although surgical reintervention is required in approximately one-third of patients. Preventing vascular thrombosis remains a major challenge.

Epidemiology, risk factors and impact on long-term pancreatic function of infection following pancreas-kidney transplantation

Limited information exists about epidemiology and risk factors of infection following pancreas-kidney transplantation and its impact on long-term pancreatic graft function. A retrospective chart review of episodes of severe infection in consecutive pancreas-kidney transplantations in a single institution was performed to assess the epidemiology, risk factors for infection and their impact on the development of pancreatic graft dysfunction. Ninety-four (81%) of 116 recipients (median follow-up of 1492 days; mean 1594) developed 248 episodes of severe infection. Bacterial infections were present in 208 episodes, with 12% of the isolates resistant to antibiotics used in prophylaxis. There were 40 episodes of fungal infection in 32 patients (28%) (mostly Candida spp), and CMV disease appeared in 20 patients (17%), of which 50% appeared after the third month following surgery. The multivariate analysis identified that surgical re-intervention and the use of steroid pulses were independently associated with the development of any infection. Additionally, pre-transplant evidence of peripheral artery disease, a longer cold ischaemia time and high transfusional requirements were associated with fungal infections. Cytomegalovirus (CMV) mismatch was independently related to CMV disease and female sex, and bladder drainage of the exocrine pancreas was associated with urinary tract infection. At the end of follow-up, 29 patients (25%) had developed severe pancreatic graft dysfunction, and fungal infection was independently associated with it. Our study identifies a subset of pancreas-kidney transplant recipients at a higher risk of developing severe infection. Fungal infection is an independent risk factor for the development of severe pancreatic graft dysfunction.

Prevention and treatment of complications after pancreas transplantation

With the development of new organ preservation solutions, the application of new immunosuppressive drugs and the improvement of intensive postoperative care, pancreas transplantation has become an ideal treatment for diabetic patients with uremia. According to the International Pancreas Transplant Registry (IPTR) latest statistics, over 30 000 cases of pancreas transplantation have been carried out in the world from 1966 to the end of 2008, of which more than 22 000 cases were implemented in the United States. Complications after pancreas transplantation have been recognized since 1966 when a patient died of rejection and sepsis two months after the first case of pancreas-kidney transplantation. With the extensive development of pancreas transplantation, a better understanding of complications after pancreas transplantation is needed.

Current status of pancreas transplantation

Pancreas transplantation has emerged as the treatment of choice for patients with end-stage diabetes mellitus. Over the last four decades, many improvements have been made in the surgical techniques and immunosuppressive regimens, which contributed to increased number of indications and improved allograft survival. Pancreas transplantation can be justified on the basis that patients replace daily injections of insulin with an improved quality of life but at the expense of a major surgical procedure with a relatively higher complication rate, and lifelong immunosuppression. Therefore, efforts to develop more minimally invasive techniques for endocrine replacement therapy such as islet transplantation have been in progress. This article summarizes the current understanding of pancreas transplantation-associated indications, donor selection, surgical techniques, immunosuppression, and rejection.

2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR)

AIM

This study aimed to analyze the outcome of pancreas and pancreas-kidney transplantations based on the comprehensive follow-up data reported to the International Pancreas Transplant Registry (IPTR).

METHODS

As of December 2010, more than 35,000 pancreas transplantations have been reported to the IPTR: more than 24,000 transplantations in the US and more than 12,000 outside the US. Cases with follow-up information until March 2011 were included in the analysis.

RESULTS

Pancreas transplantations in diabetic patients were divided into 3 categories: those performed simultaneously with a kidney (SPK) (75%), those given after a previous kidney transplantation (PAK) (18%), and pancreas transplantation alone (PTA) (7%). The total number of pancreas transplantations steadily increased until 2004 but has since declined. The largest decrease was seen in PAK, which decreased by 50% from 2004 through 2010. Comparatively, the number of SPK decreased by 7% during this time. Era analysis of US transplantations between 1987 and 2010 showed changes in recipient and donor characteristics. Recipient age at transplantation increased significantly as well as transplantations in type 2 diabetes patients. The trend over time was towards tighter donor criteria. There was a concentration on younger donors, preferable trauma victims, with short preservation time. Surgical techniques for the drainage of the pancreatic duct changed over time, too. Now enteric drainage is the predominantly used technique in combination with systemic drainage of the venous effluent of the pancreas graft. Immunosuppressive protocols developed towards antibody induction therapy with tacrolimus and MMF as maintenance therapy. The rate of transplantations with steroid avoidance increased over time in all 3 categories. These changes have led to improved patient and graft survival. Patient survival now reaches over 95% at one year post-transplant and over 83% after 5 years. The best graft survival was found in SPK with 86% pancreas and 93% kidney graft function at one year. PAK pancreas graft function reached 80%, and PTA pancreas graft function reached 78% at one year. In all 3 categories, early technical graft loss rates decreased significantly to 8-9%. Likewise, the 1-year immunological graft loss rate also decreased: in SPK, the immunological 1-year graft loss rate was 1.8%, in PAK 3.7%, and in PTA 6.0%.

CONCLUSIONS

Patient survival and graft function improved significantly over the course of 24 years of pancreas transplantation in all 3 categories. With further reduction in surgical complications and improvements in immunosuppressive protocols, pancreas transplantation offers excellent outcomes for patients with labile diabetes.