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Srinivas Rao S, Pandey A, Mroueh N, Elias N, Katabathina VS, Kambadakone A. Comprehensive review of imaging in pancreas transplantation: a primer for radiologists. Abdom Radiol (NY) 2024; 49:2428-2448. [PMID: 38900315 DOI: 10.1007/s00261-024-04383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/06/2024] [Accepted: 05/10/2024] [Indexed: 06/21/2024]
Abstract
Pancreas transplantation is a complex surgical procedure performed to restore normoglycemia in patients with type 1 diabetes and includes whole/segmental organ transplant and islet cell transplantation (ICT). In the United States, simultaneous pancreas-kidney transplant (SPK) is most commonly performed due to the higher occurrence of end-stage renal disease in diabetic patients. Understanding the surgical technique and postoperative anatomy is imperative for effective and accurate surveillance following transplantation. Imaging plays an essential role in patients with pancreatic transplants and is often used to evaluate viability, vascular and parenchymal anatomy, and identify potential complications. Imaging techniques such as ultrasound, color and spectral Doppler, computed tomography (CT), magnetic resonance imaging (MRI), and angiography have a complementary role in the postoperative evaluation following a pancreas transplant. The common complications after a whole organ pancreas transplant include vascular thrombosis, graft rejection, pancreatitis, and infections. Complications can be classified into vascular (partial or complete venous thrombosis, arterial thrombosis, stenosis or pseudoaneurysm), parenchymal (pancreatitis, graft rejection), and bowel-related or miscellaneous causes (bowel obstruction, anastomotic leak, and peripancreatic fluid collections). Islet cell transplantation is an innovative therapy for patients with type 1 diabetes. It involves isolating insulin-producing islet cells from donor pancreas and transplanting into recipients, to provide long-term insulin independence or significantly reduce insulin requirements. In recent years, isolation techniques, immunosuppressive regimens, and post-transplant monitoring advancements have propelled ICT as a viable therapeutic option. This comprehensive review aims to provide insights into the current state-of-the-art imaging techniques discussing both normal and abnormal features following pancreas transplantation.
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Affiliation(s)
- Shravya Srinivas Rao
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114-2696, USA
| | - Ankur Pandey
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114-2696, USA
| | - Nayla Mroueh
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114-2696, USA
- Department of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA, 15212, USA
| | - Nahel Elias
- Department of Surgery, Transplantation Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Venkata S Katabathina
- Department of Radiology, University of Texas Health at San Antonio, Floyd Curl Drive, 7703, San Antonio, TX, 78229, USA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114-2696, USA.
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Sharda B, Jay CL, Gurung K, Harriman D, Gurram V, Farney AC, Orlando G, Rogers J, Garner M, Stratta RJ. Improved surgical outcomes following simultaneous pancreas-kidney transplantation in the contemporary era. Clin Transplant 2022; 36:e14792. [PMID: 36029250 PMCID: PMC10078434 DOI: 10.1111/ctr.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Complications leading to early technical failure have been the Achilles' heel of simultaneous pancreas-kidney transplantation (SPKT). The study purpose was to analyze longitudinally our experience with early surgical complications following SPKT with an emphasis on changes in practice that improved outcomes in the most recent era. STUDY DESIGN Single center retrospective review of all SPKTs from 11/1/01 to 8/12/20 with enteric drainage. Early relaparotomy was defined as occurring within 3 months of SPKT. Patients were stratified into two sequential eras: Era 1 (E1): 11/1/01-5/30/13; Era 2 (E2) 6/1/13-8/12/20 based on changes in practice that occurred pursuant to donor age and pancreas cold ischemia time (CIT). RESULTS 255 consecutive SPKTs were analyzed (E1, n = 165; E2, n = 90). E1 patients received organs from older donors (mean E1 27.3 vs. E2 23.1 years) with longer pancreas cold CITs) (mean E1 16.1 vs. E2 13.3 h, both p < .05). E1 patients had a higher early relaparotomy rate (E1 43.0% vs. E2 14.4%) and were more likely to require allograft pancreatectomy (E1 9.1% vs. E2 2.2%, both p < .05). E2 patients underwent systemic venous drainage more frequently (E1 8% vs. E2 29%) but pancreas venous drainage did not influence either relaparotomy or allograft pancreatectomy rates. The most common indications for early relaparotomy in E1 were allograft thrombosis (11.5%) and peri-pancreatic phlegmon/abscess (8.5%) whereas in E2 were thrombosis, pancreatitis/infection, and bowel obstruction (each 3%). CONCLUSION Maximizing donor quality (younger donors) and minimizing pancreas CIT are paramount for reducing early surgical complications following SPKT.
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Affiliation(s)
- Berjesh Sharda
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - David Harriman
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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Gjeorgjievski M, Abdelqader A, Sarkar A, Shahid H, Tyberg A, Kahaleh M. Transurethral endoscopic retrograde pancreatography: a novel endoscopic technique to treat complications after pancreas transplantation. Endoscopy 2022; 54:E470-E471. [PMID: 34571560 DOI: 10.1055/a-1625-2628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Mihajlo Gjeorgjievski
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Abdelhai Abdelqader
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Haroon Shahid
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Amy Tyberg
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Ling JEH, Coughlan T, Polkinghorne KR, Kanellis J. Risk indices predicting graft use, graft and patient survival in solid pancreas transplantation: a systematic review. BMC Gastroenterol 2021; 21:80. [PMID: 33622257 PMCID: PMC7901078 DOI: 10.1186/s12876-021-01655-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Risk indices such as the pancreas donor risk index (PDRI) and pre-procurement pancreas allocation suitability score (P-PASS) are utilised in solid pancreas transplantation however no review has compared all derived and validated indices in this field. We systematically reviewed all risk indices in solid pancreas transplantation to compare their predictive ability for transplant outcomes. METHODS Medline Plus, Embase and the Cochrane Library were searched for studies deriving and externally validating risk indices in solid pancreas transplantation for the outcomes of pancreas and patient survival and donor pancreas acceptance for transplantation. Results were analysed descriptively due to limited reporting of discrimination and calibration metrics required to assess model performance. RESULTS From 25 included studies, discrimination and calibration metrics were only reported in 88% and 38% of derivation studies (n = 8) and in 25% and 25% of external validation studies (n = 12) respectively. 21 risk indices were derived with mild to moderate ability to predict risk (C-statistics 0.52-0.78). Donor age, donor body mass index (BMI) and donor gender were the commonest covariates within derived risk indices. Only PDRI and P-PASS were subsequently externally validated, with variable association with post-transplant outcomes. P-PASS was not associated with pancreas graft survival. CONCLUSION Most of the risk indices derived for use in solid pancreas transplantation were not externally validated (90%). PDRI and P-PASS are the only risk indices externally validated for solid pancreas transplantation, and when validated without reclassification measures, are associated with 1-year pancreas graft survival and donor pancreas acceptance respectively. Future risk indices incorporating recipient and other covariates alongside donor risk factors may have improved predictive ability for solid pancreas transplant outcomes.
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Affiliation(s)
- Jonathan E H Ling
- Department of Nephrology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia. .,Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Melbourne, Australia.
| | - Timothy Coughlan
- Department of Renal Services, Latrobe Regional Hospital, Victoria, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.,Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Melbourne, Australia
| | - John Kanellis
- Department of Nephrology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.,Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Melbourne, Australia
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Ibáñez JM, Robledo AB, López-Andujar R. Late complications of pancreas transplant. World J Transplant 2020; 10:404-414. [PMID: 33437673 PMCID: PMC7769730 DOI: 10.5500/wjt.v10.i12.404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/18/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.
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Affiliation(s)
- Javier Maupoey Ibáñez
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
| | - Andrea Boscà Robledo
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
| | - Rafael López-Andujar
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
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Delayed Bleeding of the Transplant Duodenum After Simultaneous Kidney-pancreas Transplantation: Case Series. Transplantation 2019; 104:184-189. [PMID: 30946219 DOI: 10.1097/tp.0000000000002718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In simultaneous pancreas-kidney (SPK) transplant recipients, the majority of complications described in the literature, are early postoperative complications. However, there is growing attention for late complications associated with SPK transplantation. METHODS In this case series, we present 3 cases, 2 enterically and 1 bladder-derived SPK transplant patients, with anastomotic hemorrhage of the donor duodenum as a very late complication, >10 years after transplantation (11, 22, and 18 y later, respectively). RESULTS In our center, 122 SPK transplantations have been performed between January 1992 and June 2018. The 3 cases reported here are the only patients in our cohort presenting with delayed anastomotic hemorrhage of the donor duodenum (2.5%). In the first 2 patients, reintervention with reconstruction of the anastomosis was performed. A congestive and friable mucosa was seen, and the resection specimen showed enlarged and congestive submucosal veins in both patients. There was no recurrence of bleeding after reintervention. In the third patient, enteric derivation was not possible because of the extremely fragile intestinal tissue perioperatively, and a conservative approach was taken. As possible precipitating factors are concerned, all 3 of our patients were taking low-dose aspirin and/or clopidogrel as secondary cardiovascular prevention. CONCLUSIONS Bleeding of the transplanted donor duodenum can present as a late complication, several years after SPK transplantation. The development of enlarged, congestive submucosal veins could play a role in these late bleedings, and antiplatelet therapy could be a precipitating factor. Further research is necessary to investigate the pathophysiology, the prevalence, optimal treatment, and the consequent influence on mortality, morbidity, and graft loss after SPK transplantation.
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