Techniques of pancreas transplantation through the world: an IPITA Center survey

Exocrine drainage in pancreas transplantation: Complications and management

The aim of this minireview is to compare various pancreas transplantation exocrine drainage techniques i.e., bladder vs enteric. Both techniques have different difficulties and complications. Numerous comparisons have been made in the literature between exocrine drainage techniques throughout the history of pancreas transplantation, detailing complications and their impact on graft and patient survival. Specific emphasis has been made on the early postoperative management of these complications and the related surgical infections and their consequences. In light of the results, a number of bladder-drained pancreas grafts required conversion to enteric drainage. As a result of technical improvements, outcomes of the varied enteric exocrine drainage techniques (duodenojejunostomy, duodenoduodenostomy or gastric drainage) have also been discussed i.e., assessing specific risks vs benefits. Pancreatic exocrine secretions can be drained to the urinary or intestinal tracts. Until the late 1990s the bladder drainage technique was used in the majority of transplant centers due to ease of monitoring urine amylase and lipase levels for evaluation of possible rejection. Moreover, bladder drainage was associated at that time with fewer surgical complications, which in contrast to enteric drainage, could be managed with conservative therapies. Nowadays, the most commonly used technique for proper driving of exocrine pancreatic secretions is enteric drainage due to the high rate of urological and metabolic complications associated with bladder drainage. Of note, 10% to 40% of bladder-drained pancreata eventually required enteric conversion at no detriment to overall graft survival. Various surgical techniques were originally described using the small bowel for enteric anastomosis with Roux-en-Y loop or a direct side-to-side anastomosis. Despite the improvements in surgery, enteric drainage complication rates ranging from 2%-20% have been reported. Treatment depends on the presence of any associated complications and the condition of the patient. Intra-abdominal infection represents a potentially very serious problem. Up to 30% of deep wound infections are associated with an anastomotic leak. They can lead not only to high rates of graft loss, but also to substantial mortality. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage. Duodenoduodenostomy is an interesting option, in which the pancreas is placed behind the right colon and is oriented cephalad. The main concern of this technique is the challenge of repairing the native duodenum when allograft pancreatectomy is necessary. Identification and prevention of technical failure remains the main objective for pancreas transplantation surgeons. In conclusion, despite numerous techniques to minimize exocrine pancreatic drainage complications e.g., leakage and infection, no universal technique has been standardized. A prospective study/registry analysis may resolve this.

Early intestinal complications following pancreas transplantation: lessons learned from over 300 cases - a retrospective single-center study

Enteric complications remain a major cause of morbidity in the post-transplant period of pancreas transplantation despite improvements surgical technique. The aim of this single-center study was to analyze retrospectively the early intestinal complications and their potential relation with vascular events. From 2000 to 2016, 337 pancreas transplants were performed with systemic venous drainage. For exocrine secretion, intestinal drainage was done with hand-sewn anastomosis duodenojejunostomy. Twenty-three patients (6.8%) had early intestinal complications. Median age was 39 years (male: 65.2%). Median cold ischemia time was 11 h [IQR: 9-12.4]. Intestinal complications were intestinal obstruction (n = 7); paralytic ileus (n = 5); intestinal fistula without anastomotic dehiscence (n = 3); ischemic graft duodenum (n = 3); dehiscence of duodenojejunostomy (n = 4); and anastomotic dehiscence in jejunum after pancreas transplantectomy (n = 1). Eighteen cases required relaparotomy: adhesiolysis (n = 6); repeated laparotomy without findings (n = 1); transplantectomy (n = 6); primary leak closure (n = 3); re-positioning of the graft (n = 1); and intestinal resection (n = 1). Of the intestinal complications, 4 were associated with vascular thrombosis, resulting in two pancreatic graft losses. Enteric drainage with duodenum-jejunum anastomosis is safe and feasible, with a low rate of intra-abdominal complications. Vascular thrombosis associated with intestinal complications presents a risk factor for the viability of pancreatic grafts, so prevention and early detection is vital.

Pancreatic Transplantation: Evaluation and Management

More than 2 million people in the United States have type 1 diabetes mellitus. Pancreatic transplantation has emerged as the single most effective means of achieving normal glucose homeostasis in this patient population. Newer immunosuppressive agents and surgical techniques continue to evolve, resulting in improved long-term graft and patient survival. Herein, an understanding of the evaluation, technical aspects, and perioperative management of pancreas transplantation is outlined.

[Role of simultaneous pancreas-kidney transplantation in the treatment of diabetes mellitus]

The life expectancy of patients with type 1 diabetes mellitus is inferior to that of patients with some malignancies. Simultaneous pancreas-kidney transplantation is the procedure providing the best survival results among all options of renal replacement therapy. The operative techniques and immunosuppresion have been standardized in the last decade. Although the number of transplantable organs falls behind the need, simultaneous pancreas-kidney transplantation is the method of choice for the eligible patients. The results of the two Hungarian simultaneous pancreas-kidney transplantation programs are in accordance with data published in the international literature.

Does surgical technique influence outcomes after simultaneous kidney-pancreas transplantation?

Since 1995, many centers have switched from bladder to enteric drainage of the exocrine secretions in simultaneous kidney-pancreas transplantation (SKPT). Enteric exocrine drainage may be performed with either systemic (systemic-enteric [S-E]) or portal (portal-enteric [P-E]) venous delivery of insulin. Controversy exists regarding the optimal surgical technique. From March 1999 to May 2001, a total of 297 SKPT patients were enrolled into a prospective, multicenter, randomized, open-label, comparative trial of two daclizumab dosing strategies versus no-antibody induction in combination with tacrolimus, mycophenolate mofetil, and steroids in SKPT recipients. Surgical techniques were center specific. A total of 171 patients (58%) underwent SKPT with S-E drainage, 96 (32%) with P-E drainage, and 30 (10%) with systemic-bladder (S-B) drainage. The two groups randomized to daclizumab induction were similar with regard to surgical technique (64% S-E, 25% P-E, 11% S-B drainage). Demographic and transplant characteristics and immunosuppression were similar among the three groups, except that more patients with P-E drainage did not receive antibody induction. At 6 months, no differences were seen in patient and graft survival rates, surgical complications including pancreas thrombosis, rates of rejection or infection, readmissions, and kidney and pancreas allograft function among the three different surgical techniques. The 6-month results of this multicenter study suggest no significant differences in outcomes in SKPT recipients according to surgical technique.

Opções técnicas utilizadas no transplante pancreático em centros brasileiros

OBJETIVO: Analisar o perfil dos principais centros de transplantes do Brasil, quanto às opções técnicas no transplante de pâncreas. MÉTODO: Foi encaminhado um questionário por correio eletrônico (email) para um membro de cada equipe de 12 centros de transplante do Brasil, com casuística mínima de um transplante de pâncreas. O questionário continha 10 perguntas, abordando aspectos controversos e não padronizados. RESULTADOS: A maioria dos centros (90,9%) utiliza incisão mediana. O órgão de escolha a ser implantado primeiro foi principalmente o rim, em 63% dos centros. Em relação à drenagem venosa, 90,9% utilizam a drenagem sistêmica. A ligadura da veia ilíaca interna é realizada em 54,5% dos centros. A maioria dos centros (90,9%) utiliza a drenagem entérica para transplante combinado pâncreas-rim. Para o transplante de pâncreas isolado, apenas cinco centros responderam, sendo que dois utilizam a drenagem entérica e três a vesical. A utilização de dreno na cavidade abdominal ocorre em 63% dos centros. Em 72,7% dos centros é realizada algum tipo de indução na imunossupressão para o transplante combinado pâncreas-rim, sendo a imunossupressão básica a associação de tacrolimus (FK506), micofenolato mofetil (MMF) e corticóide. A antibioticoprofilaxia é realizada por todos os centros e profilaxia para fungos é realizada por seis centros (54,5%). Oito centros (72,7%) utilizam algum tipo de profilaxia para trombose vascular, em esquemas diversos. CONCLUSÃO: Existem diversos caminhos técnicos na condução do transplante pancreático. A falta de padronização dificulta a análise e a comparação dos resultados. Apesar dessa heterogeneidade das equipes, observamos uma tendência para a realização de incisão mediana, drenagem venosa sistêmica e exócrina entérica, com a utilização de algum tipo de profilaxia para trombose vascular nos transplantes combinados pâncreas-rim.

[Pancreatic Transplantation: 2. Surgical technique and post-operative complications]

Since the first pancreatic allograft in 1966, pancreatic transplantations have been performed by numerous surgical teams throughout the world. Initial results were disappointing with a high percentage of technical failures and rejection. Over-optimistic enthusiasm for islet-cell allografts also retarded the development of pancreatic transplantation. Despite this slow start, results of pancreatic transplantation from 1995 onward have been very satisfactory and equivalent to or even better than the results of other solid organ transplants. This success has been due to better graft selection, improved surgical techniques and preservation solutions, and especially to improvements in immunosuppressive protocols. More than 19,000 pancreatic transplantations have now been performed throughout the world including both combined kidney-pancreas transplantations and pancreas-only transplantations. The most satisfactory results occur in the setting of dialysis-dependent renal failure due to diabetes; simultaneous combined kidney and pancreas transplantation is performed with the total pancreas implanted into the bowel and with venous drainage into the portal system. The long-term risks and constraints of chronic diabetes with renal failure must be weighed against the risks of a complex surgical procedure, significant post-operative complications, and the need for long-term immunosuppressive therapy.

Long-term experience with simultaneous kidney-pancreas transplantation with portal-enteric drainage and tacrolimus/mycophenolate mofetil-based immunosuppression

Refinements in surgical techniques and advances in clinical immunosuppression have led to steadily improving results in pancreas transplantation (PTX). Although there is renewed interest in enteric exocrine drainage, most PTXs are performed with systemic venous delivery of insulin. To improve the physiology of PTX, we developed a novel technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [P-E]). The purpose of the study was to analyse outcomes in patients undergoing PTX with P-E drainage and contemporary immunosuppression.

MATERIALS AND METHODS

From January 1997 through September 2002, we performed 67 primary simultaneous kidney-PTXs (SKPT) with P-E drainage. Maintenance immunosuppression consisted of tacrolimus (TAC), mycophenolate mofetil (MMF) and steroids. No antibody induction therapy occurred in 33 patients (49%) with the remainder receiving daclizumab (n = 15), basiliximab (n = 2), or thymoglobulin (n = 14) induction therapy. The patient group included 38 males and 29 females with a mean age of 39.7 year (range 23-58) and a mean duration of pretransplant diabetes of 24.5 year (9-46). Fourteen patients (21%) were African-American.

RESULTS

The mean waiting time for SKPT was 3.3 months (range 0.1-10). Mean kidney and pancreas cold ischaemia times were 15.1 and 15.4 h, respectively. Patient, kidney and pancreas graft survival rates were 97%, 92.5% and 82%, respectively, with a mean follow-up of 20 months (range 1-56). Two deaths (one sepsis, one cardiac event) occurred at 1 month after SKPT; both patients died with functioning grafts (DWFG). Three patients (4.5%) had delayed renal allograft function and received temporary dialysis after SKPT. Five kidney graft losses occurred (two DWFG, one thrombosis, two chronic rejection). All but four patients (6%) had immediate PTX function. A total of 12 pancreas graft losses occurred (two DWFG, five thrombosis, five chronic rejection). The incidence of acute rejection was 28%, but no grafts were lost due to isolated acute rejection. The incidence of major infection was 51%, but only five patients (7.5%) developed cytomegalovirus infection. A total of 19 patients (28%) underwent early relaparotomy within 3 months of SKPT. The composite endpoint of no rejection, graft loss, or mortality was attained by 63% of patients. At present, 58 patients (87%) are both dialysis and insulin-independent (including four retransplants).

CONCLUSION

These findings suggest that SKPT with P-E drainage and contemporary immunosuppression may result in excellent intermediate-term outcomes.

Role of sonography in pancreatic transplantation

Despite recent advancements in surgical technique and immunosuppressive therapy, postoperative complications of pancreatic transplantation are still common. A complex spectrum of such adverse events includes graft rejection, peripancreatic fluid collections, pancreatitis, exocrine leaks, vascular thrombosis, and hemorrhage. Sonography plays a key role in the initial evaluation of the transplanted pancreas. Gray-scale sonography, duplex Doppler imaging, and sonographic guidance for percutaneous biopsy all contribute to posttransplantation evaluation and detection of sequelae. Color and power Doppler imaging offer valuable information regarding the regional vasculature and potential vascular complications. Because gray-scale sonographic findings alone are often nonspecific, several clinical criteria, including those from biochemical analysis of the urine and serum, must be reviewed with the sonographic findings to provide a thorough evaluation of the transplanted pancreas. When used in conjunction with serologic and urinary markers, the findings from sonography can help direct management options or suggest the need for further examination. Therefore, an understanding of the spectrum of complications combined with knowledge concerning the limitations of this imaging modality are essential for proper diagnosis and effective treatment.

Pancreas transplantation: contemporary surgical techniques

Since its inception more than 30 years ago, vascularized pancreas transplantation has undergone considerable progress. Given the unique complications associated with transplantation of this organ, modifications in surgical technique have been necessary to improve outcomes. As a result of these surgical advances and improvements in organ preservation and immunosuppression, contemporary graft survival rates approach 90% at 1 year. Despite this level of success, the technique of pancreas transplantation remains controversial. Future efforts to reduce morbidity and minimize immunosuppression will enable pancreas transplantation to remain an important therapeutic option for selected patients with type 1 diabetes mellitus.

A prospective comparison of simultaneous kidney-pancreas transplantation with systemic-enteric versus portal-enteric drainage

OBJECTIVE

To compare pancreas transplantation with systemic-enteric (SE) versus portal-enteric (PE) drainage in a prospective fashion.

SUMMARY BACKGROUND DATA

To improve the physiology of pancreas transplantation, the authors developed a new technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions.

METHODS

During a 26-month period, the authors prospectively alternated 54 consecutive simultaneous kidney and pancreas transplants to either SE (n = 27) or PE (n = 27) drainage. The two groups were well matched for numerous characteristics. Maintenance immunosuppression in both groups consisted of tacrolimus, mycophenolate mofetil, and steroids.

RESULTS

Patient survival rates were 93% SE versus 96% PE; kidney graft survival rates were 93% in both groups. Pancreas transplantation survival (complete insulin independence) was 74% after SE versus 85% after PE drainage with a mean follow-up of 17 months. The mean length of initial hospital stay was 12.4 days in the SE group and 12.8 days in the PE group. The SE group was characterized by a slight increase in the number of readmissions. The incidences of acute rejection (33%) and major infection (52%) were similar in both groups. The incidence of intraabdominal infection was slightly higher in the SE group. However, the early relaparotomy rate was similar between groups. The composite endpoint of no rejection, graft loss, or death was attained in 56% of SE versus 59% of PE patients.

CONCLUSIONS

These results suggest that simultaneous kidney and pancreas transplantation with SE or PE drainage can be performed with comparable short-term outcomes.

Simultaneous cadaver pancreas living-donor kidney transplantation: a new approach for the type 1 diabetic uremic patient

OBJECTIVE

To review the authors' experience with a new approach for type I diabetic uremic patients: simultaneous cadaver-donor pancreas and living-donor kidney transplant (SPLK).

SUMMARY BACKGROUND DATA

Simultaneous cadaver kidney and pancreas transplantation (SPK) and living-donor kidney transplantation alone followed by a solitary cadaver-donor pancreas transplant (PAK) have been the transplant options for type I diabetic uremic patients. SPK pancreas graft survival has historically exceeded that of solitary pancreas transplantation. Recent improvement in solitary pancreas transplant survival rates has narrowed the advantage seen with SPK. PAK, however, requires sequential transplant operations. In contrast to PAK and SPK, SPLK is a single operation that offers the potential benefits of living kidney donation: shorter waiting time, expansion of the organ donor pool, and improved short-term and long-term renal graft function.

METHODS

Between May 1998 and September 1999, the authors performed 30 SPLK procedures, coordinating the cadaver pancreas transplant with simultaneous transplantation of a laparoscopically removed living-donor kidney. Of the 30 SPLKs, 28 (93%) were portally and enterically drained. During the same period, the authors also performed 19 primary SPK and 17 primary PAK transplants.

RESULTS

One-year pancreas, kidney, and patient survival rates were 88%, 95%, and 95% for SPLK recipients. One-year pancreas graft survival rates in SPK and PAK recipients were 84% and 71%. Of 30 SPLK transplants, 29 (97%) had immediate renal graft function, whereas 79% of SPK kidneys had immediate function. Reoperative rates, early readmission to the hospital, and initial length of stay were similar between SPLK and SPK recipients. SPLK recipients had a shorter wait time for transplantation.

CONCLUSIONS

Early pancreas, kidney, and patient survival rates after SPLK are similar to those for SPK. Waiting time was significantly shortened. SPLK recipients had lower rates of delayed renal graft function than SPK recipients. Combining cadaver pancreas transplantation with living-donor kidney transplantation does not harm renal graft outcome. Given the advantages of living-donor kidney transplant, SPLK should be considered for all uremic type I diabetic patients with living donors.

A prospective comparison of systemic-bladder versus portal-enteric drainage in vascularized pancreas transplantation

BACKGROUND

Most pancreas transplants are performed with systemic venous delivery of insulin and bladder drainage of the exocrine secretions (systemic-bladder [S-B]). To develop a more physiologic procedure, we performed pancreas transplantations with portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [P-E]).

METHODS

During an 11-month period, we prospectively alternated 32 consecutive pancreas transplant recipients to either S-B (n = 16) or P-E (n = 16) drainage with standardized immunosuppression.

RESULTS

Patient, kidney, and pancreas graft survival rates after simultaneous kidney-pancreas transplantation were 91% S-B versus 92% P-E, 91% S-B versus 92% P-E, and 82% S-B versus 92% P-E, respectively. Pancreas graft survival rates after solitary pancreas transplantation were 80% S-B versus 75% P-E. There were no graft losses either to immunologic or infectious complications in either group, but the incidence of acute rejection was slightly higher in the S-B group (44% S-B vs 31% P-E, P = NS). The cost and length of the initial hospital stay were similar between groups. The incidence of operative complications, major infections, and cytomegalovirus infections were likewise comparable. However, the S-B group was characterized by a slight increase in the number of readmissions, urinary tract infections, and urologic complications. Furthermore, metabolic acidosis and dehydration were more common in the S-B group.

CONCLUSIONS

Pancreas transplantation with P-E drainage can be performed with short-term results comparable to those of transplantation with S-B drainage.

Vascularized pancreas allotransplantation--clinical indications and outcome

AIMS

This review examines the status of vascularized pancreas transplantation as a treatment for Type 1 diabetes mellitus (DM).

METHODS

The world literature, with a particular emphasis on data from the International Pancreas Transplant Registry (IPTR), is reviewed and interpreted particularly for clinical indications and outcome.

RESULTS

Over 9000 cases of vascularized pancreas transplant (VPT) have been registered, with insulin dependence approaching 82% at 1 year with 94% patient survival. The majority of transplants are simultaneous pancreas and kidney (SPK) transplants, with far fewer pancreas after kidney (PAK) or pancreas transplants alone (PTA). The success rates differ between the procedures but are generally improving as technical advances, improvements in immunosupression and greater experience are gained. The most obvious advantage is an improved quality of life (QoL) but there are risks associated with the procedure and with the immunosuppression. There is some evidence coming to light of a very slow beneficial effect on microvascular complications.

CONCLUSIONS

VPT is an attractive option to offer Type 1 DM patients who need or already have a renal allograft. Patients have to decide between the increased surgical risk and the risks of long-term immunosuppression and the benefits of improved QoL. In the absense of end-stage renal failure (ESRF) there is no justification for PTA, except where the diabetes itself poses a greater risk to life than the transplantation procedure.

Evolution in pancreas transplantation techniques: simultaneous kidney-pancreas transplantation using portal-enteric drainage without antilymphocyte induction

OBJECTIVE

To report initial experience with the combination of a novel technique of portal-enteric pancreas transplantation with newer immunosuppressive strategies that eliminate antilymphocyte induction therapy.

BACKGROUND

A new surgical technique of pancreas transplantation has been developed with portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric). The introduction of potent immunosuppressive agents may allow simultaneous kidney and pancreas transplants (SKPT) to be performed without antilymphocyte induction.

METHODS

From September 1996 to November 1998, the authors performed 28 primary SKPTs with portal-enteric drainage and no antilymphocyte induction. All patients received triple immunosuppression with tacrolimus, mycophenolate mofetil, and steroids. The study group had a mean age of 38 years and a mean preoperative duration of diabetes of 25 years. Four patients (14%) had prior kidney transplants.

RESULTS

All patients had immediate renal allograft function. Actual patient, kidney, and pancreas graft survival rates were 86%, 82%, and 82%, respectively, after a mean follow-up of 12 months. Four patients died, three as a result of cardiac events unrelated to SKPT. Five kidney and five pancreas grafts were lost, including five deaths with function and three cases of chronic rejection. The mean length of stay and total charges for the initial hospital stay were 12.5 days and $99,517. The mean number of readmissions was 2.9, and 10 patients (36%) had no readmissions. Six patients (21 %) developed acute rejection, with five (18%) receiving antilymphocyte therapy. Seven patients (25%) underwent relaparotomy, including two (7%) for intraabdominal infection. Nine patients (32%) had major infections, including three (11%) with cytomegaloviral infection. Of the 24 surviving patients, 22 (92%) are both dialysis- and insulin-free.

CONCLUSION

These preliminary results suggest that SKPT with portal-enteric drainage without antilymphocyte induction can be performed with excellent outcomes.