One hundred pancreas transplants at a single institution

Simultaneous Kidney-Pancreas Transplantation With an Original "Transverse Pancreas" Technique: Initial 9 Years' Experience With 56 Cases

An innovative technique for pancreas transplantation is described. The main aspect consists of the horizontal positioning of the pancreas, which allows a better venous outflow, thus preventing thrombosis and graft loss. The program of pancreas transplantation in this national reference center for pancreatic and liver surgery was started in 2007; the initial results were considered poor, resulting in the loss of half of the grafts due to venous thrombosis. After analyzing the possible causes, this technique was proposed and successfully implemented, reducing the postoperative complications, particularly the problem of venous thrombosis. A detailed description of the new surgical technique is provided. The main clinical and demographic characteristics of the 56 patients who underwent the surgery are analyzed. The incidence of venous thrombosis was 5.3% (3 patients) and graft loss was 3.5% (2 patients). Due to the good results, this technique became the standard surgery for transplantation of the pancreas in our center. The technique proved to be safe and successful. Due to the unique pancreas graft implantation, we called it "transverse pancreas surgery."

Risk of serious opportunistic infections after solid organ transplantation: interleukin-2 receptor antagonists versus polyclonal antibodies. A meta-analysis

BACKGROUND

We aimed to evaluate and quantify the risk of serious opportunistic infections after induction with polyclonal antibodies versus IL-2 receptor antagonists (IL-2RAs) in randomized clinical trials.

METHODS

PRISMA guidelines were followed and random-effects models were performed.

RESULTS

70 randomized clinical trials (10,106 patients) were selected: 36 polyclonal antibodies (n = 3377), and 34 IL-2RAs (n = 6729). Compared to controls, polyclonal antibodies showed higher risk of serious opportunistic infections (OR: 1.93, 95% CI: 1.34-2.80; p < 0.0001); IL-2RAs were associated with lower risk of serious opportunistic infections (OR: 0.80, 95% CI: 0.68-0.94; p = 0.009). Polyclonal antibodies were associated with higher risk of bacterial (OR: 1.58, 95% CI: 1.00-2.50; p = 0.049) and viral infections (OR: 2.37, 95% CI: 1.60-3.49; p < 0.0001), while IL-2RAs were associated with lower risk of cytomegalovirus (CMV) disease (OR: 0.73, 95% CI: 0.56-0.97; p = 0.032). Adjusted indirect comparison: compared to polyclonal antibodies, IL-2RAs were associated with lower risk of serious opportunistic infections (OR: 0.41, 95% CI: 0.34-0.49; p < 0.0001), bacterial infections (OR: 0.51, 95% CI: 0.39-0.67; p < 0.0001) and CMV disease (OR: 0.58, 95% CI: 0.34-0.98; p = 0.043). Results remained consistent across allografts.

CONCLUSION

The risk of serious opportunistic infections, bacterial infections and CMV disease were all significantly decreased with IL-2RAs compared to polyclonal antibodies.

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.

Lessons learned from more than 1,000 pancreas transplants at a single institution

OBJECTIVE

To determine outcome in diabetic pancreas transplant recipients according to risk factors and the surgical techniques and immunosuppressive protocols that evolved during a 33-year period at a single institution.

SUMMARY BACKGROUND DATA

Insulin-dependent diabetes mellitus is associated with a high incidence of management problems and secondary complications. Clinical pancreas transplantation began at the University of Minnesota in 1966, initially with a high failure rate, but outcome improved in parallel with other organ transplants. The authors retrospectively analyzed the factors associated with the increased success rate of pancreas transplants.

METHODS

From December 16, 1966, to March 31, 2000, the authors performed 1,194 pancreas transplants (111 from living donors; 191 retransplants): 498 simultaneous pancreas-kidney (SPK) and 1 simultaneous pancreas-liver transplant; 404 pancreas after kidney (PAK) transplants; and 291 pancreas transplants alone (PTA). The analyses were divided into five eras: era 0, 1966 to 1973 (n = 14), historical; era 1, 1978 to 1986 (n = 148), transition to cyclosporine for immunosuppression, multiple duct management techniques, and only solitary (PAK and PTA) transplants; era 2, 1986 to 1994 (n = 461), all categories (SPK, PAK, and PTA), predominantly bladder drainage for graft duct management, and primarily triple therapy (cyclosporine, azathioprine, and prednisone) for maintenance immunosuppression; era 3, 1994 to 1998 (n = 286), tacrolimus and mycophenolate mofetil used; and era 4, 1998 to 2000 (n = 275), use of daclizumab for induction immunosuppression, primarily enteric drainage for SPK transplants, pretransplant immunosuppression in candidates awaiting PTA.

RESULTS

Patient and primary cadaver pancreas graft functional (insulin-independence) survival rates at 1 year by category and era were as follows: SPK, era 2 (n = 214) versus eras 3 and 4 combined (n = 212), 85% and 64% versus 92% and 79%, respectively; PAK, era 1 (n = 36) versus 2 (n = 61) versus 3 (n = 84) versus 4 (n = 92), 86% and 17%, 98% and 59%, 98% and 76%, and 98% and 81%, respectively; in PTA, era 1 (n = 36) versus 2 (n = 72) versus 3 (n = 30) versus 4 (n = 40), 77% and 31%, 99% and 50%, 90% and 67%, and 100% and 88%, respectively. In eras 3 and 4 combined for primary cadaver SPK transplants, pancreas graft survival rates were significantly higher with bladder drainage (n = 136) than enteric drainage (n = 70), 82% versus 74% at 1 year (P =.03). Increasing recipient age had an adverse effect on outcome only in SPK recipients. Vascular disease was common (in eras 3 and 4, 27% of SPK recipients had a pretransplant myocardial infarction and 40% had a coronary artery bypass); those with no vascular disease had significantly higher patient and graft survival rates in the SPK and PAK categories. Living donor segmental pancreas transplants were associated with higher technically successful graft survival rates in each era, predominately solitary (PAK and PTA) in eras 1 and 2 and SPK in eras 3 and 4. Diabetic secondary complications were ameliorated in some recipients, and quality of life studies showed significant gains after the transplant in all recipient categories.

CONCLUSIONS

Patient and graft survival rates have significantly improved over time as surgical techniques and immunosuppressive protocols have evolved. Eventually, islet transplants will replace pancreas transplants for suitable candidates, but currently pancreas transplants can be applied and should be an option at all stages of diabetes. Early transplants are preferable for labile diabetes, but even patients with advanced complications can benefit.

Pancreas transplantation

Although intensified insulin therapy regimens enable normalization of blood glucose levels and related metabolic parameters, these regimens are associated with an increased incidence of hypoglycemic episodes. Pancreas transplantation has achieved the goal of providing insulin independence with stable and continuous normoglycemia. But because of the associated morbidity and mortality and the need for life-long immunosuppression after transplant, it is difficult to justify pancreas transplantation in diabetic patients at a pre-uremic stage. Pancreas transplantation is therefore performed in conjugation with renal transplantation. The majority of renal transplant centers, however, have been reluctant to perform simultaneous kidney-pancreas transplantation in insulin-dependent uremic patients because of the additional risks associated with pancreas transplantation. More recently, refinements in surgical technique, introduction of new immunosuppressive agents, and better selection of transplant candidates have contributed to improved survival. Today, combined pancreas-kidney transplantation is an accepted treatment for carefully selected patients with insulin dependent diabetes and end-stage renal disease and in a small group of patients with uncontrolled severe metabolic problems. The effect of a euglycemic state after pancreas transplantation on the progression of micro- and macroangiopathy remains to be proved, although recently there is evidence to suggest that some end-organ lesions may be halted or even ameliorated. Further improvement in anti-rejection strategies may achieve better long-term graft survival and provide the incentive to perform pancreas transplantation at an earlier stage, before severe secondary complications of diabetes develop.

Pancreas-kidney transplantation for intensivists: perioperative care and complications

Simultaneous pancreas-kidney transplantation is a therapeutic option for type I diabetics with end-stage renal disease. It aims to correct the uremic state, to normalize glucose hemeostasis, and to ameliorate diabetic complications. Careful donor-recipient selection and meticulous intra-operative and postoperative care will substantially impact recipient morbidity. An understanding of the technical aspects of the surgical procedure and its metabolic and immunological consequences is necessary to successfully manage a pancreas-kidney transplant recipient, many of whom are nursed in intensive care units. A successful outcome is predicted in early recognition of technical complications and aggressive management of rejection to achieve the current 1-year graft survival rates of 75% for pancreas transplants and 84% for kidney transplants.

Evolution of kidney, pancreas, and islet transplantation for patients with diabetes at the University of Minnesota

Transplantation began at the University of Minnesota in 1963. Treatment of diabetes and its complications has been emphasized since 1966, when the first pancreas-kidney transplant was done. Of 3,640 kidneys transplanted by 1992, 1,373 were for diabetic recipients, including 658 from living donors and 715 from cadaver donors. The results progressively improved; since 1984, survival rates of kidney grafts have been similar for diabetic and nondiabetic recipients, with three fourths of the grafts functioning at 4 years. As of 1992, 501 pancreas transplants had been done, including 170 simultaneous with a kidney, 142 after a kidney, and 188 alone for nonuremic diabetic patients; again, the results have improved: by the 1990s, graft survival rates were similar in the 3 recipient categories. Successful pancreas transplants have been shown by our coworkers to stabilize or improve neuropathy and prevent recurrence of diabetic nephropathy in kidney grafts. In an attempt to simplify endocrine replacement therapy, we have done 63 human islet transplants, 34 as allografts for patients with type I diabetes and 29 as autografts after total pancreatectomy to treat chronic pancreatitis. Insulin independence occurs for about 50% of islet autograft recipients. Two recent islet allograft recipients treated with 15-deoxyspergualin have had sustained insulin independence. We anticipate that endocrine replacement therapy by transplantation will become routine for diabetic patients as methods to prevent rejection are refined.

External iliac vein stenosis after segmental pancreatic transplantation: treatment by percutaneous endoprosthesis

A stenosis of the iliac vein secondary to a fluid collection in a pancreas transplant was identified by color Doppler flow sonography. The pancreatic venous drainage was reversed to the contralateral iliac veins via venous collaterals. After two unsuccessful angioplasties of the vein stenosis, a Wallstent was positioned above the venous anastomosis, and has remained patent for 8 months. The pancreatic venous drainage became normal after the procedure.

Donor hyperglycemia as a minor risk factor and immunologic variables as major risk factors for pancreas allograft loss in a multivariate analysis of a single institution's experience

The impact of multiple donor and recipient variables on functional survival of 307 cadaveric pancreas allografts transplanted in 253 recipients at the authors' institution between July 25, 1978 and September 4, 1990 was determined using the Cox proportional hazards regression model. Relative risk of graft loss was calculated for all cases as well as for technically successful (TS) ones. Factors with an impact in descending order of significance for TS cases were immunosuppression (RR = 3.9 for double-drug versus triple-drug maintenance, p less than 0.0001); recipient category (RR = 2.4 for pancreas alone versus simultaneous pancreas/kidney, p = 0.009); retransplantation (RR = 1.8 for retransplants versus primary grafts, p = 0.007); donor hyperglycemia (RR = 1.7 for blood glucose greater than or equal to 200 versus less than 200 mg/dL, p = 0.02); human leukocyte antigen (HLA) matching (RR = 2.1 for poor versus a good match, p = 0.04). A logistic regression analysis also was performed to determine which factors predisposed to technical failure; none were identified. To make the model as relevant as possible to their current program, the authors analyzed only the bladder-drained cases (n = 221; 1984 to 1990). All patients received triple therapy. Recipient category, retransplantation, donor hyperglycemia, and degree of HLA matching remained as significant risk factors. Construction of estimated survival curves showed that the results of retransplantation were significantly improved, and the penalty incurred by using hyperglycemic donors was partially ameliorated by using well-matched donors. Because preservation times up to 30 hours did not exert an adverse effect on outcome, an argument is made to share pancreata between centers to achieve good matches.

Mechanisms of acute pancreatitis. Vascular etiology

Vascular mechanisms play an important but controversial role in the pathogenesis of acute pancreatitis. In experimental animals, injection of wax, powder, air, mercury, and microspheres into the pancreatic artery causes pancreatitis by end artery occlusion with resulting cellular infarction. Larger microspheres do not cause pancreatitis because collateral blood flow is preserved. Clinical evidence, such as microthrombi and atheromatous emboli in the pancreatic artery of patients with pancreatitis, supports pancreatic infarction as an etiologic agent. Experimental and clinical studies have suggested that pancreatic ischemia may also cause pancreatitis, but these studies have not been conclusive. We have compared five hours of total occlusion of the pancreaticoduodenal artery along with four hours of reperfusion to bile injection into the pancreatic duct as causes of pancreatitis. Bile injection caused a significant increase in serum amylase, activation of trypsin in pancreatic exudate, and histologic evidence of necrotizing pancreatitis. Pancreatic blood flow decreased as pancreatitis developed. Ischemia for five hours did not cause a significant increase in serum amylase or activation of trypsin in pancreatic exudate. Only edema was seen histologically, but there was no necrosis. Pancreatic blood flow increased with reperfusion. We believe ischemia aggravates, but does not initiate pancreatitis. Ischemia does not induce inflammation and necrosis in the pancreas, although infarction does.

Glucose metabolism after pancreas autotransplantation. The effect of open duct versus urinary bladder drainage technique

Glucose metabolism and insulin secretion after pancreas transplantation may be affected by the technique used for ductal drainage. We evaluated peripheral glucose and insulin levels after oral (oral glucose tolerance test [OGTT]) and sustained stable hyperglycemic challenge (clamp) in dogs who had undergone pancreas autotransplantation with intraperitoneal drainage (PAT) or with urinary bladder to pancreatic duct anastomosis (PAT/B). Both groups had basal glucose values comparable to normal controls; PAT/B animals had fasting hyperinsulinemia. Pancreas autotransplantation animals had an increased integrated glucose response to OGTT and blunted insulin response to hyperglycemic clamp. Urinary bladder to pancreatic duct anastomosis animals had a significantly decreased integrated glucose response to OGTT compared to PAT and an exaggerated insulin response to hyperglycemic challenge, which approximated normal control values by the last 30-minute period of the clamp. Interestingly M values, which approximate glucose metabolized during the hyperglycemic challenge, were depressed in both surgical groups. It is concluded that the technique of bladder drainage allows a 'normalization' of peripheral levels of insulin that is associated with amelioration of an altered glucose response after oral challenge. However the clamp studies show that, despite the improvement in insulin response, an insensitivity may exist to a wide range of endogenous levels after pancreas transplantation.

Glipizide treatment of pancreas autotransplantation: effects on alterations in glucose-insulin relationships

Pancreas transplantation has been proven effective in supplying an endogenous insulin supply in diabetics. However, alterations in glucose metabolism after transplantation suggest a possible "insensitivity" to its action in the periphery. We hypothesized that sulfonylurea treatment of canines who had received segmental pancreas autotransplants would correct these alterations by altering peripheral insulin sensitivity. Glipizide therapy (5 mg p.o. b.i.d.) did appear, in fact, to enhance basal insulin sensitivity by lowering fasting glucose (100 +/- 3 to 81 +/- 11 mg/dl pre-treatment to post-treatment) while not affecting basal insulin levels. However, glipizide therapy was associated with decreased insulin response to challenge by either oral glucose (2 gm/kg) or sustained intravenous hyperglycemia (150 mg/dl above basal). We conclude that our model of pancreas autotransplantation documents alterations in glucose metabolism which are devoid of the effect of immunosuppression. Glipizide treatment appears to affect fasting sensitivity to insulin, but results in a decrement of insulin response to oral or intravenous glucose challenge.

Effects of pancreatic transplantation on diabetic neuropathy

Reestablishment of the euglycemic state by successful transplantation of the pancreas might halt or reverse diabetic neuropathy. To test this possibility we evaluated neurologic function by clinical examination, nerve conduction studies, and autonomic-function tests in patients with insulin-dependent (Type I) diabetes mellitus before and after successful pancreatic transplantation. Sixty-one patients were studied before and 12 months after transplantation, 27 again after 24 months, and 11 again after 42 months. A control group of patients with Type I diabetes treated with insulin underwent the same studies at similar intervals--48 patients before and after 12 months had elapsed, 21 again after 24 months, and 12 again after 42 months. In the control group, neuropathy tended to worsen during the follow-up period. The scores on the clinical examination indicated increased impairment after 12 months. Composite indexes of the degree of abnormality found on neurophysiologic testing of the function of peripheral motor, sensory, and autonomic nerves indicated decreased autonomic function after 12 months. The examination score and the three index values worsened slightly but not significantly in the patients followed for 24 and 42 months. In contrast, in the patients who had received pancreatic transplants, the neuropathy tended to improve. There was significant improvement in the motor and sensory indexes 12 months after transplantation and in the sensory index 24 months after transplantation. The other measures improved slightly but not significantly at these times, as did all four measures in the patients studied 42 months after transplantation. We conclude that the progression of diabetic polyneuropathy may be halted through the restoration of a euglycemic state by successful pancreatic transplantation.

Future health care technology and the hospital

The past decades have been a time of rapid technological change in health care, but technological change will probably accelerate during the next decade or so. This will bring problems, but it will also present certain opportunities. In particular, the health care system is faced with the need to spend its limited resources more effectively. The number of hospital beds is being reduced, and lengths of stay are falling. In the future, the health care system will have to care for an increasing number of elderly people, both with chronic disease and also with dependency because of frailty and functional problems. The hospital of the future will probably be smaller and more intensive in the nature of its care. In part, this is because many present and future clinical technologies can be delivered outside of the hospital setting. And communication technologies offer the possibility of tying the various parts of the health care system into one true system. This would mean that the future hospital would have a more active role in supervising technical care outside of the hospital, and in making specialized knowledge accessible in all parts of the health system.

Metabolic control and effect on secondary complications of diabetes mellitus by pancreatic transplantation

After successful pancreatic transplantation blood glucose can be normalized without exogenous insulin, although oral and intravenous glucose tolerance remains impaired in 10-45% of the patients. There is no significant deterioration of glucose control with time in most patients. Since most recipients of pancreatic grafts have far advanced secondary diabetic lesions and the observation time after grafting is rather short, the effects of pancreatic transplantation on these complications are difficult to interpret. However, the development of diabetic nephropathy can be prevented, skin microcirculation improves significantly, while autonomic and peripheral neuropathy and diabetic retinopathy remain stable or improve slightly in most patients. But these ameliorations may be in part due to elimination of uraemia, since in almost all patients combined pancreas/kidney transplantations were performed. It is concluded that pancreas grafting probably has to be performed much earlier in the course of diabetes, although the improvement in the quality of life is striking even in the end-stage diabetics studied so far.

Indication, selection of patients and timing for pancreatic transplantation

For more than 20 years pancreas transplantation has been advocated as a therapeutic modality in patients with insulin-dependent diabetes mellitus. When successful, this procedure is the only method for attaining long-term normoglycaemia in diabetic recipients. However, because of the potential morbidity and mortality, pancreas transplantation should be restricted to diabetic patients in whom the complications of the diabetic state are more serious than those of surgery and chronic immunosuppression. Currently three recipient categories have been identified in which pancreas transplantation would seem justifiable. The first includes diabetic patients with end-stage nephropathy who are already obligated to life-long immunosuppressive therapy because of the kidney replacement. In this recipient category the main benefit of receiving a pancreas transplant in addition to a kidney is that the quality of life is markedly improved. In addition, it seems that a functioning pancreas transplant prevents the recurrence of diabetic nephropathy in the simultaneously transplanted kidney. Since the success rate with combined pancreas-kidney transplantations is approaching that of renal transplantation alone, there is little controversy about performing the combined procedure in diabetic uraemic patients. However, if the main objective of pancreas transplantation, namely to prevent the late diabetic microvascular complications, were to be fulfilled this intervention would have to be performed earlier in the course of the disease. Therefore, single pancreatic transplantations have recently been conducted in diabetic patients with early signs of clinical nephropathy which, currently, is the most powerful predictor of susceptibility to detrimental diabetic complications. Preliminary findings indicate that, in this second recipient category, single pancreatic transplantation and subsequent euglycaemia may prevent the progression of diabetic neuropathy and nephropathy; with regard to diabetic retinopathy the results remain obscure.(ABSTRACT TRUNCATED AT 250 WORDS)

Regression of perineurial cell basement membrane in a human diabetic following isogenic pancreas transplant

Perineurial cell basement membrane (PCBM) thickening is a consistent feature in diabetes mellitus (DM) and may have relevance to the cause of DM neuropathy. In this ultrastructural morphometric study of identical twins discordant for DM, we found that the PCBM was significantly thicker in the dermal nerves of the diabetic twin. Following pancreas transplantation (PT) and a 2-year period of euglycemia, the PCBM in both dermal and sural nerves was significantly thinner. At the end of the 2nd year post-PT, the PCBM thickness in the dermal nerves of the diabetic was not significantly different from the non-DM twin. The correction of diabetic dysmetabolism may have played a role in the regression of PCBM. These data suggest that PCBM thickening may not be a permanent legacy of DM.

A 10-year experience with 290 pancreas transplants at a single institution

Since our report at the 1984 American Surgical Association meeting of 100 pancreas transplants from 1966 through 1983, another 190 have been performed. The current series, begun in 1978, now numbers 276 cases, and includes 133 nonuremic recipients of pancreas transplants alone (PTA), 46 simultaneous pancreas/kidney transplants (SPK), and 97 pancreas tranplants after a kidney transplant (PAK). Duct management techniques used were free intraperitoneal drainage in 44 cases, duct occlusion in 44, enteric drainage in 89, and bladder drainage in 128. The 1-year patient and graft survival rates in the entire cohort of 276 were 91% and 42%. One-year patient survival rates were 88% in the first 100, 91% in the second 100, and 92% in the last 76 cases; corresponding 1-year graft survival rates were 28%, 47%, and 56% (p less than 0.05). A prospective comparison of bladder drainage (n = 82) versus enteric drainage (n = 46) in PAK/PTA cases since November 1, 1984 favored bladder drainage (1-year graft survival rates of 52% vs. 41%) because of urinary amylase monitoring. The best results were in recipients of primary SPK bladder-drained transplants (n = 39), with a 1-year pancreas graft survival rate of 75%, kidney graft survival rate of 80%, and patient survival rate of 95%. Logistic regression analysis, with 1-year graft function as the independent variable, showed significant (p less than 0.05) predictors of success (odds ratio) to be technique: bladder drainage (5.8) versus enteric drainage (2.5) versus duct injection (1.0); category: SPK (6.0) versus PAK from same donor (3.2) versus PAK from different donor (1.2) versus PTA (1.0); and donor HLA DR mismatch: 0 (5.0) versus 1 (2.5) versus 2 (1.0) antigens. On April 1, 1989, 90 patients had functioning grafts (60 euglycemic and insulin-free for more than 1 year, 10 for 5 to 10 years); these, along with 24 others whose grafts functioned for 1 to 6 years before failing, are part of an expanding cohort in whom the influence of inducing a euglycemic state on pre-existing secondary complications of diabetes is being studied. Only preliminary data is available. In regard to neuropathy, at more than 1 year after transplant in patients with functioning grafts, conduction velocities in some nerves were increased over baseline. In regard to retinopathy, deterioration in grade occurred in approximately 30% of the recipients by 3 years, whether the graft functioned continuously or failed early, but thereafter retinopathy in the patients with functioning grafts remained stable.(ABSTRACT TRUNCATED AT 400 WORDS)

Current status of pancreas transplantation

Pancreas transplantation for the treatment of diabetes mellitus is being done with increasing frequency. Refined operative techniques, an improved immunosuppression regimen, and an earlier recognition of rejection have led to dramatic increases in both graft and patient survival rates. Preliminary data suggest that a functioning pancreatic allograft may arrest or reverse most of the complications of diabetes, although the effects on retinopathy remain controversial. Patients also acquire a strong sense of well-being after successful pancreas transplantation.

Pancreas transplantation: the Minnesota experience

Between July 1978 and April 1987, a total of 182 pancreas transplants were performed at the University of Minnesota. For the first 100 cases (through October 1984), a variety of surgical techniques and immunosuppressive regimens were used, and 1 year patient and graft functional (insulin-independent) survival rates were 88% and 27%, respectively. From November 1984 to April 1987, a triple therapeutic drug regimen of cyclosporine, azathioprine, and prednisone was used for maintenance immunosuppression, and bladder drainage (BD) (n = 39; 38 cadaver (CAD) and 1 related (REL) donor grafts) and enteric drainage (ED) (n = 40; 21 CAD and 19 REL donor grafts) techniques were compared in 59 nonuremic, nonkidney (NUNK) transplant recipients, 21 recipients of previous kidney (PK) transplants and 8 uremic recipients of simultaneous pancreas and kidney (SPK) transplants. The survival rates were higher in recipients of BD CAD and ED REL than of ED CAD grafts (58% and 59% versus 29% at one year for all, and 84%, 84% and 40% for technically successful cases), but patient survival rates were similar (90%, 93% and 90% at one year). BD allows for early diagnosis of rejection based on urine amylase monitoring, and REL grafts are less prone to incite rejection; thus, we are currently performing only BD for grafts from CAD donors, while both techniques are used for REL donor grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal transplantation in diabetic patients is confirmed therapy while pancreas transplantation should be performed only in an investigational setting

Kidney transplantation is now firmly established as the standard treatment for all diabetic patients with end-stage renal failure. In an analysis of all renal transplants at the University of Minnesota between June 1, 1980 and May 31, 1987, there were no differences in renal allograft functional survival rates for diabetic and nondiabetic recipients. At one year the survival rates were 84% (n = 151) and 86% (n = 260) for those treated with azathioprine, prednisone and ALG; 86% (n = 101) and 87% (n = 104) for those treated with cyclosporine-prednisone, and 92% (n = 165) and 89% (n = 191) for those treated with triple therapy (cyclosporine, azathioprine, and prednisone). Pancreas transplantation remains an investigational procedure for nonuremic diabetic patients but may be considered therapeutic in diabetic renal allograft recipients because such patients are obligated to immunosuppression and only the surgical risks of pancreas transplantation need to be considered, which are now acceptably low. Recipients of pancreas transplants performed simultaneous with the kidney have patient and pancreas graft survival rates of greater than 90% and +/- 60% at several institutions, including our own. The potential for benefit of pancreas transplantation, however, is greater in the nonuremic nonkidney transplant patient, and pancreas transplantations are being performed in such patients at a few institutions. An early beneficial effect of pancreas transplantation preexisting proliferative retinopathy has not been discerned, although long-term retinopathy has been stable in patients with functioning grafts. Preliminary studies have shown a beneficial effect on neuropathy and on microscopic lesions of diabetic nephropathy, but at the expense of cyclosporine toxicity.(ABSTRACT TRUNCATED AT 250 WORDS)

Early diagnosis and treatment of pancreas allograft rejection

A major problem in vascularized pancreas transplantation is the lack of reliable methods for the early diagnosis and effective treatment of allograft rejection. Over a 2-year period, 54 rejection episodes occurred in 31 patients (13 isolated pancreas, 18 simultaneous pancreas-kidney recipients) with pancreaticoduodenocystostomy. A total of 253 radionuclide pancreas examinations were performed (mean 8.4 per patient) utilizing 99mtechnetium-DTPA. Computer analysis generated a quantitative measure of blood flow to the allograft caused the technetium index (TI). Rejection episodes were characterized as isolated pancreas (22), combined pancreas-kidney (16), or isolated renal (16) allograft rejection in combined engraftments. The majority of rejection episodes occurred early (within 3 months of transplant, N = 47) and were more responsive than late rejection to anti-rejection therapy (89.4% vs 42.9%, P = 0.01). Mean urinary amylase (UA) levels and TI during normal allograft function were 29,398 U/l and 0.55%, while levels heralding rejection were 6,528 U/l and 0.40%, respectively (P less than 0.05). The treatment of rejection based upon renal dysfunction or combined renal and pancreas dysfunction resulted in significantly higher graft salvage with a lower incidence of hyperglycemia when compared to isolated pancreas allograft rejection. Of the 11 patients who developed hyperglycemia, 8 (72.7%) ultimately lost their pancreas grafts (P less than 0.001). Following therapy, a TI above 0.3% was associated with 97.4% graft survival, while levels below 0.3% resulted in a 70% rate of graft loss (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Is HLA matching relevant in pancreas transplantation? A registry analysis

The International Pancreas Transplant Registry data base was analyzed for the effect of HLA and mismatching on pancreas survival rate. Typing data was available for both donor and recipient at the A, B and DR loci in 524 of 855 cadaver cases reported since 1982 and in 37 related cases. For cadaver cases, the 1-year functional survival rates for grafts mismatched at less than or equal to 3 (N = 163) versus greater than or equal to 4 (N = 361) A, B and DR antigens were 49% versus 39% (P = 0.121); for technically successful (TS) cases the rates were 66% (N = 123) versus 54% (N = 257) (P = 0.038). An effect was seen at A, B and DR loci, but the differences were not significant when considered separately. THe analysis of TS related donor transplants showed a 1-year graft survival rate of 89% for HLA mismatched donors (N = 11) and of 80% for HLA identical donors (N = 11). The survival rate of the latter is significantly higher (P = 0.046) than that of the TS cadaver donor transplants (59% at 1 year, N = 361). The data suggest that the results of pancreas transplantation will be improved by minimizing HLA mismatches. However, a reanalysis with a more complete data base is needed before firm conclusions can be drawn.

Progression of diabetic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus

We studied the effect of successful pancreas transplantation and consequent normoglycemia (mean total hemoglobin A1, 7.0 percent; range, 5.8 to 8.3) on visual function and diabetic retinopathy in 22 patients with Type I diabetes mellitus (study group). Sixteen similar patients in whom pancreas transplantation had been unsuccessful (mean total hemoglobin A1, 12.0 percent; range, 8.0 to 18.0) served as a control group. The majority of patients in both groups had advanced proliferative retinopathy. At a mean follow-up of 24 months we found no significant difference between the groups in the rate of progression of retinopathy, expressed as a score. Success of the transplantation did not prevent progression of retinopathy across the range of retinopathy studied. Progressive retinopathy was observed more commonly in patients with low retinopathy scores (nonproliferative or mild proliferative retinopathy) at base line in both the study group (13 of 17 eyes, or 76 percent) and the control group (7 of 12 eyes, or 58 percent). Further analysis suggested the possibility that after three years of euglycemia, the study group had less deterioration than the control group, particularly in eyes with advanced retinopathy. We observed no difference in the rate of loss of vision between the two groups. This study provides evidence that pancreas transplantation and subsequent normoglycemia neither reverse nor prevent the progression of diabetic retinopathy.

Pancreas transplantation

The number of pancreas transplants being performed and the success rate have continued to increase. Most pancreas transplants have been placed in diabetic recipients of kidney transplants, but application to nonuremic, non-kidney transplant recipients without end-stage disease is increasing. Drainage of pancreatic graft duct into the bladder allows exocrine function to be assessed directly and has led to earlier diagnosis and treatment of rejection episodes. The improvement in graft survival rates has been associated with the use of cyclosporine in combination with other immunosuppressants. The effect that establishment of a euglycemic state by successful pancreas transplantation has on the specific complications of diabetes is just beginning to be discerned but appears to be favorable if the transplant is performed sufficiently early in the course of the disease.

Comparison of whole pancreas and pancreatic islet transplantation in controlling nephropathy and metabolic disorders of diabetes

To compare the long-term effectiveness of whole pancreas transplantation and pancreatic islet transplantation in controlling the metabolic disorders and preventing the kidney lesions of alloxan diabetes, metabolic and morphologic studies were performed in four groups of rats: (1) NC-116 nondiabetic controls; (2) DC-273 untreated alloxan-diabetic controls; (3) PDT-182 rats that received syngeneic pancreaticoduodenal transplants not long after induction of diabetes with alloxan; and (4) IT-92 rats that received an intraportal injection of at least 1500 and usually 2000 syngeneic pancreatic islets soon after induction of diabetes with alloxan. Each month for 24 months after diabetes was well established, body weight and plasma concentrations of glucose and insulin were measured, and five lesions were scored by light microscopy in 50 glomeruli and related tubules in each kidney by a "blind" protocol: glomerular basement membrane thickening, mesangial enlargement, Bowman's capsule thickening, Armanni-Ebstein lesions of the tubules, and tubular protein casts. There were progressive and highly significant increases in the incidence and severity of all five kidney lesions in the diabetic control rats compared with the nondiabetic control rats. No significant differences were found between the kidneys of Group PDT and those of Group NC, demonstrating that whole pancreas transplantation prevented all of the diabetic kidney lesions throughout the 2-year study period. In contrast, within 3-9 months after pancreatic islet transplantation and thereafter, the incidence and severity of the five diabetic kidney lesions were similar in Group IT and Group DC. Whole pancreas transplantation produced precise metabolic control of diabetes throughout the 24 months of study, whereas pancreatic islet transplantation did not accomplish complete metabolic control, particularly beyond the first several months after transplantation. The difference in the completeness of metabolic control achieved by the two types of transplants is the most likely explanation for their sharp difference in effectiveness in preventing diabetic nephropathy.

Pancreas transplantation. An immunohistologic and histopathologic examination of 100 grafts

The authors examined tissues obtained by biopsy, pancreatectomy, and autopsy from 100 pancreas grafts to determine the cause of dysfunction or failure of the graft. Immunohistologic examination of 42 tissues to determine the mononuclear cell phenotypes and Class I and II antigen expression was performed as well. Technical factors--infections, thrombosis, obstruction--accounted for a large number of graft losses, but immunologic-mediated mechanisms resulted in graft dysfunction and failure as well. Pleomorphic inflammatory infiltrates were present in grafts with acute rejection, as well as Silastic and Prolamine duct-obstructed grafts. Criteria useful in the identification of acute rejection from pancreatitis included a more intense, predominantly mononuclear cell infiltration of transformed lymphocytes in the exocrine pancreas and evidence of vascular rejection--endovasculitis or fibrinoid necrosis. Increased expression and/or induction of Class I and II antigens on pancreatic constituents occurred in grafts with evidence of acute rejection, but also with Silastic and prolamine duct-obstructed pancreatitis. An isletitis occurred in 25% of the grafts. Nine of the 25 grafts (36%) with isletitis also had selective loss of beta cells from the islets. Recurrent diabetes mellitus appeared to have developed in these cases, which accounted for loss of graft function.

Evaluation of insulin secretion after pancreas autotransplantation by oral or intravenous glucose challenge

Segmental pancreatic autotransplantation is accompanied by surgical alterations to the pancreas that may have consequences for carbohydrate metabolism. Four mongrel dogs were evaluated before operation and sequentially until 40 weeks after total pancreatectomy and autotransplantation of the splenic lobe of the pancreas with bolus intravenous and oral administration. Intravenous glucose tolerance test (IVGTT) (0.5 g/kg) revealed maintenance of fasting euglycemia for as long as 40 weeks after operation. Peak glucose and integrated glucose values did not show significant changes as a result of autotransplantation. Following transplantation, a delayed peak insulin response was seen; however, basal, peak, and integrated insulin values were largely unaltered. Only K values, a measure of glucose disposal, showed severe alterations (2.44 +/- 0.21 before operation to 1.24 +/- 0.30 at 40 weeks after operation). Oral glucose tolerance tests (OGTT) (2.0 g/kg) demonstrated an increased peak hyperglycemic response after autotransplantation with increased integrated glucose responses. Insulin levels remained at those levels seen before operation, and glucose-dependent insulinotropic polypeptide (GIP) responses were unchanged during the OGTT as late as 20 weeks after operation. In conclusion, pancreas autotransplantation after total pancreatectomy results in significant metabolic alterations that the IVGTT fails to detect with absolute glucose or insulin levels. However, K values are significantly lowered, which indicates alterations in cellular glucose transport. The OGTT demonstrates hyperglycemia without increased insulin or GIP levels, which suggests an altered beta cell response to the enteric stimulus of insulin release. These changes are nonetheless well tolerated by animals that have remained clinically healthy and euglycemic in the basal state.

Segmental pancreatic autotransplantation with pancreatic ductal occlusion after near total or total pancreatic resection for chronic pancreatitis. Results at 5- to 54-month follow-up evaluation

Reported are eight patients with idiopathic chronic pancreatitis and two patients with alcoholic pancreatitis who had near total distal pancreatectomy for disabling pain and underwent simultaneous segmental pancreatic autotransplantation of the body and tail of the gland to the femoral area in an attempt to prevent or delay the onset of diabetes. The median follow-up period was 31 months, and follow-up study in nine patients ranged from 24 to 54 months. Patency of the grafts was determined by angiography and selected percutaneous venous assays for insulin. Islet cell function was determined by oral glucose tolerance tests, intravenous (I.V.) glucose tolerance tests, and I.V. glucagon stimulation studies. Segmental autotransplantation was technically successful in eight patients, only one of whom required insulin (at 2 years after grafting). The other seven patients with technically successful grafts have remained insulin independent, including two patients who later underwent pyloric preserving pancreatoduodenectomy for completion pancreatectomy. Variable pain relief was observed in patients who underwent near total pancreatectomy, but pain was unrelieved in those patients who underwent limited distal resection. Patients with idiopathic pancreatitis appear to have better pain relief and preservation of endocrine function than alcoholic patients. Segmental pancreatic autotransplantation prevents or delays the onset of diabetes mellitus and should be considered as an alternative for those patients who require extensive pancreatic resection for chronic pancreatitis.

Pancreas transplantation

The data on vascularized pancreas transplant cases reported to the old American College of Surgeons/National Institutes of Health Organ Transplant Registry from December 17, 1966, through December 31, 1984, are summarized in this article. Also described is the experience at the University of Minnesota, where more than one fifth of the transplants have been performed. The authors conclude that pancreas transplantation is now an effective treatment for human diabetes.

In search of an in vitro index of viability during pancreatic preservation

To determine an index of viability during pancreatic preservation, 15 dogs underwent segmental pancreatic autografting after 24 hr of pulsatile perfusion. These animals were divided into Group A (6) and Group B (9) on the basis of post-transplant normoglycemia or hyperglycemia. In each experiment, sequential perfusate amylase and arterial and venous blood gases were analyzed during preservation. In addition, sequential pancreatic tissue slices were obtained to determine in vitro insulin release. A comparison of perfusion parameters demonstrated no significant differences in pancreas weight (41 +/- 2.9 vs 38.3 +/- 1.5 mg), perfusate flow (0.24 +/- 0.2 vs 0.20 +/- 0.06 ml/min/g), diastolic (24.3 +/- 2.3 vs 26.9 +/- 1.6 mm Hg) or mean pressure (27.4 +/- 1.9 vs 30.1 +/- 1.5 mm Hg). Perfusate amylase levels (u/100 ml) and percentage change from baseline are as follows: (Table: see text). Perfusate amylase was significantly greater at 21 hr in Group A (P less than 0.005). In addition, a significantly greater rate of amylase release was evident in Group A at 1 hr (P less than 0.02), 3 hr (P less than 0.02), and 21 hr (P less than 0.01). Group B pancreata demonstrated significantly increased oxygen extraction at 1 hr (A-V O2 difference: Group A = -33, Group B = -68; P less than 0.05). In vitro insulin release of tissue slices obtained pre-harvest, post-flush, post-preservation, and 15 min post-transplantation was not significantly different in the two groups. In conclusion, sequential perfusate amylase and blood gas determinations may be useful in predicting pancreatic transplant function.

Intra-abdominal infections in pancreas transplant recipients

During a 7-year period, 116 pancreas transplants were performed in 98 diabetic patients (49 with and 49 without previous kidney transplants) at the University of Minnesota. The posttransplant clinical course of 26 recipients (22%) was complicated by an intra-abdominal infection (8 with and 18 without previous kidney transplants). Infections occurred in 19/57 cases (33%) in which exocrine secretions were managed by enteric drainage, in 5/15 cases (33%) managed by free drainage into the peritoneal cavity, in 1/39 cases (3%) in which the duct was injected with a synthetic polymer, and in 1/2 cases (50%) in which a pancreaticocystostomy was performed. The organisms Escherichia coli, enterococci, bacteroides, and several anaerobes were cultured from the patients with enteric drainage, while staphylococci were associated with the open duct drainage. Fungal infections with Candida were found with all techniques. Surgical and percutaneous drainage was performed in all patients. In 14 patients, functioning and, in four patients, nonfunctioning grafts were removed. In five patients, the infection resolved while the grafts were functioning, and these patients are currently alive and well. Seven of the 26 patients with infections died (27% mortality rate), five after graft removal and two with the graft still in place (1 with and 1 without function), five in the open-duct, and one each in the enteric and urinary drainage categories. In the 90 cases without intra-abdominal infection, only six patients died (4 cardiovascular, 1 anaphylaxis, 1 cytomegalovirus infection), for a mortality rate of 7%.

What of the next 25 years?

The early history of the Society for Surgery of the Alimentary Tract has been reviewed, and the remarkable progress in gastrointestinal surgery over the first 25 years of its existence has been acknowledged. The challenging dimensions of the problems that remain unsolved have been emphasized, and the directions that fruitful research may take in the next quarter century have been suggested. The alimentary tract surgeon will be called upon to adapt to change, and to move into new fields of clinical physiology and surgery. The discoveries and progress to be anticipated in the years to come are vast.

Pancreatic transplantation

In the last few years there has been considerable improvement in results with pancreatic transplantation. Several centers now report a 1-year graft survival rate of 50%-60%. Patients with well-functioning grafts become insulin independent and have normal or near normal fasting ans post-prandial glucose levels and normal glycosylated hemoglobin values. The glucose tolerance as measured by oral and intravenous glucose tolerance tests is normal in 50%-80% of the patients but subnormal in the others. One important reason for subnormal glucose tolerance is medication with cyclosporin and prednisolone. In most cases an improvement in neuropathy is found and retinopathy seems to be stabilized. Preliminary data indicate that the provision of a pancreatic graft prevents the occurrence of diabetic nephropathy in a simultaneously or previously transplanted kidney.

One institution's experience with pancreas transplantation

The University of Minnesota has the largest experience with pancreas transplantation of any institution, with 130 cases since 1966, including 116 in 98 patients between July 1978 and June 1985. Currently, 30 patients are insulin-independent, 19 for greater than one year, the longest for seven years. One-year patient and graft survival rates overall are 87% and 30%, respectively. Of 98 recipients, 49 had had previous kidney transplants, while 49 had not, and currently most of the pancreas recipients do not have uremia and have not had a kidney transplant but have early complications of diabetes. A total of 44 of the grafts were procured from related and 72 from cadaver donors. Although 32 of the 116 grafts (28%) failed for technical reasons, the most common cause of graft failure has been rejection. Various immunosuppressive regimens have been used in attempts to reduce the rejection rate, and one combination, low-dose cyclosporine-azathioprine-prednisone (triple therapy), has been particularly effective, with a one-year functional survival rate of 73% in recipients of technically successful grafts from human leukocyte antigen-mismatched cadaver or related donors (N = 20). The pancreas graft survival rates have improved gradually (43% for 1984 to 1985, N = 30; versus 27% for 1978 to 1983, N = 86) for transplants from both related and cadaver donors. Metabolic studies from most recipients with functioning grafts (insulin-independent) show normal or nearly normal results. Preliminary observations on secondary complications suggest a more favorable course in recipients whose grafts have functioned long term than in those whose grafts failed early.

Pancreas transplantation--registry report and a commentary

From December 1966 through December 1984, there were 561 pancreas transplants reported to the American College of Surgeons/National Institutes of Health Organ Transplant Registry, including 60 from 1966 through June 1977, 206 from July 1977 through December 1982 and 295 from January 1983 through December 1984. One-year graft function-survival rates (insulin-independent) in each of the three periods were 3%, 20% and 40%, and the corresponding patient survival rates were 40%, 72% and 77%. Currently 140 patients have functioning grafts, 76 for more than one year. Of the transplants since July 1977, one-year graft survival rates according to technique are 41% for enteric drainage (N = 155), 30% for polymer injection (N = 260) and 29% for urinary drainage (N = 47). Pancreas graft survival rates at one year according to whether or not the recipients have had a kidney transplant were 35% for recipients of simultaneous grafts (N = 281), 28% in recipients of a pancreas after a kidney (N = 112) and 26% in recipients of a pancreas only who did not have uremia (N = 106); corresponding patient survival rates were 69%, 83% and 83%. Overall, one-year pancreas graft survival rates according to whether the patients did or did not have end-stage diabetic nephropathy were 33% versus 25% and the corresponding patient survival rates were 73% versus 84% (P < .01). Patient survival rates were significantly higher in those without than in those with end-stage diabetic nephropathy. An analysis of technically successful grafts according to principal immunosuppressant showed one-year function rates of 46% in 258 cyclosporine-treated recipients and 26% in 143 azathioprine-treated recipients. Pancreas graft survival rates have progressively improved and the procedure has become safer with advances in surgical technique and immunosuppression. Pancreas transplantation is currently applicable to patients with diabetes mellitus whose complications are, or predictably will be, more serious than the possible side effects of long-term immunosuppression.

Studies of kidney and muscle biopsy specimens from identical twins discordant for type I diabetes mellitus

To distinguish metabolic from genetic factors in the development of microangiopathy in diabetes, we evaluated biopsy specimens of kidney and quadriceps muscle from seven pairs of identical twins who were discordant for Type I (insulin-dependent) diabetes mellitus. Two of the diabetic patients had clinical diabetic nephropathy, including hypertension, marked albuminuria, and a substantially reduced creatinine clearance; the other five had normal renal function and only minor clinical indications of complications. All the twins of the diabetic patients had normal glomerular basement membrane widths and normal fractional volumes of the glomerular mesangium. Values for glomerular basement membrane width, tubular basement membrane width, and mesangial volume in each diabetic twin exceeded the values in the respective sibling (P less than or equal to 0.0035), even if the value in the diabetic twin lay within established normal ranges. Values for muscle capillary basement membrane width in the diabetic twins did not differ from those in their siblings (P = 0.5). Our observations suggest that the metabolic abnormalities of diabetes are necessary, if not sufficient, for the development of glomerular abnormalities. We also conclude that in diabetic patients, alterations in muscle capillary basement membrane width do not necessarily accompany pathologic lesions in the kidney.