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Drury A, Huber S, Loya E, Powelson JA, Lutz A, Kasper K, Rothenberg JM, Fridell JA. Abdominal Gynecologic Procedures in Pancreas Transplant Recipients. Clin Transplant 2024; 38:e70004. [PMID: 39427301 DOI: 10.1111/ctr.70004] [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: 06/18/2024] [Revised: 09/19/2024] [Accepted: 10/07/2024] [Indexed: 10/22/2024]
Abstract
INTRODUCTION With the growing population of pancreas transplant recipients followed long-term, some female recipients are going to require surgical intervention for gynecologic symptoms and pathologies. Currently, there is a lack of literature describing how to approach this population and whether pelvic gynecologic procedures (GYN) can be performed safely given the proximity of the pancreatic (and possibly renal) allograft. In this single-center retrospective analysis, all pancreas transplant recipients that subsequently underwent GYN were reviewed. METHODS Subjects were identified by cross-referencing all pancreas transplants performed between January 2003 and December 2022 for any subsequent GYN. Demographics at transplant and GYN, indications and procedure performed, operative time, presence and involvement of a transplant surgeon, complications length of stay, and readmissions were reviewed. RESULTS Seventeen patients who underwent a total of 19 GYN after pancreas transplantation were identified. Operations performed included tubal ligation (n = 2), total abdominal hysterectomy with (n = 6) or without bilateral salpingectomy (n = 2), oophorectomy versus cyst drainage (n = 2), bilateral oophorectomy (n = 1), and unilateral (n = 4) versus bilateral (n = 2) salpingectomy. Four were performed through an open laparotomy and 15 were performed laparoscopically. In 11 cases, a transplant surgeon was involved intra-operatively. Eight of the 17 patients developed post-operative complications including post-operative fevers, fluid overload, neutropenia, elevated creatinine (n = 2), nephrolithiasis, urinary tract infection, and incisional hernia. Five required readmission. CONCLUSION GYN can be performed safely following pancreas transplantation, but careful planning and the involvement of the transplant surgery team are advised.
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Affiliation(s)
- Allison Drury
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarah Huber
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elena Loya
- Department of Obstetrics and Gynecology, University of Chicago College of Medicine, Peoria, Illinois, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kelly Kasper
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeffrey M Rothenberg
- Department of Obstetrics and Gynecology, Ascension St. Vincent, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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2
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Drury AM, Albunni H, Al-Haddad M, Powelson JA, Lutz A, Fridell JA. Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation. Clin Transplant 2024; 38:e15176. [PMID: 37922244 DOI: 10.1111/ctr.15176] [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: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 11/05/2023]
Abstract
Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.
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Affiliation(s)
- Allison M Drury
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hashem Albunni
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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3
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Fridell JA, Lutz AJ, Powelson JA. Simultaneous pancreas and kidney transplant after bilateral lung transplant for a recipient with cystic fibrosis. Am J Transplant 2021; 21:3180-3183. [PMID: 33811791 DOI: 10.1111/ajt.16597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/21/2021] [Accepted: 03/24/2021] [Indexed: 01/25/2023]
Abstract
Cystic fibrosis (CF) is an inherited autosomal recessive disorder. Despite optimized therapy, the majority of affected individuals ultimately die of respiratory failure. Lung transplantation is the only available therapy that deals definitively with the end-stage pulmonary disease and has become the treatment of choice for some of these patients. As patients with CF are living longer, extrapulmonary manifestations may develop including pancreatic failure, which manifests as exocrine insufficiency and CF-related diabetes (CFRD). Both of these can be managed through pancreas transplantation. We have previously reported our series of three simultaneous lung and pancreas transplants in patients with CF, which were complicated by surgical issues for both the thoracic and abdominal portions, rejection and resistant infections with disappointing long-term survival. Based on these results, a sequential approach was adopted: first, the thoracic transplant; and second, once the patient has recovered, the abdominal transplants. This is the first reported case of pancreas and kidney transplantation performed after a lung transplant in a patient with CF. It demonstrates a successful approach to treating CF with a lung transplant, and in an effort to improve the patient's long-term outcome, treating CFRD and pancreatic enzyme insufficiency, with a subsequent pancreas transplant.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew J Lutz
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - John A Powelson
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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LAMS for Creation of an Anastomosis Between the Native and Donor Duodenum to Bypass a Proximal Jejunal Obstruction in a Pancreas Transplant Recipient. Transplant Direct 2021; 7:e665. [PMID: 33564716 PMCID: PMC7862799 DOI: 10.1097/txd.0000000000001114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 12/26/2022] Open
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5
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Atoa SM, Mangus RS, Graham RC, Kroepfl EA, Powelson JA, Fridell JA. Effect of volatile anesthetics on early and delayed outcomes in pancreas transplantation. Clin Transplant 2021; 35:e14153. [PMID: 33185894 DOI: 10.1111/ctr.14153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 10/12/2020] [Accepted: 10/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ischemia-reperfusion injury (IRI) is a common cause of allograft dysfunction and patient morbidity in solid organ transplantation. This study compares the effect of different inhaled anesthetics on early IRI and clinical outcomes in pancreas allograft recipients. METHODS Data were extracted retrospectively for pancreas transplants at a single center over a 15-year period. Early postoperative pancreatic amylase and lipase levels were used as a marker for graft injury. Clinical outcomes measured included length of hospital stay, readmission, and graft survival. RESULTS There were 625 pancreas transplants included in the analysis with 3 primary inhaled anesthetics: sevoflurane (53%), desflurane (35%), and isoflurane (12%). In the first 30 days post-transplant, peak amylase was lowest for sevoflurane (147) followed by desflurane (159) and isoflurane (229) (p = .03). Peak lipase levels followed the same trend (peak values 118, 131, and 135, respectively; p = .02). Early graft loss, length of hospital stay, and readmission within 3 months were similar among all three anesthetic groups. There was no difference in 10-year graft survival by Cox regression. CONCLUSIONS Sevoflurane and desflurane are associated with lower peak amylase and lipase levels postoperatively in pancreas transplantation. Short- and long-term clinical outcomes were equivalent for the three agents.
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Affiliation(s)
- Sam M Atoa
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ryan C Graham
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elizabeth A Kroepfl
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John A Powelson
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Zhang L, Chen Z, Lai X, Ma J, Fang J, Guo Y, Li G, Xu L, Yin W, Xiong Y, Liu L, Chen R, Li L. The homolateral simultaneous pancreas-kidney transplantation: a single-center experience in China. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:629. [PMID: 31930030 DOI: 10.21037/atm.2019.10.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To preliminarily explore the clinical effect of the homolateral simultaneous pancreas and kidney (SPK) transplantation in China. Methods SPK using the surgical technique was performed in 88 patients from September 2016 to July 2019 in the Department of Transplantation of the Second Affiliated Hospital of Guangzhou Medical University. Patients were followed up for 2 to 36 months to summarize the efficacy and complications. Results Up to now, 83 patients have achieved good clinical efficacy with no major surgical complications, but 3 patients died of severe infection and 2 have graft loss. The serum creatinine (Scr) at 1, 3, 6, 12, 24 months after operation were 118, 119, 116, 114, 110 umol/L; fasting blood glucose were 5.8, 5.0, 5.0, 4.9, 4.8 mmol/L; and glycated hemoglobin at 3, 6, 12, 24 months after transplantation were 5.2%, 5.5%, 5.2%, 5.1%. One- and 2-year patient, pancreas, and kidney graft survival rates were 96.1%, 93.8%, 95.0% and 96.1%, 93.8%, 95.0%. Main complications included 20 cases of kidney rejection (22.7%), 22 cases of pancreas rejection (25.0%), 31 cases of pulmonary infection (35.2%), 28 cases of gastrointestinal bleeding (31.8%), 2 cases of splenic vein thrombosis (2.3%), 2 case of artery thrombosis and anastomotic leak (2.3%) and 2 cases of pancreas allograft dysfunction (2.3%). Conclusions homolateral simultaneous pancreas-kidney transplantation has a definite therapeutic effect. The relatively simple surgical method can be done with a smaller wound in unilateral fossa iliaca.
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Affiliation(s)
- Lei Zhang
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China.,Sino-French Hoffmann Institute, Guangzhou Medical University, Guangzhou 511436, China
| | - Zheng Chen
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China.,Sino-French Hoffmann Institute, Guangzhou Medical University, Guangzhou 511436, China
| | - Xingqiang Lai
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Junjie Ma
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Jiali Fang
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Yuhe Guo
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Guanghui Li
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Lu Xu
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Wei Yin
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Yunyi Xiong
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Luhao Liu
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Rongxin Chen
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Li Li
- Department of Organ Transplantation, Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
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Papachristos S, Tavakoli A, Dhanda R, Pararajasingam R, Campbell T, Forgacs B. Comparison of Ipsilateral and Contralateral Simultaneous Pancreas and Kidney Transplantation: A Single-Center Analysis with 5-Year Outcome. Ann Transplant 2019; 24:298-303. [PMID: 31123244 PMCID: PMC6556074 DOI: 10.12659/aot.912633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background It is routine to implant the pancreas on the right and the renal graft on the left iliac fossa during a simultaneous kidney and pancreas transplant (cSPK). Ipsilateral placement of both organs on the same side raises concerns that the pancreas graft might compromise the distally placed kidney. However, ipsilateral SPK (iSPK) can be faster than the conventional contralateral graft placement and allows for preservation of the other side for future transplants. Material/Methods In a single unit, 67 SPK transplantations (cSPK n=49, iSPK n=18) were performed from 2008 to 2011. The decision for graft placement was made during the procedure. Donor and recipient demographics, surgical complications, reoperations, surgical time, and patient and graft survival with 5-year follow-up were compared between the 2 groups. Results Duration of operation was shorter in the iSPK group. Recipient and donor demographics were comparable, apart from more females receiving ipsilateral graft placement. The broader female pelvis was probably the determining factor contributing to this outcome. The iSPK group included marginally younger recipients. The ipsilateral group also demonstrated a trend to improved survival of patient, pancreas, and kidney graft, at 1- and 5-year follow-up. There was no difference in complication rates between the 2 groups. Conclusions There were no significant differences in overall outcomes. iSPK is a safe procedure, which proves similar patient and graft survival as with cSPK. Both procedures have comparable surgical complication rates. iSPK is a safe and quicker procedure that allows for preservation of the contralateral side for potential subsequent transplants.
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Affiliation(s)
- Stavros Papachristos
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Afshin Tavakoli
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Raman Dhanda
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Ravi Pararajasingam
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Tunde Campbell
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Bence Forgacs
- Department of Transplantation Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
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Yeap YL, Fridell JA, Wu D, Mangus RS, Kroepfl E, Wolfe J, Powelson JA. Comparison of methods of providing analgesia after pancreas transplant: IV opioid analgesia versus transversus abdominis plane block with liposomal bupivacaine or continuous catheter infusion. Clin Transplant 2019; 33:e13581. [DOI: 10.1111/ctr.13581] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/17/2019] [Accepted: 04/25/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Yar L. Yeap
- Department of Anesthesia Indiana University School of Medicine Indianapolis Indiana
| | - Jonathan A. Fridell
- Department of Surgery Indiana University School of Medicine Indianapolis Indiana
| | - Derrick Wu
- Department of Anesthesia Indiana University School of Medicine Indianapolis Indiana
| | - Richard S. Mangus
- Department of Surgery Indiana University School of Medicine Indianapolis Indiana
| | - Elizabeth Kroepfl
- Department of Anesthesia Indiana University School of Medicine Indianapolis Indiana
| | - John Wolfe
- Department of Anesthesia Indiana University School of Medicine Indianapolis Indiana
| | - John A. Powelson
- Department of Surgery Indiana University School of Medicine Indianapolis Indiana
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Gunder M, Lakhter V, Lau K, Karhadkar SS, Di Carlo A, Bashir R. Endovascular intervention for iliac vein thrombosis after simultaneous kidney-pancreas transplant. J Surg Case Rep 2019; 2019:rjz024. [PMID: 30997007 PMCID: PMC6457065 DOI: 10.1093/jscr/rjz024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/13/2018] [Accepted: 03/27/2019] [Indexed: 11/13/2022] Open
Abstract
May–Thurner syndrome (MTS) is an anatomic variant where the overlying right common iliac artery compresses and chronically obstructs the left common iliac vein, leading to thrombosis. Interventions for symptomatic MTS include endovascular thrombectomy and stenting. Occluding venous thrombus can be fatal to transplanted allografts. No guidelines exist for patients with MTS after simultaneous kidney-pancreas transplant. A 57-year-old female with ESRD and diabetes mellitus underwent a kidney-pancreas transplant. Post-operative imaging revealed a compressed left CIV with an occlusive thrombus threatening the renal graft. Thrombectomy with stent placement was performed, maintaining patency of both allograft venous outflows. Post-intervention the patient has demonstrated preserved kidney and pancreas allograft function through 1 year of follow-up. Interventions for MTS in patients after transplant are challenging given the complex allograft vascular reconstruction. We present a case which demonstrates that angiographic interventions for MTS can be safely performed after simultaneous kidney-pancreas transplant.
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Affiliation(s)
- Meredith Gunder
- Department of Surgery, Temple University Hospital, 3401 N. Broad Street, 400 Parkinson Pavilion, Philadelphia, PA 19140, USA
| | - Vladimir Lakhter
- Temple Heart and Vascular Institute, Temple University Hospital, 3509 N. Broad Street, Boyer Pavilion 4th Floor, Philadelphia, PA 19140, USA
| | - Kwan Lau
- Department of Surgery, Temple University Hospital, 3401 N. Broad Street, 400 Parkinson Pavilion, Philadelphia, PA 19140, USA
| | - Sunil S Karhadkar
- Department of Surgery, Temple University Hospital, 3401 N. Broad Street, 400 Parkinson Pavilion, Philadelphia, PA 19140, USA
| | - Antonio Di Carlo
- Department of Surgery, Temple University Hospital, 3401 N. Broad Street, 400 Parkinson Pavilion, Philadelphia, PA 19140, USA
| | - Riyaz Bashir
- Temple Heart and Vascular Institute, Temple University Hospital, 3509 N. Broad Street, Boyer Pavilion 4th Floor, Philadelphia, PA 19140, USA
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10
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Schroering JR, Mangus RS, Powelson JA, Fridell JA. Impact of Deceased Donor Cardiac Arrest Time on Postpancreas Transplant Graft Function and Survival. Transplant Direct 2018; 4:e381. [PMID: 30234150 PMCID: PMC6133408 DOI: 10.1097/txd.0000000000000813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/04/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction Transplantation of pancreas allografts from donors that have experienced preprocurement cardiopulmonary arrest (PPCA) is not common, though use of PPCA grafts is routine in liver and kidney transplantation. This article reviews a large number of PPCA pancreas grafts at a single center and reports posttransplant outcomes including early graft dysfunction, length of hospital stay, rejection, and early and late graft survival. Methods Preprocurement cardiopulmonary arrest, arrest time, and donor and recipient pancreatic enzyme levels were collected from electronic and written medical records. The PPCA donors were stratified into 4 groups: none, less than 20 minutes, 20-39 minutes, and 40 minutes or greater. Graft survival was assessed at 7 and 90 days and at 1 year. Long-term graft survival was assessed by Cox regression analysis. Results The records of 606 pancreas transplants were reviewed, including 328 (54%) simultaneous pancreas and kidney transplants. Preprocurement cardiopulmonary arrest occurred in 176 donors (29%; median time, 20 minutes). Median peak donor lipase was higher in PPCA donors (40 μ/L vs 29 μ/L, P = 0.02). Posttransplant, peak recipient amylase, and lipase levels were similar (P = 0.63). Prolonged arrest time (>40 minutes) was associated with higher donor peak lipase and lower recipient peak amylase (P = 0.05 for both). Stratified by donor arrest time, there was no difference in 7-day, 90-day, or 1-year graft survival. Cox regression comparing the 4 groups demonstrated no statistical difference in 10-year survival. Conclusions These results support transplantation of pancreas allografts from PPCA donors. Prolonged asystole was associated with higher peak donor serum lipase but lower peak recipient serum amylase. There were no differences in allograft survival.
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Affiliation(s)
- Joel R Schroering
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - John A Powelson
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jonathan A Fridell
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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11
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Yin H, Arpali E, Leverson GE, Sollinger HW, Kaufman DB, Odorico JS. Ipsilateral versus contralateral placement of the pancreas allograft in pancreas after kidney transplant recipients. Clin Transplant 2018; 32:e13337. [PMID: 29952108 DOI: 10.1111/ctr.13337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 06/08/2018] [Accepted: 06/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In a diabetic, uremic kidney transplant recipient that may receive a future pancreas after kidney (PAK) transplant, the kidney is typically implanted on the left side in anticipation of the subsequent pancreas transplant on the right side. In this study, we sought to determine if ipsilateral PAK (iPAK) is as safe as contralateral PAK (cPAK). METHODS The 115 PAK transplants (iPAK n = 57, cPAK n = 58) were performed from 1997-2010 and results were compared between the groups. RESULTS Kidney graft survival and pancreas graft survival was similar between the two groups. Kidney graft function according to serum creatinine and eGFR was not different between the cPAK and the iPAK groups and there were no episodes of kidney graft thrombosis in either group. Subgroup analyses focusing on donor source also did not show worse outcomes for graft survivals in iPAK group when compared to cPAK group. CONCLUSIONS Pancreas and kidney graft survival in PAK transplants is unaffected by the surgical procedure and iPAK is safe.
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Affiliation(s)
- Hang Yin
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Emre Arpali
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Glen E Leverson
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
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12
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Nagaraju S, Mangus RS, Powelson JA, Fridell JA. Pancreas transplantation using compatible but non-identical ABO blood group donors. Clin Transplant 2018; 32:e13284. [PMID: 29774602 DOI: 10.1111/ctr.13284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are limited data on the outcomes of pancreas transplants using ABO non-identical but compatible (NIC) donors. METHODS A review of all pancreas transplants from a single institution from 01/2003 to 07/2016 (n = 606) revealed 41 recipients of a NIC donor pancreas which were matched for age, race, gender, year, and type of transplant with 41 ABO identical cases. Groups were compared for allograft survival, incidence of acute cellular rejection (ACR), length of hospital stay, 3-month readmissions and transfusion requirements. Serum haptoglobin and lactate dehydrogenase were used to identify hemolysis in patients requiring repeated transfusions without overt blood loss. RESULTS The 1-year graft survival was 100% and 88% in the study and control groups. In the study group, 6/41(14%) developed hemolysis, all of which were ABO O into A. All responded to donor blood type specific transfusions. DISCUSSION There are limited data on outcomes of solid organ transplant using NIC donors with almost none specifically addressing pancreas transplantation. In this study, graft survival was similar but 14% developed hemolysis, which was transient and treated with transfusion of donor blood type specific blood. CONCLUSION Non-identical but compatible pancreas transplants have similar graft survival compared to ABO identical. Hemolysis may occur so some caution is required.
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Affiliation(s)
- Santosh Nagaraju
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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13
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Stiegler P, Schemmer P. Robot-Assisted Transplant Surgery - Vision or Reality? A Comprehensive Review. Visc Med 2018; 34:24-30. [PMID: 29594166 DOI: 10.1159/000485686] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Minimally invasive surgery is standard procedure for many operations. Further refinements include the introduction of robotic surgery which is still an emerging field especially in laparoscopic surgery. Since the successful introduction of the da Vinci Robotic Surgical System, the robotic approach in organ transplantation has become of great interest in both the live donor organ retrieval and the recipient operation. Robotic surgery for kidney, liver, and pancreas transplantation is feasible. Over 700 donor nephrectomies and 100 kidney transplantations have been performed already, and robotic surgery is standard in a small number of pioneer centers; however, larger series and most importantly randomized controlled trials for the highest evidence are needed. Longer warm ischemia time and higher costs limit these procedures at the moment.
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Affiliation(s)
- Philipp Stiegler
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Division of Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
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14
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Donation After Circulatory Arrest in Pancreas Transplantation: A Report of 10 Cases. Transplant Proc 2017; 49:2310-2314. [DOI: 10.1016/j.transproceed.2017.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Shah AP, Chen JM, Fridell JA. Incidence and outcomes of cytomegalovirus in pancreas transplantation with steroid-free immunosuppression. Clin Transplant 2015; 29:1221-9. [DOI: 10.1111/ctr.12655] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Ashesh P. Shah
- Department of Surgery; Indiana University School of Medicine; Indianapolis IN USA
| | - Jeanne M. Chen
- Department of Pharmacy; Indiana University Health-University Hospital; Indianapolis IN USA
| | - Jonathan A. Fridell
- Department of Surgery; Indiana University School of Medicine; Indianapolis IN USA
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16
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Laftavi MR, Pankewycz O, Kohli R, Feng L, Said M, Sharma R, Patel S. Short and long-term outcomes of systemic drainage to IVC: a new technique for pancreas transplantation. Transplant Proc 2015; 46:1900-4. [PMID: 25131066 DOI: 10.1016/j.transproceed.2014.06.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ninety-eight percent of the whole pancreas does not serve the purpose of pancreatic transplantation and it is a major cause of surgical complications. Up to 30% of pancreas transplant recipients experience surgical complications and require reoperation. Graft thrombosis and pancreatitis are the most common complications of pancreas transplantation (PT). Thus, different surgical techniques have been described to overcome the surgical hurdles and reduce surgical complications. In this study, for the first time, we report short- and long-term outcomes of PT with inferior vena cava (IVC) venous drainage. Forty-five PTs (22 simultaneous pancreas and kidney [SPK] transplantations and 23 pancreas after kidney [PAK] transplantations) were performed with this technique in our center. Sixty-eight percent of the donors were imported from outside of our area after they were declined by their local transplantation center. Patient and graft survival rates were 100% at 1 year. No graft thrombosis or pancreatitis occurred with this technique. Six patients (13.3%) required reoperation (3 bleeding, 2 anastomotic leak, and 1 small bowel perforation). No patient or graft loss occurred due to surgical complications. We conclude that this technique provides fast and easy dissection of the venous drainage of the PT without the need of complete occlusion of venous outflow. Surgical complication rates were lower with this technique compared with other reported techniques.
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Affiliation(s)
- M R Laftavi
- Surgery, SUNY at Buffalo, Buffalo, New York, United States.
| | - O Pankewycz
- Medicine, SUNY at Buffalo, Buffalo, New York, United States
| | - R Kohli
- Medicine, SUNY at Buffalo, Buffalo, New York, United States
| | - L Feng
- Surgery, SUNY at Buffalo, Buffalo, New York, United States
| | - M Said
- Surgery, SUNY at Buffalo, Buffalo, New York, United States
| | - R Sharma
- Surgery, SUNY at Buffalo, Buffalo, New York, United States
| | - S Patel
- Surgery, SUNY at Buffalo, Buffalo, New York, United States
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Nagai S, Powelson JA, Taber TE, Goble ML, Mangus RS, Fridell JA. Allograft Pancreatectomy: Indications and Outcomes. Am J Transplant 2015; 15:2456-64. [PMID: 25912792 DOI: 10.1111/ajt.13287] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/22/2015] [Accepted: 02/23/2015] [Indexed: 01/25/2023]
Abstract
This study evaluated the indications, surgical techniques, and outcomes of allograft pancreatectomy based on a single center experience. Between 2003 and 2013, 47 patients developed pancreas allograft failure, excluding mortality with a functioning pancreas allograft. Early graft loss (within 14 days) occurred in 16, and late graft loss in 31. All patients with early graft loss eventually required allograft pancreatectomy. Nineteen of 31 patients (61%) with late graft loss underwent allograft pancreatectomy. The main indication for early allograft pancreatectomy included vascular thrombosis with or without severe pancreatitis, whereas one recipient required urgent allograft pancreatectomy for gastrointestinal hemorrhage secondary to an arterioenteric fistula. In cases of late allograft pancreatectomy, graft failure with clinical symptoms such as abdominal discomfort, pain, and nausea were the main indications (13/19 [68%]), simultaneous retransplantation without clinical symptoms in 3 (16%), and vascular catastrophes including pseudoaneurysm and enteric arterial fistula in 3 (16%). Postoperative morbidity included one case each of pulmonary embolism leading to mortality, formation of pseudoaneurysm requiring placement of covered stent, and postoperative bleeding requiring relaparotomy eventually leading to femoro-femoral bypass surgery 2 years after allograftectomy. Allograft pancreatectomy can be performed safely, does not preclude subsequent retransplantation, and may be lifesaving in certain instances.
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Affiliation(s)
- S Nagai
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - J A Powelson
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - T E Taber
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - M L Goble
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R S Mangus
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - J A Fridell
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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18
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Impact of duration of diabetes on outcome following pancreas transplantation. Int J Surg 2015; 18:21-7. [PMID: 25868423 DOI: 10.1016/j.ijsu.2015.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/08/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The impact of duration of T1DM on outcomes following simultaneous pancreas and kidney transplantation (SPK), pancreas after kidney transplantation (PAK), and pancreas transplantation alone (PTA) is currently unknown. MATERIALS AND METHODS A total of 451 pancreas transplants performed at a single institution between January 2003 and April 2013 (SPK n = 238, PAK, n = 97, and PTA, n = 116) were divided into three groups based on cumulative years of T1DM (0-20 years, 21-30 years, and >30 years). Early (7-day) and late (90-day) pancreas allograft loss, patient and pancreas allograft survivals were analyzed. RESULTS While, PAK was more common in recipients with >30 years of T1DM (29%, p < 0.0047), PTA was more common in recipients with 0-20 years of T1DM (41%, p < 0.0011). In all transplant types, recipients age was significantly higher the longer the duration of diabetes. Although longer duration of T1DM correlated with a higher rate of major amputations in PAK recipients (p < 0.0032), no difference was observed in SPK or PTA. While early pancreas graft loss was 2-4% in SPK and PAK with shorter or longer T1DM (p = n.s.), it reached to 10% in PTA with T1DM > 30 years (p < 0.0097). Longer duration of T1DM affected late pancreas graft loss in PAK patients (8%, p < 0.0349). Patient and death-censored graft survival rates were similar in all types of pancreas transplantation extracted by accumulation of years of T1DM prior to transplant. CONCLUSIONS Longstanding T1DM does not seem to negatively impact recipient outcomes following all types of pancreas transplantation.
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Stratta RJ, Rogers J, Farney AC, Orlando G, El-Hennawy H, Gautreaux MD, Reeves-Daniel A, Palanisamy A, Iskandar SS, Bodner JK. Pancreas transplantation in C-peptide positive patients: does "type" of diabetes really matter? J Am Coll Surg 2014; 220:716-27. [PMID: 25667140 DOI: 10.1016/j.jamcollsurg.2014.12.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 12/15/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND In the past, type 2 (C-peptide positive) diabetes mellitus (DM) was a contraindication for simultaneous pancreas-kidney transplantation (SPKT). STUDY DESIGN We retrospectively analyzed outcomes in SPKT recipients according to pretransplantation C-peptide levels ≥ 2.0 ng/mL or < 2.0 ng/mL. RESULTS From November 2001 to March 2013, we performed 162 SPKTs including 30 (18.5%) in patients with C-peptide levels ≥ 2.0 ng/mL pretransplantation (C-peptide positive group, range 2.1 to 12.4 ng/mL) and 132 in patients with absent or low C-peptide levels (<2.0 ng/mL, C-peptide "negative"). C-peptide positive patients were older at SPKT, had a later age of onset and shorter duration of pretransplantation DM, and more were African-American (all p < 0.05) compared with C-peptide negative patients. With a mean follow-up of 5.6 years, patient (80% vs 82.6%), kidney graft (63.3% vs 68.9%), and pancreas graft survivals (50% vs 62.1%, all p = NS) rates were comparable in C-peptide positive and negative patients, respectively. At latest follow-up, there were no differences in acute rejection episodes, surgical complications, major infections, readmissions, hemoglobin A1c levels, serum creatinine, and estimated glomerular filtration rate levels between the 2 groups. C-peptide levels were higher (mean 5.0 vs 2.6 ng/mL, p < 0.05) and post-transplant weight gain (≥ 5 kg) was more common (57% vs 33%, p = 0.004) in the C-peptide positive group. Survival outcomes in C-peptide positive (n = 14) vs C-peptide negative (n = 22) African-American patients were similar, as were outcomes in C-peptide positive patients with a body mass index < or ≥ 28 kg/m(2). CONCLUSIONS Patients with higher pretransplantion C-peptide levels appear to have a type 2 DM phenotype compared to insulinopenic patients undergoing SPKT. However, survival and functional outcomes were similar, suggesting that pretransplantation C-peptide levels should not be used exclusively to determine candidacy for SPKT.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC.
| | - Jeffrey Rogers
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan C Farney
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Giuseppe Orlando
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Hany El-Hennawy
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael D Gautreaux
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amber Reeves-Daniel
- Department of Internal Medicine (Section of Nephrology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Amudha Palanisamy
- Department of Internal Medicine (Section of Nephrology), Wake Forest School of Medicine, Winston-Salem, NC
| | - Samy S Iskandar
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason K Bodner
- Department of General Surgery (Section of Transplantation), Wake Forest School of Medicine, Winston-Salem, NC
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20
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Fridell JA, Mangus RS, Chen JM, Goble ML, Mujtaba MA, Taber TE, Powelson JA. Late pancreas retransplantation. Clin Transplant 2014; 29:1-8. [DOI: 10.1111/ctr.12468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Jeanne M. Chen
- Department of Pharmacy; Indiana University Health - University Hospital; Indianapolis IN USA
| | | | | | - Tim E. Taber
- Medicine; Indiana University School of Medicine; Indianapolis IN USA
| | - John A. Powelson
- Surgery; Indiana University School of Medicine; Indianapolis IN USA
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21
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Mangus RS, Powelson J, Kinsella SB, Farar DT, Creal CA, Fridell JA. Pretransplant coronary artery disease associated with worse clinical outcomes in pancreas transplantation. Clin Transplant 2014; 27:E442-7. [PMID: 23923972 DOI: 10.1111/ctr.12185] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) is common in patients with type I diabetes and may be associated with worse outcomes in patients undergoing pancreas transplantation (PT). This study evaluates PT patients to determine the pre transplant prevalence of CAD and assesses the post-transplant outcomes including complications and survival. METHODS This study is a retrospective review of PTs from 2003 to 2011. Diagnosis of CAD required cardiac catheterization. Outcomes included: myocardial infarction (MI), stroke, and survival. RESULTS There were 405 transplants in 389 patients with median follow-up of 56 months. Pre transplant prevalence of CAD was 19% (n = 74). There was no increased risk of perioperative, 90-d or one-yr mortality for patients with CAD. The CAD group did have increased risk of MI (11% vs. 1%, p < 0.001) and stroke (8% vs. 3%, p = 0.02). Controlling for patient and donor age, and history of CAD, the CAD group had decreased patient survival at five yr (82% vs. 90%, p = 0.09, HR 1.77) by Cox regression. CONCLUSIONS Patients with type I diabetes and CAD have increased risk of MI and stroke post-pancreas transplant, with decreased five-yr survival. Patients without CAD and a negative pre transplant cardiac evaluation carry a low risk of post-transplant MI.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5250, USA.
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22
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Rogers J, Farney AC, Orlando G, Farooq U, Al-Shraideh Y, Stratta RJ. Pancreas transplantation with portal venous drainage with an emphasis on technical aspects. Clin Transplant 2013; 28:16-26. [PMID: 24410731 DOI: 10.1111/ctr.12275] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 12/17/2022]
Abstract
Advances in surgical techniques and clinical immunosuppression have led to improving results in vascularized pancreas transplantation. Most pancreas transplants are performed with enteric exocrine drainage and systemic venous delivery of insulin (systemic-enteric technique) although bladder drainage (systemic-bladder technique) remains a viable option. To improve the physiology of pancreas transplantation, an innovative technique of portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric technique) was developed and refined over the past 27 yr. However, the potential of portal-enteric pancreas transplantation has never been fully realized as it is currently performed in only 18% of simultaneous pancreas-kidney/sequential pancreas after kidney and 10% of pancreas-alone transplants with enteric drainage. A number of studies have demonstrated no major or consistent differences in outcomes for bladder-drained or enteric-drained pancreas transplants with either portal or systemic venous drainage although some studies suggest purported metabolic and immunologic advantages associated with portal venous delivery of insulin. The purpose of this study is to review the existing literature on portal-enteric pancreas transplantation with an emphasis on surgical aspects and technical modifications/nuances that have been introduced with time and experience.
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Affiliation(s)
- Jeffrey Rogers
- Section of Transplantation, Department of General Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
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23
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Shah AP, Mangus RS, Powelson JA, Samy KP, Taber TE, Goble ML, Fridell JA. Impact of recipient age on whole organ pancreas transplantation. Clin Transplant 2012; 27:E49-55. [PMID: 23228216 DOI: 10.1111/ctr.12047] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 01/10/2023]
Abstract
AIM The goal of this study was to assess the impact of recipient age on post-transplant outcome. METHODS All pancreas transplants performed at Indiana University between 2003 and 2011 were reviewed. Demographic data were compared using standard chi-square and ANOVA testing. Standard Cox regression survival analysis was performed using a direct entry method for covariates. RESULTS Patients (n = 405) were divided by decade: <30 yr (n = 37), 30-39 (n = 109), 40-49 (n = 156), 50-59 (n = 85), and ≥ 60 yr of age (n = 18). Group demographics did not differ except for median ischemia time, which was between 7.0 and 8.5 h (p = 0.02). Early graft loss and one yr graft and patient survival were similar between the groups. Long-term patient survival demonstrated a trend toward decreased five-yr survival with increasing recipient age (p = NS). Graft survival at five yr by Cox regression was the lowest for the <30 yr group (74%), while all other groups were similar around 80% (p = NS). CONCLUSION No statistically significant differences in pancreas transplant outcomes were demonstrated when recipients were stratified by recipient age. These results suggest that older recipients can successfully undergo pancreas transplantation and expect five-yr outcomes similar to those seen in younger recipients.
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Affiliation(s)
- Ashesh P Shah
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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24
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Mujtaba MA, Fridell JA, Higgins N, Sharfuddin AA, Yaqub MS, Kandula P, Chen J, Mishler DP, Lobashevsky A, Book B, Powelson J, Taber TE. Early findings of prospective anti-HLA donor specific antibodies monitoring study in pancreas transplantation: Indiana University Health Experience. Clin Transplant 2012; 26:E492-9. [DOI: 10.1111/ctr.12005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Muhammad A. Mujtaba
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Jonathan A. Fridell
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Nancy Higgins
- Transplant Immunology lab; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Asif A. Sharfuddin
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Muhammad S. Yaqub
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Praveen Kandula
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Jeanne Chen
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Dennis P. Mishler
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Andrew Lobashevsky
- Transplant Immunology lab; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Benita Book
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - John Powelson
- Division of Transplant; Department of Surgery; Indiana University School of Medicine; Indianapolis; IN; USA
| | - Tim E. Taber
- Division of Nephrology; Department of Medicine; Indiana University School of Medicine; Indianapolis; IN; USA
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Linhares MM, Beron RI, Gonzalez AM, Tarazona C, Salzedas A, Rangel EB, Sá JR, Melaragno C, Goldman SM, Souza MG, Sato NY, Matos D, Lopes-Filho GJ, Medina JO, Medina JO. Duodenum-stomach anastomosis: a new technique for exocrine drainage in pancreas transplantation. J Gastrointest Surg 2012; 16:1072-5. [PMID: 22258867 DOI: 10.1007/s11605-011-1806-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 12/14/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Poor vascular access due to previous surgery can be a major obstacle in pancreas transplantation for which new exocrine and vascular outflow techniques might be useful. A 34-year-old female with early onset type 1 diabetes who underwent living donor kidney transplantation 20 years ago and a failed pancreas transplantation 2 years ago presented for pancreas retransplantation. METHODS The inferior vena cava was used in the previous deceased donor pancreas transplantation and both iliac arteries had intense perivascular fibrosis, making arterial anastomosis impossible. The only remaining option for the implant was the infrarenal aorta, with venous drainage to the superior mesenteric vein and exocrine drainage to the gastric antrum. RESULTS The patient had an uneventful recovery and graft function appeared normal. This report shows that when the recipient's abdominal cavity does not provide clear access for the usual surgical techniques regarding exocrine drainage, the stomach drainage procedure is an option. CONCLUSION Duodenum-stomach anastomosis might be an alternative to portal enteric drainage because there is easy access for graft biopsies and even for procedures involving the papilla major.
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Mujtaba M, Fridell J, Sharfuddin A, Kandula P, Yaqub MS, Phillips CL, Mishler D, Taber T. BK virus nephropathy in simultaneous pancreas kidney transplant: a potentially preventable cause of kidney allograft loss. Clin Transplant 2012; 26:E87-93. [PMID: 22448973 DOI: 10.1111/j.1399-0012.2012.01599.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 12/16/2022]
Abstract
More than half of the simultaneous pancreas kidney transplant (SPK) patients afflicted with BK virus nephropathy (BKVN) lose their kidney allograft. Fear of pancreatic rejection limits the ability to reduce immunosuppression; this may result in inadequate treatment of BKVN. This single-center retrospective review included 138 SPK patients who underwent periodic BKV screening and were managed with IS reduction alone as a treatment of choice for BKVN. All patients underwent rabbit anti-thymocyte globulin (rATG) induction and were maintained on tacrolimus/sirolimus or mycophenolate. The incidence of BKVN was 4.4%. BKVN was diagnosed at a median of 11 months; mean serum creatinine 2.1 mg/dL and the geometric mean BK serum viral load at diagnosis 1,758,000 DNA copies/mL. Median time to BKV clearance was 5.6 months; there was 96% reduction in the mycophenolate dose, 100% reduction in sirolimus, and 40% reduction in the tacrolimus blood level at BKVN clearance. No BKVN-related kidney failure was noted, and patients retained excellent kidney and pancreatic allograft function till last follow-up (43 months). BKVN in SPK is a potentially preventable cause of end-stage kidney disease, and IS reduction alone is an acceptable treatment modality in SPK without a higher risk of kidney/pancreas allograft loss as long as close monitoring can be ensured.
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Affiliation(s)
- Muhammad Mujtaba
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
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27
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Abstract
BACKGROUND Surgical complications are a major disincentive to pancreas transplantation, despite the undisputed benefits of restored insulin independence. The da Vinci surgical system, a computer-assisted electromechanical device, provides the unique opportunity to test whether laparoscopy can reduce the morbidity of pancreas transplantation. METHODS Pancreas transplantation was performed by robot-assisted laparoscopy in three patients. The first patient received a pancreas after kidney transplant, the second a simultaneous pancreas kidney transplantation, and the third a pancreas transplant alone. Operations were carried out through an 11-mm optic port, two 8-mm operative ports, and a 7-cm midline incision. The latter was used to introduce the grafts, enable vascular cross-clamping, and create exocrine drainage into the jejunum. RESULTS The two solitary pancreas transplants required an operating time of 3 and 5 hr, respectively; the simultaneous pancreas kidney transplantation took 8 hr. Mean warm ischemia time of the pancreas graft was 34 min. All pancreatic transplants functioned immediately, and all recipients became insulin independent. The kidney graft, revascularized after 35 min of warm ischemia, also functioned immediately. No patient had complications during or after surgery. At the longer follow-up of 10, 8, and 6 months, respectively, all recipients are alive with normal graft function. CONCLUSIONS We have shown the feasibility of laparoscopic robot-assisted solitary pancreas and simultaneous pancreas and kidney transplantation. If the safety and feasibility of this procedure can be confirmed by larger series, laparoscopic robot-assisted pancreas transplantation could become a new option for diabetic patients needing beta-cell replacement.
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Fridell JA, Johnson MS, Goggins WC, Beduschi T, Mujtaba MA, Goble ML, Powelson JA. Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center. Clin Transplant 2011; 26:164-72. [PMID: 22129039 DOI: 10.1111/j.1399-0012.2011.01560.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Complications of pancreas transplantation involving the arterial anastomosis are potentially life threatening. In this report, we review our experience with such vascular catastrophes. METHODS Pancreas transplants performed between January 2003 and December 2009 were reviewed. All cases of pseudoaneurysm (PA) or arterioenteric fistula (AEF) were included. RESULTS Of 346 pancreas transplants, 10 vascular catastrophes in nine recipients were identified. There were five PAs, one involving the pancreas allograft, one involving the donor iliac artery Y-graft stump following allograft pancreatectomy, two involving the kidney allograft, and one involving the bifurcation of the Y-graft. The latter was treated with coil embolization, but subsequently developed into an AEF. There were five AEFs including the recipient mentioned above. Four had a failed allograft and three had discontinued immunosuppression. The final case had a clamp injury to the proximal common iliac artery that fistulized to the donor duodenum. The management, course and outcome of all nine recipients are described in detail. CONCLUSION Vascular catastrophes such as PA and AEF are potentially life-threatening complications of pancreas transplantation. Immediate treatment at the time of bleeding is essential and covered stenting of the involved artery may provide immediate vascular control in these situations.
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Affiliation(s)
- Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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29
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Single dose of alemtuzumab induction with steroid-free maintenance immunosuppression in pancreas transplantation. Transplantation 2011; 92:678-85. [PMID: 21841541 DOI: 10.1097/tp.0b013e31822b58be] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The use of alemtuzumab (humanized anti-CD52 monoclonal antibody) has been primarily studied in renal transplantation, and the experience of alemtuzumab induction in pancreas transplantation is still limited. The objective of this study is to analyze the outcome of pancreas transplantation by using a single dose of 30 mg alemtuzumab induction with steroid-free maintenance immunosuppression. METHODS We performed a total 28 pancreas transplants (17 simultaneous kidney-pancreas transplantation [SPK], 5 pancreas after kidney transplantation [PAK], and 6 pancreas transplant alone [PTA]) between November 2006 and April 2010. Median follow-up was 25 months (range, 8-49 months). Maintenance immunosuppression consists of tacrolimus and mycophenolate. We analyzed patient/graft survival, graft function, and complications. RESULTS One-year actuarial patient/graft survival was 100%/100% in SPK, PAK, and PTA. Three-year actuarial patient/pancreas graft survival rates for SPK, PAK, and PTA were 100%/100%, 100%/100%, and 100%/83%, respectively. Excellent pancreas and kidney graft functions were observed. Acute cellular rejection occurred in 42% of patients. Most of the rejection episode occurred approximately 1 or 6 months after transplant. Absolute lymphocyte count remained below preoperative level for 1 year posttransplant and WBC counts were significantly lower for 3 years after transplant compared with pretransplant level. Cytomegalovirus infection and bacterial infection occurred in 28% and 36% of patients, respectively. Eleven percent of patients developed donor-specific antibodies and 7% of patients experienced antibody-mediated rejection. CONCLUSION A single dose of 30 mg alemtuzumab induction with steroid-free maintenance immunosuppression achieved excellent mid-term patient and graft survival for pancreas transplantation with acceptable complication rate.
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Shokouh-Amiri H, Zakhary JM, Zibari GB. A novel technique of portal-endocrine and gastric-exocrine drainage in pancreatic transplantation. J Am Coll Surg 2011; 212:730-8; discussion 738-9. [PMID: 21463823 DOI: 10.1016/j.jamcollsurg.2010.12.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 12/16/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pancreas transplant (PT) is an established treatment for patients with diabetes mellitus. Diagnosis of rejection has continued to be problematic. In 2007, a new technique of PT with gastric exocrine (P-G) drainage was first performed at our institution. This technique facilitates access to pancreas allograft. The purpose of this study was to compare our experience with PT using P-G technique and the technique of portal enteric (P-E) with venting jejunostomy. STUDY DESIGN Thirty patients who underwent PT between 2007 and 2009 (G-I) and 30 consecutive patients before this time (G-II) were studied. In both groups arterial and venous anastomosis was similar to standard P-E technique. In G-I, the end of allograft jejunum was anastomosed to the anterior aspect of the stomach. In the G-II, allograft duodenum was anastomosed to the Roux-en-Y and end of Roux-en-Y was brought out as venting jejunostomy. RESULTS Donor and recipient demographic data, number of antigen matches, and immunosuppressant were similar in both groups. All patients achieved euglycemia. In G-I, 3 patients underwent pancreatectomy, 2 owing to vessel thrombosis and 1 owing to chronic rejection. Two patients died with functioning pancreatic allografts. In G-II, 1 pancreas was removed owing to vessel thrombosis. Seven patients with cytomegalovirus and 4 patients with rejection in G-I were diagnosed with endoscopy of allograft duodenum. One-year patient and graft survivals were similar. CONCLUSIONS This technique has proven to be safe with good patient and allograft survival. Access to donor duodenum and pancreas allograft via endoscopy is unique to this technique and provides the added advantage of life-long easy access to allograft.
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Affiliation(s)
- Hosein Shokouh-Amiri
- Louisiana State University Health Sciences Center/Willis Knighton, Shreveport, LA, USA
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Abstract
BACKGROUND Graft thrombosis is the most common cause of early graft loss after pancreas transplantation. Early reexploration may permit salvage or timely removal of the thrombosed graft. METHODS This was a retrospective review of 345 pancreas transplants performed at a single center between January 2003 and December 2009. Early reexploration was defined as within 1 week of pancreas transplantation. RESULTS Of the 345 transplants, there were 35 early reexplorations. The graft was compromised in 20 cases (57%): 10 venous thromboses, 3 arterial thromboses, 2 combined arterial and venous thrombosis, 2 thromboses secondary to allograft pancreatitis, and 3 cases of positional ischemia without thrombosis. Of these allografts, three reperfused once repositioned and six were successfully thrombectomized for a graft salvage rate of 45%. One of the thrombectomized grafts remained perfused but never functioned and was removed at retransplantation. The 10 remaining compromised grafts that were deemed unsalvageable and required allograft pancreatectomy. Nine of these recipients were retransplanted (eight within 2 weeks) and one was not a retransplantation candidate. CONCLUSIONS Reexploration for suspected graft thrombosis after pancreas transplantation resulted in a negative laparotomy rate of 43%, but permitted graft salvage in 45% of compromised grafts.
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Boggi U, Signori S, Vistoli F, Amorese G, Consani G, De Lio N, Perrone V, Croce C, Marchetti P, Cantarovich D, Mosca F. Current perspectives on laparoscopic robot-assisted pancreas and pancreas-kidney transplantation. Rev Diabet Stud 2011; 8:28-34. [PMID: 21720670 DOI: 10.1900/rds.2011.8.28] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pancreas transplant recipients continue to suffer high surgical morbidity. Current robotic technology provides a unique opportunity to test whether laparoscopy can improve the post-operative course of pancreas transplantation (PT). Current knowledge on robotic pancreas and renal transplantation was reviewed to determine feasibility and safety of robotic PT. Information available from literature was included in this review, together with personal experience including three PT, and two renal allotransplants. As of April 2011, the relevant literature provides two case reports on robotic renal transplantation. The author's experience consists of one further renal allotransplantation, two solitary PT, and one simultaneous pancreas-kidney transplantation. Information obtained at international conferences include several other renal allotransplants, but no additional PT. Preliminary data show that PT is feasible laparoscopically under robotic assistance, but raises concerns regarding the effects of increased warm ischemia time on graft viability. Indeed, during construction of vascular anastomoses, graft temperature progressively increases, since maintenance of a stable graft temperature is difficult to achieve laparoscopically. There is no proof that progressive graft warming produces actual damage to transplanted organs, unless exceedingly long. However, this important question is likely to elicit a vibrant discussion in the transplant community.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy.
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Fridell JA, Mangus RS, Taber TE, Goble ML, Milgrom ML, Good J, Vetor R, Powelson JA. Growth of a nation part II: impact of recipient obesity on whole-organ pancreas transplantation. Clin Transplant 2011; 25:E366-74. [DOI: 10.1111/j.1399-0012.2011.01422.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Fridell JA, Mangus RS, Taber TE, Goble ML, Milgrom ML, Good J, Vetor R, Powelson JA. Growth of a nation part I: impact of organ donor obesity on whole-organ pancreas transplantation. Clin Transplant 2011; 25:E225-32. [DOI: 10.1111/j.1399-0012.2011.01419.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Fridell JA, Mangus RS, Powelson JA. Histidine-tryptophan-ketoglutarate for pancreas allograft preservation: the Indiana University experience. Am J Transplant 2010; 10:1284-9. [PMID: 20353471 DOI: 10.1111/j.1600-6143.2010.03095.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Histidine-tryptophan-ketoglutarate solution (HTK) has been scrutinized for use in pancreas transplantation. A recent case series and a United Network for Organ Sharing data base review have suggested an increased incidence of allograft pancreatitis and graft loss with HTK compared to the University of Wisconsin solution (UW). Conversely, a recent randomized, controlled study failed to show any significant difference between HTK and UW for pancreas allograft preservation. This study was a retrospective review of all pancreas transplants performed at Indiana University between 2003 and 2009 comparing preservation with HTK or UW. Data included recipient and donor demographics, 7-day, 90-day and 1-year graft survival, peak 30-day serum amylase and lipase, HbA1c and C-peptide levels. Of the 308 pancreas transplants, 84% used HTK and 16% UW. There were more SPK compared to pancreas after kidney and pancreas transplant alone in the HTK group. Donor and recipient demographics were similar. There was no significant difference in 7-day, 90-day or 1-year graft survival, 30-day peak serum amylase and lipase, HbA1c or C-peptide. No clinically significant difference between HTK and UW for pancreas allograft preservation was identified. Specifically, in the context of low-to-moderate flush volume and short cold ischemia time (<or=10 h), no increased incidence of allograft pancreatitis or graft loss was observed.
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Affiliation(s)
- J A Fridell
- The Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Abstract
PURPOSE OF REVIEW Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function. RECENT FINDINGS Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion. SUMMARY Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.
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Fridell JA, Mangus RS, Hollinger EF, Taber TE, Goble ML, Mohler E, Milgrom ML, Powelson JA. The case for pancreas after kidney transplantation. Clin Transplant 2009; 23:447-53. [DOI: 10.1111/j.1399-0012.2009.00996.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Hollinger EF, Powelson JA, Mangus RS, Kazimi MM, Taber TE, Goble ML, Fridell JA. Immediate retransplantation for pancreas allograft thrombosis. Am J Transplant 2009; 9:740-5. [PMID: 19298453 DOI: 10.1111/j.1600-6143.2009.02517.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Early pancreas allograft failure most commonly results from thrombosis and requires immediate allograft pancreatectomy. Optimal timing for retransplantation remains undefined. Immediate retransplantation facilitates reuse of the same anatomic site before extensive adhesions have formed. Some studies suggest that early retransplantation is associated with a higher incidence of graft loss. This study is a retrospective review of immediate pancreas retransplants performed at a single center. All cases of pancreas allograft loss within 2 weeks were examined. Of 228 pancreas transplants, 12 grafts were lost within 2 weeks of surgery. Eleven of these underwent allograft pancreatectomy for thrombosis. One suffered anoxic brain injury and was not a retransplantation candidate, one was retransplanted at 3.5 months and nine patients underwent retransplantation 1-16 days following the original transplant. Of the nine early retransplants, one pancreas was lost to heparin-induced thrombocytopenia, one recipient died with function at 2.9 years and the other grafts continue to function at 76-1137 days (mean 572 days). One-year graft survival for early retransplantation was 89% compared to 91% for all pancreas transplants at our center. Immediate retransplantation following pancreatic graft thrombosis restores durable allograft function with outcomes comparable to first-time pancreas transplantation.
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Affiliation(s)
- E F Hollinger
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Agarwal A, Powelson JA, Goggins WC, Milgrom ML, Fridell JA. Organ preservation with histidine-tryptophan ketogluatarate solution in clinical pancreas transplantation: an update of the indiana university experience. Transplant Proc 2008; 40:498-501. [PMID: 18374113 DOI: 10.1016/j.transproceed.2008.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In May 2003, University of Wisconsin (UW) solution was replaced with Histidine-Tryptophan Ketoglutarate (HTK) solution as the preservation fluid for abdominal organ procurements in our center. Herein we have reported our updated results with HTK in pancreas transplantation. Between May 2003 and October 2006, 152 pancreas transplantations were performed in which 146 used HTK. The procedures were as follows: simultaneous kidney pancreas transplantation (n = 85; 55%), pancreas after kidney transplantation (n = 41; 30%), and solitary pancreas transplantation (n = 20; 15%). Donor and recipient data were collected with primary outcomes as primary nonfunction (PNF), and 30-day and 1-year graft and patient survival. Patient demographics are as follows: age (36 +/- 12 years), gender (males, 89: females, 57), race (white, 135; African American, 11). Mean flush volume was 3.8 +/- 1 L. The mean cold ischemia time was 8 +/- 3 hours. Mean warm ischemia time was 48 +/- 23 minutes. There were no cases of PNF in this cohort. Thirty-day and 1-year patient survival rates were 99% and 95%, respectively. The 30-day and 1-year graft survivals rates were 95% and 93%, respectively. There were 10 grafts lost with 7 vascular complications (6 venous and 1 arterial thrombosis). There were 2 cases of chronic rejection and 1 graft lost to noncompliance. These statistics compare favorably with International Pancreas Transplant Registry reported 1-year survival for pancreas allografts. All other patients were insulin independent by discharge. Serum fasting blood glucose and serial amylase remained comparable at all intervals posttransplantation to those of a historical UW cohort. Within this range of cold ischemia times, HTK appears to provide effective pancreas preservation.
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Affiliation(s)
- A Agarwal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Fridell JA, Gage E, Goggins WC, Powelson JA. Complex Arterial Reconstruction for Pancreas Transplantation in Recipients With Advanced Arteriosclerosis. Transplantation 2007; 83:1385-8. [PMID: 17519791 DOI: 10.1097/01.tp.0000261629.02700.ef] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pancreas transplantation can be very challenging in the recipient with iliac artery disease. In this report, we describe three techniques we have applied in these difficult situations and include demonstrative case reports. In principle, we believe that this is a problem that should be dealt with carefully to prevent further complicating the situation and should be resolved before bringing the allograft to the operative field in order to prevent prolonged warm ischemic times.
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Affiliation(s)
- Jonathan A Fridell
- The Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Gage EA, Jones GE, Powelson JA, Johnson MS, Goggins WC, Fridell JA. Treatment of Enterocutaneous Fistula in Pancreas Transplant Recipients Using Percutaneous Drainage and Fibrin Sealant: Three Case Reports. Transplantation 2006; 82:1238-40. [PMID: 17102779 DOI: 10.1097/01.tp.0000228240.78290.28] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Complications involving the enteric anastomosis site, including intra-abdominal abscess and enterocutaneous fistula formation, have been well documented following pancreas transplantation. Although uncommon, these complications remain particularly difficult to manage and frequently mandate surgical re-exploration. In this manuscript, we will review three cases of enterocutaneous fistula in pancreas transplant recipients managed nonoperatively with percutaneous drainage and subsequent occlusion of the tract with fibrin sealant.
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Affiliation(s)
- Earl A Gage
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Losanoff JE, Harland RC, Thistlethwaite JR, Garfinkel MR, Williams JW, Milner J, Millis JM. Omega jejunoduodenal anastomosis for pancreas transplant. J Am Coll Surg 2006; 202:1021-4. [PMID: 16735221 DOI: 10.1016/j.jamcollsurg.2006.02.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Accepted: 02/15/2006] [Indexed: 11/18/2022]
Affiliation(s)
- Julian E Losanoff
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, USA
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Agarwal A, Murdock P, Pescovitz MD, Goggins WC, Milgrom ML, Fridell JA. Follow-up experience using histidine-tryptophan ketoglutarate solution in clinical pancreas transplantation. Transplant Proc 2006; 37:3523-6. [PMID: 16298649 DOI: 10.1016/j.transproceed.2005.09.069] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In May 2003, at Indiana University, the standard cold preservation solution University of Wisconsin (UW) solution was replaced by histidine-tryptophan ketogluatarate (HTK) solution. Earlier, we presented our initial experience with HTK in pancreas preservation with an analysis of the first 10 pancreas transplants. Here we report updated results with HTK in pancreas transplantation over the past 18 months. Between May 2003 and March 2005, a total of 87 pancreas transplants were performed with 78 of these organs utilizing HTK. Seventy five patients received 78 organ transplants. Surgical procedures performed were: simultaneous kidney pancreas transplantation (n = 50, 64%), pancreas after kidney transplantation (n = 19, 24%), solitary pancreas transplantation (n = 9, 12%). Donor and recipient data were collected with primary outcomes as primary nonfunction and 30-day graft and patient survivals, and compared to the UW cohort from our original report. Donor and recipient demographics were similar. Mean follow-up time is 12 +/- 6 months. The mean cold ischemia time was 9 +/- 3 hours. There were no cases of primary graft nonfunction. Thirty-day and 1-year patient survivals were 99% and 93%. The 30-day and 1-year graft survivals were 96% and 93%. There were five grafts lost, including three within the first month (two venous and one arterial thrombosis). There was one case of chronic rejection and one noncompliance. All other patients were insulin-independent by discharge. Serum fasting blood glucose and serial amylase remained comparable at all intervals posttransplantation. Within this range of cold ischemia time, HTK appears to provide effective pancreas preservation.
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Affiliation(s)
- A Agarwal
- Department of Surgery, Indiana University School of Medicine, 550 N. University Boulevard #4258, Indianapolis, IN 46202, USA
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Agarwal A, Maglinte DDT, Goggins WC, Milgrom ML, Pescovitz MD, Fridell JA. Internal Hernia after Pancreas Transplantation with Enteric Drainage: An Unusual Cause of Small Bowel Obstruction. Transplantation 2005; 80:149-52. [PMID: 16003248 DOI: 10.1097/01.tp.0000162983.59042.e9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although complications involving leaking at the enteric anastomosis site, graft thrombosis, and intraabdominal abscess formation have been well documented after pancreas transplantation, the occurrence of small bowel obstruction in this setting has received scant attention. Although uncommon, intestinal obstruction after pancreas transplantation may have atypical etiologies. In this article, we will review three unusual cases of intestinal obstruction in pancreas transplant recipients. The value of computed tomographic (CT) enteroclysis in equivocal situations in the diagnosis of the obstruction is emphasized. METHODS In this study, we reviewed the posttransplant course of all pancreas transplants performed between July 1, 2002 and June 1, 2004. We specifically focused on all patients that required reexploration for suspected small bowel obstruction at any time after transplantation. RESULTS A total of 65 pancreas transplants were performed between July 1, 2002 and June 1, 2004. Pancreas graft survival was 97%, and patient survival was 98.5%. Five (7.7%) patients presented with mechanical small bowel obstruction, three of which were secondary to internal herniation of small intestine through a defect posterior to the pancreas allograft. All patients recovered well postsurgically. DISCUSSION Small bowel obstruction is an uncommon complication after pancreas transplantation. CT enteroclysis in the evaluation of small bowel obstruction may assist the patient care decision-making process by providing information on the location and severity of the obstruction in the clinical situation where conventional abdominal CT and radiography are equivocal. Prompt detection of small bowel obstruction with early surgical intervention can minimize complications and preserve allograft function.
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Affiliation(s)
- Avinash Agarwal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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