Pancreas graft drainage in recipient duodenum: preliminary experience

[Surgical aspects of pancreas transplantation: exocrine drainage. Part 3]

Exocrine drainage is an Achilles heel of pancreas transplantation. The author analyzed the outcomes of pancreas transplantations with different types of exocrine drainage in various centers (n=93). The article will ensure insight into evolution of techniques of exocrine drainage within the historical context and current state of this issue.

Feasibility of Laparoscopic Combined Para-Orthotopic Pancreas and Orthotopic Kidney Transplantation: Initial Research with a Pig Model

BACKGROUND The aim of this study was to investigate the feasibility of laparoscopic combined para-orthotopic pancreas and orthotopic kidney transplantation in a pig model. MATERIAL AND METHODS Twelve white female pigs, (4-5 months old, weight range 40-45 kg) were used as donors and recipients, and 6 laparoscopic-combined pancreas and kidney transplantations were performed. After bilateral nephrectomy, the pancreatic artery and vein were anastomosed to the right renal artery and vein, respectively, and the pancreatic fluid was diverted to the duodenum or jejunum. The renal artery and vein were anastomosed to the left renal artery and vein, respectively. The ureter (or kidney pelvis) was anastomosed to the left native ureter (or kidney pelvis). The data of the operations were recorded, and grafts were inspected at autopsy. RESULTS Four of the 6 recipient pigs underwent the entire procedure. The duodenum-to-duodenum anastomosis was unfinished in 1 case, and both the duodenum-to-duodenum and renal pelvis-to-pelvis anastomoses were left unperformed in another case. The mean recipient operative time was 429±43 minutes. The mean venous and arterial anastomotic times were 69±15 minutes and 37±18 minutes, respectively, for pancreas transplantation and 56±09 minutes and 42±06 minutes, respectively, for kidney transplantation. The time for renal pelvis-to-pelvis anastomosis was 56±13 minutes and for duodenum-to-duodenum anastomosis was 90±13 minutes. The mean blood loss for recipient pigs was 98±35 mL. An immediate viable blood supply was seen in the 4 pancreatic grafts and in the 5 kidney grafts during the operation by the appearance of a bright red color after revascularization. Five pancreatic grafts had autopsy-proven reliable artery anastomoses and 4 reliable vein anastomoses. All 6 kidney grafts had autopsy-proven reliable artery anastomoses; however, 1 had a vein anastomotic stricture. CONCLUSIONS Our study showed that laparoscopic-combined para-orthotopic pancreas and orthotopic kidney transplantation in pigs is surgically possible.

Protocol Duodenal Graft Biopsies Aid Pancreas Graft Surveillance

BACKGROUND

Histological evaluation of the pancreas graft is usually done on demand resulting in significant delays. This analysis reports on endoscopic protocol duodenal graft biopsies at regular intervals to determine feasibility, safety, and monitoring benefits.

METHODS

Protocol duodenal graft biopsies in 27 consecutive pancreas transplants (10 simultaneous pancreas kidney [SPK], 17 pancreas after kidney [PAK]) with a follow-up of a minimum of 12 months were performed at days 14, 30, 90, 180, 360, 430. University of Pittsburgh Medical Center classification for intestinal rejection was used. C4d staining was performed when antibody-mediated rejection was suspected.

RESULTS

Overall patient and pancreas graft survival was 100% and 93% at a mean follow-up of 2.8 years. One hundred sixty-seven endoscopic biopsy procedures were performed in 27 grafts without any complication. Biopsies revealed rejection in 3 (30%) SPK recipients and in 15 (82%) of PAK recipients as early as 14 days posttransplant. Two patients underwent PAK retransplantation diagnosed with acute rejection at day 180. All except 1 recipient being treated for rejection, showed histological improvement following antirejection treatment. Following transient treatment success, a total of 3 pancreas grafts were lost for immunological reason. One loss was immediate despite antirejection treatment, 1 secondary to nonresolving rejection at 7 months and the third due to recurrent rejection 15 months posttransplantation. Additionally, biopsies detected vascular (venous thrombosis) and overimmunosuppression (cytomegalovirus infection) complications.

CONCLUSIONS

Protocol graft duodenal biopsies detect complications after whole-organ pancreas transplantation, are useful in guiding therapy, and carry potential for improving outcome.

Outcomes in Pancreas Transplantation With Exocrine Drainage Through a Duodenoduodenostomy Versus Duodenojejunostomy

Until recently, pancreas transplantation has mostly been performed with exocrine drainage via duodenojejunostomy (DJ). Since 2012, DJ was substituted with duodenoduodenostomy (DD) in our hospital, allowing endoscopic access for biopsies. This study assessed safety profiles with DD versus DJ procedures and clinical outcomes with the DD technique in pancreas transplantation. DD patients (n = 117; 62 simultaneous pancreas-kidney [SPK_DD ] and 55 pancreas transplantation alone [PTA_DD ] with median follow-up 2.2 years) were compared with DJ patients (n = 179; 167 SPK_DJ and 12 PTA_DJ ) transplanted in the period 1998-2012 (pre-DD era). Postoperative bleeding and pancreas graft vein thrombosis requiring relaparotomy occurred in 17% and 9% of DD patients versus 10% (p = 0.077) and 6% (p = 0.21) in DJ patients, respectively. Pancreas graft rejection rates were still higher in PTA_DD patients versus SPK_DD patients (p = 0.003). Hazard ratio (HR) for graft loss was 2.25 (95% CI 1.00, 5.05; p = 0.049) in PTA_DD versus SPK_DD recipients. In conclusion, compared with the DJ procedure, the DD procedure did not reduce postoperative surgical complications requiring relaparatomy or improve clinical outcomes after pancreas transplantation despite serial pancreatic biopsies for rejection surveillance. It remains to be seen whether better rejection monitoring in DD patients translates into improved long-term pancreas graft survival.

Pancreas transplantation: Advantages of a retroperitoneal graft position

INTRODUCTION

In the 50 years since the first pancreas transplant performed at the University of Minnesota, the surgical techniques employed have undergone many modifications. Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the «native» pancreas. We herein present our experience of a modified technique for pancreatic transplant, with the organ placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodeno-duodenostomy.

METHODS

All pancreas transplantations performed between May 2016 and January 2017 were prospectively entered into our transplant database and retrospectively analyzed.

RESULTS

A total of 10 transplants were performed using the retroperitoneal technique (6 men: median age of 41 years [IQR 36-54]). Median cold ischemia times was 10,30h [IQR 5,30-12,10]. The preservation solution used was Celsior (n=7), IGL-1 (n=2), and UW (n=1). No complications related to the new surgical technique were identified. In one patient, transplantectomy at 12h was performed due to graft thrombosis, probably related to ischemic conditions from a donor with prolonged cardio-respiratory arrest. Another procedure was aborted without completing the graft implant due to an intraoperative immediate arterial thrombosis in a patient with severe iliac atheromatosis. No primary pancreas non-function occurred in the remaining 8patients. The median hospital stay was 13,50 days [IQR 10-27].

CONCLUSIONS

Retroperitoneal graft placement appears feasible with easy access for dissection the vascular site; comfortable technical vascular reconstruction; and a decreased risk of intestinal obstruction by separation of the small bowel from the pancreas graft.

125 Cases of duodenoduodenostomy in pancreas transplantation: a single-centre experience of an alternative enteric drainage

Several exocrine drainage procedures have been successfully developed to perform pancreas transplantation (PT). Retroperitoneal graft placement allows exocrine drainage via direct duodenoduodenostomy (DD). This technique provides easy access for endoscopic surveillance and biopsy. A total of 241 PT procedures were performed in our centre between 2002 and 2012. DD was performed in 125 patients, and duodenojejunostomy (DJ) in 116 patients. We retrospectively compared our experience with these two types of enteric drainage, focusing on graft and patient survivals, as well as postoperative complications. With a mean follow-up of 59 months, both groups demonstrated comparable patient and graft survivals. 14 (11%) of 125 cases in the DD group and 21 (18%) of 116 cases in the DJ group had pancreatic graft loss (P = 0.142). Graft thrombosis [5 (4%) vs. 18 (16%) P = 0.002], anastomotic insufficiency [2 (1.6%) vs. 8 (7%) P = 0.052] and relaparotomy [52 (41%) vs. 56 (48%) P = 0.29] occurred more frequently in the DJ group, whereas gastrointestinal bleeding [14 (11%) vs. 4 (3%) P = 0.026] occurred more often in the DD group. DD is a feasible and safe technique in PT, with no increase in enteric complications. It is equivalent to other established techniques and extends the feasibility of anastomotic sites, especially in recipients who have undergone a second transplantation.

Experience with 53 portal-duodenal drained solitary pancreas transplants

Systemic-enteric drainage is currently the most common technique for pancreas transplantation (PT). A novel alternative technique, portal-duodenal drainage (PDD), has potential physiological benefits and provides improved monitoring of the pancreatic graft. The current study describes 53 solitary PT procedures (43 pancreas after kidney and 10 pancreas transplant alone) using the PDD technique over the last three yr. This method resulted in one-yr patient survival at 96% and 83% graft survival. There were five cases (9.4%) of thrombosis, in which transplantectomy and two-layer closure of the native duodenum were performed. No fistulas were observed. Here, we demonstrate that the PDD technique in PT was as safe and effective as current techniques in clinical use.

Pancreas transplantation with portal venous drainage with an emphasis on technical aspects

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.

Transplantation of the pancreas

Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.

Duodenum-stomach anastomosis: a new technique for exocrine drainage in pancreas transplantation

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.

Duodenoduodenostomy in pancreas transplantation

Enteric drainage (ED) using duodenojejunostomy (DJ) is an established technique in pancreatic transplantation. Duodenoduodenostomy (DD), an alternative ED technique, may provide unique advantages over DJ. We compared our experience with these two types of ED through a retrospective review of all pancreas transplants performed at our institution from November 2007 to November 2009. The allograft duodenum was anastomosed to the recipient jejunum or duodenum. Duodenal drainage was performed by a stapled or hand-sewn technique. Patient demographics, operative times, major post-operative complications, and graft survival data were analyzed. Of 57 pancreas transplants, DJ was performed in 36 patients, stapled DD in 14 patients, and hand-sewn DD in seven patients. Two DD grafts (9.5%) thrombosed compared with no DJ grafts (p = NS). Enteric leak and small-bowel obstruction occurred in 3 of 36 DJ patients and in two DD patients (p = NS). Gastrointestinal bleeding occurred more frequently in stapled DD compared with DJ (4 vs. 0, p < 0.015). In conclusion, DD is technically feasible with no increase in operative time or enteric complications. GI bleeding rates appear to be higher following DD (stapled) technique. Potential complications of DD should be balanced against the benefits conferred by this technique.

Surgical techniques for pancreas transplantation

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.

A retrospective monocenter review of simultaneous pancreas-kidney transplantation

OBJECTIVE

Herein we have reviewed a consecutive series of simultaneous pancreas-kidney (SPK) transplantations performed at our institution over a 6-year period.

PATIENTS AND METHODS

The study population included 22 patients (15 males and 7 females) who underwent SPK transplantation between 2001 and 2007. The mean recipient age was 47 years (range, 26-63 years). Eighteen patients suffered type 1 and 4 type 2 diabetes mellitus. The mean donor age was 33 years (range, 14-56 years). The mean HLA match was 2.1 (range, 1-5). Immunosuppressive treatment consisted of basiliximab induction followed by tacrolimus, mycophenolate mofetil, and prednisone.

RESULTS

The mean hospital stay was 20 days (range, 11-52 days). After a mean follow-up of 44 months (range, 17-88 months), patient, kidney, and pancreas graft survivals were 86%, 82%, and 73%, respectively. Two patients died in the immediate postoperative period due to, respectively, disseminated intravascular coagulation and pulmonary embolism. A kidney graft was lost due to early hyperacute rejection. Other early complications associated with the pancreas graft included 2 cases of immediate reperfusion defects that led to early vascular thrombosis in 1 patient and a duodenal graft fistula in the other patient; a third patient developed type 2 diabetes mellitus. Beyond the postoperative period, graft loss was limited to 1 case of noncompliance to the immunosuppressive medications and 1 death secondary to pulmonary infection with a functional allograft after 4 years.

CONCLUSIONS

SPK transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus and renal failure due to diabetic nephropathy. The main complications of SPK transplantation occur in the immediate postoperative period consequent to vascular or rejection processes.

[Pancreas and islet transplantation]

Pancreas transplantation is a successful and effective procedure resulting in tight glucose control. Due to the postoperative morbidity and the need for immunosuppression pancreas transplantation should be considered in patients with type I diabetes at the time of kidney transplantation. Besides this pancreas transplantation alone can be taken into consideration for patients with very poor metabolic control and quality of life despite optimal medical treatment. Recently, islet transplantation became a less invasive alternative to pancreas transplantation. Due to the lack of long-term follow-up and due to the need of multiple donor grafts for one recipient, islet transplantation should be performed under experimental settings in experienced centers. New developments in protecting transplanted islets and in the induction of donor-specific tolerance could increase the indication to perform the procedure. Therefore alternative sources of beta-cells have to be identified.