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Jiménez Lasanta J, Garcia Criado M, Garcia Roch C. Informe en los trasplantes renal y pancreático. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Techniques of pancreas graft salvage/indications for allograft pancreatectomy. Curr Opin Organ Transplant 2017; 21:405-11. [PMID: 27058314 DOI: 10.1097/mot.0000000000000318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite improvements in pancreas allograft outcome, graft complications remain a significant cause of morbidity and mortality. This review analyses the issues involved in the management of conditions that may require graft pancreatectomy, including the indications and techniques for graft salvage. RECENT FINDINGS With early recognition of graft complications, liberal use of radiological interventions, improved infection control, access to critical care and innovative surgical techniques, graft salvage is now feasible in many circumstances where graft pancreatectomy would previously have been necessary. SUMMARY The outcome of pancreas transplantation continues to improve with advances in the management of graft-threatening complications.
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Harbell JW, Morgan T, Feldstein VA, Roll GR, Posselt A, Kang SM, Feng S, Hirose R, Freise CE, Stock P. Splenic Vein Thrombosis Following Pancreas Transplantation: Identification of Factors That Support Conservative Management. Am J Transplant 2017; 17:2955-2962. [PMID: 28707821 DOI: 10.1111/ajt.14428] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 01/25/2023]
Abstract
Prophylaxis for graft portal/splenic venous thrombosis following pancreas transplant varies between institutions. Similarly, treatment of venous thrombosis ranges from early re-exploration to conservative management with anticoagulation. We wished to determine the prevalence of graft splenic vein (SV) thrombosis, as well as the clinical significance of non-occlusive thrombus observed on routine imaging. Records of 112 pancreas transplant recipients over a 5-year period at a single center were reviewed. Venous thrombosis was defined as absence of flow or presence of thrombus identified in any part of the graft SV on ultrasound. Thirty patients (27%) had some degree of thrombus or absence of flow in the SV on postoperative ultrasound. There were 5 graft losses in this group. Four were due to venous thrombosis, and occurred within 20 days of transplant. All patients with non-occlusive partial SV thrombus but normal arterial signal on Doppler ultrasound were successfully treated with IV heparin followed by warfarin for 3-6 months, and remained insulin independent. Findings of arterial signal abnormalities, such as absence or reversal of diastolic flow within the graft, require urgent operative intervention since this finding can be associated with more extensive thrombus that may lead to graft loss.
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Affiliation(s)
- J W Harbell
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - T Morgan
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - V A Feldstein
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - G R Roll
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - A Posselt
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - S-M Kang
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - S Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - R Hirose
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - C E Freise
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - P Stock
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
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Endovascular Management for the Treatment of Pancreas Transplant Venous Thrombosis: A Single-Center Experience. J Vasc Interv Radiol 2016; 27:882-8. [PMID: 27107981 DOI: 10.1016/j.jvir.2016.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/12/2016] [Accepted: 02/14/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To investigate the safety and efficacy of mechanical thrombectomy used as a tool for graft rescue in patients with pancreas graft venous thrombosis (PGVT). MATERIALS AND METHODS Graft venous thrombosis was discovered in 36 (33%) of 110 patients who underwent pancreas transplantation. Percutaneous aspiration thrombectomy was performed in seven patients (mean age, 31 y; range, 15-36 y) who had complete or severe thrombosis of the splenic vein or superior mesenteric vein seen on postoperative computed tomography. RESULTS Successful evacuation of PGVT was possible in six of seven patients; the thrombus was partially evacuated in one patient. In this patient, subsequent anticoagulation salvaged the graft, rendering primary and secondary technical success rates as 86% and 100%, respectively. As pancreas grafts were successfully functioning in all seven patients within 1 month after endovascular treatment, the clinical success rate was 100%. There were no procedure-related complications. At the last follow-up evaluation, all seven patients were alive with no graft loss (mean follow-up time, 9.4 mo; range, 3.6-22.2 mo). CONCLUSIONS Endovascular treatment may be considered in patients with severe PGVT to prevent early graft loss.
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Morgan TA, Smith-Bindman R, Harbell J, Kornak J, Stock PG, Feldstein VA. US Findings in Patients at Risk for Pancreas Transplant Failure. Radiology 2016; 280:281-9. [PMID: 26807892 DOI: 10.1148/radiol.2015150437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Purpose To determine if ultrasonographic (US) findings, including Doppler US findings, are associated with subsequent pancreas transplant failure. Materials and Methods A cohort of adult patients who underwent pancreas transplantation at a tertiary institution over the course of 10 years (from 2003 to 2012) was retrospectively evaluated for failure, which was defined as return to insulin therapy or surgical graft removal. The institutional review board provided a waiver of informed consent. All US images obtained within the 1st postoperative year were reviewed for three findings: arterial flow (presence or absence of intraparenchymal forward diastole flow), splenic vein thrombus, and edema. These findings were correlated with pancreas graft failure within 1-year after surgery by using Cox proportional hazards models and hazard ratios. Results A total of 228 transplants were included (mean patient age, 41.6 years; range, 19-57 years; 122 men, 106 women). Absent or reversed arterial diastolic flow was identified in nine of 20 failed transplants (sensitivity, 45%; 95% confidence interval [CI]: 23, 68) and in 15 of 208 transplants that survived (specificity, 93% [193 of 208]; 95% CI: 89, 96). The Cox proportional hazard ratio was 6.2 (95% CI: 3.1, 12.4). Splenic vein thrombus was identified in 10 of 20 failed transplants (sensitivity, 50%; 95% CI: 27, 73) and in 25 of 208 transplants that survived (specificity, 88% [183 of 208]; 95% CI: 83, 92). The Cox proportional hazard ratio was 4.2 (95% CI: 2.4, 7.4). Edema had the lowest specificity (Cox proportional hazard ratio, 2.0; 95% CI: 1.3, 2.9). In the multivariate analysis, only absent or reversed arterial diastolic flow remained significantly associated with transplant failure (adjusted hazard ratio, 3.6; 95% CI: 1.0, 12.8; P = .045). Conclusion Absent or reversed diastolic arterial Doppler flow has a stronger association with transplant failure than does splenic vein thrombus or edema. (©) RSNA, 2016.
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Affiliation(s)
- Tara A Morgan
- From the Department of Radiology and Biomedical Imaging (T.A.M., R.S., V.A.F.), Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies (R.S., J.K.), and Department of Surgery (J.H., P.G.S.), University of California-San Francisco, 505 Parnassus Ave, Room L374, San Francisco, CA 94143
| | - Rebecca Smith-Bindman
- From the Department of Radiology and Biomedical Imaging (T.A.M., R.S., V.A.F.), Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies (R.S., J.K.), and Department of Surgery (J.H., P.G.S.), University of California-San Francisco, 505 Parnassus Ave, Room L374, San Francisco, CA 94143
| | - Jack Harbell
- From the Department of Radiology and Biomedical Imaging (T.A.M., R.S., V.A.F.), Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies (R.S., J.K.), and Department of Surgery (J.H., P.G.S.), University of California-San Francisco, 505 Parnassus Ave, Room L374, San Francisco, CA 94143
| | - John Kornak
- From the Department of Radiology and Biomedical Imaging (T.A.M., R.S., V.A.F.), Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies (R.S., J.K.), and Department of Surgery (J.H., P.G.S.), University of California-San Francisco, 505 Parnassus Ave, Room L374, San Francisco, CA 94143
| | - Peter G Stock
- From the Department of Radiology and Biomedical Imaging (T.A.M., R.S., V.A.F.), Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies (R.S., J.K.), and Department of Surgery (J.H., P.G.S.), University of California-San Francisco, 505 Parnassus Ave, Room L374, San Francisco, CA 94143
| | - Vickie A Feldstein
- From the Department of Radiology and Biomedical Imaging (T.A.M., R.S., V.A.F.), Department of Epidemiology and Biostatistics and Philip R. Lee Institute for Health Policy Studies (R.S., J.K.), and Department of Surgery (J.H., P.G.S.), University of California-San Francisco, 505 Parnassus Ave, Room L374, San Francisco, CA 94143
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Tolat PP, Foley WD, Johnson C, Hohenwalter MD, Quiroz FA. Pancreas transplant imaging: how I do it. Radiology 2015; 275:14-27. [PMID: 25799333 DOI: 10.1148/radiol.15131585] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pancreas transplantation aims to restore physiologic normoglycemia in diabetic patients with glomerulopathy and avoid or delay the onset of diabetic retinopathy and arteriopathy. Simultaneous pancreas-kidney transplant is the most common approach, using a cadaveric pancreas donation in conjunction with either cadaveric or live donor renal transplant. Alternative techniques include pancreas after kidney transplant, in which the pancreas transplant is performed some years after renal transplant. Pancreas transplant alone is utilized rarely in diabetic patients with compensated renal function. Pancreas grafts have vascular and enteric connections that vary in their anatomic approach, and understanding of this is critical for imaging with ultrasonography, computed tomography, or magnetic resonance imaging. Imaging techniques are directed to display the pancreatic transplant arterial and venous vasculature, parenchyma, and intestinal drainage pathway. Critical vascular information includes venous thrombosis (partial or complete), arterial occlusion, or aneurysm. Parenchymal abnormalities are nonspecific and occur in pancreatitis, graft rejection, and subsequent graft ischemia. Peripancreatic fluid collections include hematoma/seroma, pseudocyst, and abscess. The latter two are related to pancreatitis, duct disruption, or leak from the duodenojejunostomy. An understanding of transplant anatomy and complications will lead to appropriate use of imaging techniques to diagnose or exclude important complications.
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Affiliation(s)
- Parag P Tolat
- From the Departments of Radiology (P.P.T., W.D.F., M.D.H., F.A.Q.) and Transplant Surgery (C.J.), Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
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Matsumoto I, Shinzeki M, Asari S, Goto T, Shirakawa S, Ajiki T, Fukumoto T, Ku Y. Functioning pancreas graft with thromboses of splenic and superior mesenteric arteries after simultaneous pancreas-kidney transplantation: a case report. Transplant Proc 2015; 46:989-91. [PMID: 24767399 DOI: 10.1016/j.transproceed.2013.09.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 09/20/2013] [Indexed: 12/14/2022]
Abstract
Graft thrombosis is the most common cause of early graft loss after pancreas transplantation. The grafted pancreas is difficult to salvage after complete thrombosis, especially arterial thrombosis, and graft pancreatectomy is required. We describe a patient presenting with a functioning pancreas graft with thromboses of the splenic artery (SA) and superior mesenteric artery (SMA) after simultaneous pancreas-kidney transplantation (SPK). A 37-year-old woman with a 20-year history of type 1 diabetes mellitus underwent SPK. The pancreaticoduodenal graft was implanted in the right iliac fossa with enteric drainage. A Carrel patch was anastomosed to the recipient's right common iliac artery, and the graft gastroduodenal artery was anastomosed to the common hepatic artery using an arterial I-graft. The donor portal vein was anastomosed to the recipient's inferior vena cava. Four days after surgery, graft thromboses were detected by Doppler ultrasound without increases in the serum amylase and blood glucose levels. Contrast enhanced computed tomography revealed thromboses in the SA, splenic vein and SMA. Selective angiography showed that blood flow was interrupted in the SA and SMA. However, pancreatic graft perfusion was maintained by the I-graft in the head of the pancreas and the transverse pancreatic artery in the body and tail of the pancreas. We performed percutaneous direct thrombolysis and adjuvant thrombolytic therapy. However, we had to stop the thrombolytic therapy because of gastrointestinal hemorrhage. Thereafter, the postoperative course was uneventful and the pancreas graft was functioning with a fasting blood glucose level of 75 mg/dL, HbA1c of 5.1%, and serum C-peptide level of 1.9 ng/mL at 30 months post-transplantation.
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Affiliation(s)
- I Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan.
| | - M Shinzeki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
| | - S Asari
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
| | - T Goto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
| | - S Shirakawa
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
| | - T Ajiki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
| | - T Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
| | - Y Ku
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Chuo-ku Kobe, Japan
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Siskind E, Maloney C, Ashburn S, Akerman M, Siskind T, Goldberg L, Bhaskaran M, Basu A, Molmenti E, Ortiz J. The use of venous jump grafts in pancreatic transplantation - no difference in patient or allograft outcomes - an update of the UNOS database. Clin Transplant 2014; 28:883-8. [PMID: 24930804 DOI: 10.1111/ctr.12397] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2014] [Indexed: 12/17/2022]
Abstract
Venous jump grafts are used in pancreas transplantation to salvage a pancreas with a short portal vein or to facilitate an easier anastomosis. There have been no large studies evaluating the safety of venous jump grafts in pancreas transplantation. We analyzed the UNOS database to determine whether venous jump grafts are associated with graft loss or patient death. Data from UNOS on all adult pancreas transplant recipients 1996-2012 were analyzed. Venous extension grafts were used in 2657 cases; they were not in 18 124. Kaplan-Meier/product-limit estimates analysis demonstrated similar patient survival (p < 0.641) and death-censored graft survival (p < 0.351) at one, three, five,10, and 15 yr between subjects with and without venous jump grafts. There was a statistically significant difference in one-yr unadjusted patient survival between the venous extension graft (94.9%) and the no-venous extension graft (95.8%) groups (p < 0.045) and a borderline difference in one-yr graft survival between the venous extension graft (84.1%) and the no-venous extension graft (82.6%) groups (p < 0.055). There was no significant difference in patient survival or allograft survival at the three-, five-, 10-, and 15-yr intervals. The use of venous jump grafts is not associated with increased graft loss or mortality.
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Affiliation(s)
- Eric Siskind
- Department of Transplantation, North Shore Long Island Jewish Health System, Hofstra University School of Medicine, Manhasset, NY, USA
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de Kort H, Mallat MJK, van Kooten C, de Heer E, Brand-Schaaf SH, van der Wal AM, Roufosse C, Roelen DL, Bruijn JA, Claas FH, de Fijter JW, Bajema IM. Diagnosis of early pancreas graft failure via antibody-mediated rejection: single-center experience with 256 pancreas transplantations. Am J Transplant 2014; 14:936-42. [PMID: 24712331 DOI: 10.1111/ajt.12624] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 11/19/2013] [Accepted: 12/10/2013] [Indexed: 01/25/2023]
Abstract
Early pancreas graft loss is usually attributed to technical failure while the possibility of antibody-mediated rejection (AMR) is generally overlooked. To investigate the role of AMR in early pancreas graft loss, we retrospectively assessed 256 patients with simultaneous pancreas-kidney transplantation (SPK) between 1985 and 2010 at our institute. We included 33 SPK patients who lost their pancreas graft <1 year after transplantation. AMR was diagnosed based on donor-specific antibodies, C4d and histology in 7 cases, 8 cases were suspicious for AMR and 18 pancreas graft losses were not due to AMR. Acute AMR occurred >1 month after transplantation in 6/7 cases, whereas all other causes typically led to loss <1 month after transplantation. Thrombotic lesions occurred equally among the 33 cases. In 12/18 concurrent kidney specimens, the diagnostic results paralleled those of the pancreas graft. All patients with acute AMR of the pancreas graft lost their renal grafts <1 year after transplantation. In the setting of a thrombotic event, histopathological analysis of early pancreas graft loss is advisable to rule out the possibility of AMR, particularly because a diagnosis of acute AMR has important consequences for renal graft outcomes.
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Affiliation(s)
- H de Kort
- Department of Pathology, Leiden University Medical Centre, Leiden, the Netherlands
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Current world literature. Curr Opin Organ Transplant 2013; 18:111-30. [PMID: 23299306 DOI: 10.1097/mot.0b013e32835daf68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Preservation of Pancreas Graft Function After Complete Venous Thrombosis. Transplantation 2012. [DOI: 10.1097/01.tp.0000414816.80959.6f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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