Allograft Pancreatectomy: Indications and Outcomes

Medical and Surgical Management of the Failed Pancreas Transplant

Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.

Vascular Complications After Simultaneous Pancreas and Kidney Transplantation: A Case Report

A 51-year-old patient with type I diabetes and end-stage renal disease was qualified for a simultaneous kidney and pancreas transplant. The procedure was performed in a typical manner: arterial anastomosis to the right common iliac artery, the graft's portal vein with inferior vena cava, and side-to-side duodenal intestinal anastomosis. The kidney was implanted retroperitoneally. Six months after the transplant, the patient reported pain in the right lower abdomen, and imaging examinations revealed arterial anastomosis. Reconstruction of the right common iliac artery was performed with a Gore-Tex prosthesis and the pancreatic artery reanastomosed to the right external iliac artery. After the surgery, the function of the transplanted pancreas deteriorated, the level of C-peptide was decreased, and the patient required low doses of insulin. After another 8 months, the imaging studies revealed an aneurysm located in the bifurcation of the aorta up to the anastomosis of the pancreatic graft artery with the iliac artery. The patient was qualified for the implantation of an endovascular of 2 prosthesis, which improved the graft's function. After another 2 months, the presence of an aneurysm at the endovascular prosthesis was found again. The patient was requalified for endovascular prosthesis implantation. Currently, there is no aneurysm but the function of the pancreas graft is impaired, though the kidney graft function is good. Patients after simultaneous kidney and pancreas transplant are a group of patients with an increased risk of vascular complications. Treatment should take place in a multidisciplinary center.

The course of Covid-19 infection in patients after pancreas and kidney transplantation – a single - centre observation

Solid graft recipients are at an increased risk of serious complications and death. Out of 130 outpatient recipients of pancreas grafts at our Clinic, 20 patients (15.73%) had a confirmed severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2). Each patient had a different course of the disease, and the forms of infection varied from mild to severe and lethal. According to recommendations, after confirmation of the infection, mycophenolate mofetil was withdrawn and the immunosuppression was based on steroids and a calcineurin inhibitor. In this study, we performed an analysis of the course of COVID-19 infection in patients after pancreatic transplantation. Twenty pancreas recipients were confirmed to have COVID-19 infections; 4 of whom required hospitalization owing to severe complications. Patients reported weakness, excessive intensity of fatigue, shortness of breath with exertion, cough, and periodically increased temperature. Weakness and fatigue persisted in these patients for about 6 weeks. In 2 patients there was a need for oxygen supplementation and empirical antibiotic. Mortality was 5%, and there was 1 graftectomy. Deterioration of either kidney or pancreas graft were not observed in any other patients.

The course of SARS-CoV-2 infection in solid graft recipients is similar to that of the rest of the population. Because of immunosuppression, recipients were accustomed to avoiding crowds and complying with obligations to wear masks.

Challenges Associated with Pancreas and Kidney Retransplantation-A Retrospective Analysis

Simultaneous pancreas and kidney transplantation (SPK) is an accepted treatment for diabetic patients with renal failure, and is associated with increased survival and quality of life for recipients. There are only a few publications on the outcomes of simultaneous pancreas–kidney retransplantation (Re-SPK) after previous SPK and the loss of function of both grafts. A total of 55 patients with type 1 diabetes mellitus underwent pancreas retransplantation at our center between January 1994 and March 2021. Twenty-four of these patients underwent Re-SPK after a previous SPK. All 24 operations were technically feasible. Patient survival rate after 3 months, 1 year, and 5 years was 79.2%, 75%, and 66.7%, respectively. The causes of death were septic arterial hemorrhage (n = 3), septic multiorgan failure (n = 2), and was unknown in one patient. Pancreas and kidney graft function after 3 months, 1 year, and 5 years were 70.8% and 66.7%, 66.7% and 62.5%, and 45.8% and 54.2%, respectively. Relaparotomy was performed in 13 out of 24 (54.2%) patients. The results of our study show that Re-SPK, after previously performed SPK, is a technical and immunological challenge, associated with a significantly increased mortality and complication rate; therefore, the indication for Re-SPK should be very strict. Careful preoperative diagnosis is indispensable.

Vascular applications of ferumoxytol-enhanced magnetic resonance imaging of the abdomen and pelvis

Ferumoxytol is an injectable ultrasmall superparamagnetic iron oxide that has been gaining interest regarding its off-label use as an intravenous contrast agent in magnetic resonance imaging (MRI). Due to its large particle size, its use with MRI produces exquisite images of blood vessels with little background contamination or parenchymal enhancement of the abdominopelvic organs, except for the liver and spleen. Because ferumoxytol is neither an iodinated nor a gadolinium-based contrast agent, there are no restrictions for its use in patients with poor renal function. This article will highlight normal features in ferumoxytol-enhanced MRI in the abdomen and pelvis as well as its applications in evaluating vascular pathology, presurgical planning, and other problem solving.

Distal allograft pancreatectomy for graft salvage after pancreas transplantation

Early pancreas allograft failure most commonly results from vascular thrombosis. Immediate surgical intervention may permit pancreas allograft salvage, typically requiring thrombectomy. In cases of partial allograft necrosis secondary to splenic arterial thrombosis, distal allograft pancreatectomy may allow salvage of at least half of the pancreas allograft with retention of function. We retrospectively reviewed four cases of simultaneous pancreas and kidney recipients who required distal allograft pancreatectomy for splenic artery thrombosis with necrosis of the distal pancreas. Three of the four maintained long-term allograft function with euglycemia independent of insulin at six months to six years of follow-up, and all patients continue to maintain normal renal allograft function. Early diagnosis and early intervention are essential in order to salvage the pancreas allograft in the case of thrombosis. Distal allograft pancreatectomy can be performed safely and result in excellent long-term outcomes in select patients.

Late complications of pancreas transplant

To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3^rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.

Early protocol computer tomography and endovascular interventions in pancreas transplantation

BACKGROUND

Early vascular complications following pancreatic transplantation are not uncommon (3%-8%). Typically, cross-sectional imaging is requested in response to clinical change. We instituted a change in protocol to request imaging pre-emptively to identify patients with thrombotic complications.

METHODS

In 2013, protocol computer tomography angiography (CTA) at days 3-5 and day 10 following pancreas transplantation was introduced. A retrospective analysis of all pancreas transplants performed at our institution from January 2001 to May 2019 was undertaken.

RESULTS

A total of 115 patients received pancreas transplants during this time period. A total of 78 received pancreas transplant without routine CTA and 37 patients with the new protocol. Following the change in protocol, we detected a high number of subclinical thromboses (41.7%). There was a significant decrease in invasive intervention for thrombosis (78.6% before vs 30.8% after, p = .02), and graft survival was significantly higher (61.5% before vs 86.1% after, p = .04). There was also a significant reduction in the number of graft failures (all-cause) where thrombosis was present (23.4% before vs 5.6% after, p = .02). Patient survival was unaffected (p = .48).

CONCLUSIONS

Implementation of early protocol CTA identifies a large number of patients with subclinical graft thromboses that are more amenable to conservative management and significantly reduces the requirement for invasive intervention.

Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.

Endovascular Interventions in Vascular Complications After Simultaneous Pancreas and Kidney Transplantations: A Single-Center Experience

Background

Vascular failures are serious complications in pancreas transplantation. Open surgery is a reliable and quick intervention method, but it carries a risk of infection and bleeding. Endovascular procedures are rare among patients after a SPK, but are becoming more frequently used. One of the main risks of the endovascular approach is that the renal function impairment caused by contrast agent.

Material/Methods

We performed a retrospective analysis of 200 transplanted pancreases at our center over the last 14 years. The analyses included those patients after pancreas transplantation who required the most challenging vascular interventions and ones that were non-standard for the procedure.

Results

Severe vascular conditions requiring endovascular intervention were observed in 3% of SPKs. In one retransplanted patient, there was an acute ischemia of the lower extremity due to the narrowing of the common iliac artery following a previous transplantectomy, above the new pancreas graft anastomoses. In another patient, local inflammation led to the disruption of the external iliac artery on the level of transplantectomy, caused severe bleeding, and we had to implement a stent-graft to reconstruct the iliac artery wall. A third patient had a pseudoaneurysm demanding further treatment with a stent-graft implemented into the femoral artery due to a pseudoaneurysm of the right external iliac artery.

Conclusions

Intravenous interventions in patients with a transplanted or retransplanted pancreas are safe and feasible. It is a technically demanding procedure, but the risk of kidney graft function deterioration, as well as of bleeding due to the high dose of heparin used, is lower than with open vascular surgery.

Case Report: Primary De Novo Sarcoma In Transplant Pancreas Allograft

BACKGROUND

The majority of malignancies after transplantation appear to be virally mediated and of recipient origin. Donor-derived neoplasms occur early, whereas recipient-origin tumors typically occur many years after transplantation. Sarcomas are a relatively rare form of cancer. The etiology of sarcomas remains largely unknown, although some are linked to viruses, familial cancer syndromes, or therapeutic radiation exposure. Primary sarcomas are extremely rare, accounting for <0.1% of all native pancreatic malignancies. The involvement of the allograft itself in the tumor is rare.

CASE REPORT

A 53-year-old white woman (body mass index, 20.1 kg/m²) with a history of type 1 diabetes, chronic kidney disease, coronary artery disease, dyslipidemia, and pancreas-alone transplantation in 2007 was admitted with small bowel obstruction secondary to a mass in the head of the pancreas allograft, for which a laparotomy with allograft pancreatectomy was required. Histopathologic exam revealed a stage III high-grade unclassified spindle cell sarcoma positive for polyomavirus. After surgery, the patient was managed with close monitoring for disease recurrence. Her most recent scan was negative for recurrence at postoperative day 489.

CONCLUSIONS

We report a previously unreported phenomenon of a soft tissue sarcoma arising in a pancreas allograft, likely of recipient origin and polyomavirus related. Standard treatment for sarcoma is wide excision of the tumor and close monitoring for recurrence. Systemic chemotherapy or radiotherapy is usually limited to advanced cases. Sarcomas may occur in a pancreas allograft. Allograft pancreatectomy and monitoring for recurrence is vital for a good outcome.

Duodenal graft complications requiring duodenectomy after pancreas and pancreas-kidney transplantation

Duodenal graft complications are poorly reported complications of pancreas transplantation that can result in graft loss. Excluding patients with early graft failure, after a median follow-up period of 126 months (range 23-198) duodenectomy was required in 14 of 312 pancreas transplants (4.5%). All patients were insulin-independent at the time of diagnosis. Reasons for duodenectomy included delayed duodenal graft perforation (n = 10, 71.5%) and refractory duodenal graft bleeding (n = 4, 28.5%). In patients with duodenal graft bleeding, a total duodenectomy was performed. In patients with duodenal graft perforation, preservation of a duodenal segment was possible in five patients but completion duodenectomy was necessary in one patient. After total duodenectomy, immediate enteric duct drainage was feasible in seven patients. In two patients, a pancreaticocutaneous fistula was created that was subsequently converted to enteric drainage in one patient. In the other patient, enteric fistulization occurred as a consequence of silent pressure perforation of the draining catheter on the ascending colon. After a mean follow-up period of 52 months (21-125), all patients were alive, well, and insulin-independent. An aggressive and timely surgical approach may permit graft rescue in patients with severe duodenal graft complications occurring after pancreas transplantation. Generalization of these results remains to be established.

Pancreatic allograft thrombosis: Suggestion for a CT grading system and management algorithm

Pancreatic allograft thrombosis (PAT) remains the leading cause of nonimmunologic graft failure. Here, we propose a new computed tomography (CT) grading system of PAT to identify risk factors for allograft loss and outline a management algorithm by retrospective review of consecutive pancreatic transplantations between 2009 and 2014. Triple-phase CT scans were graded independently by 2 radiologists as grade 0, no thrombosis; grade 1, peripheral thrombosis; grade 2, intermediate non-occlusive thrombosis; and grade 3, central occlusive thrombosis. Twenty-four (23.3%) of 103 recipients were diagnosed with PAT (including grade 1). Three (2.9%) grafts were lost due to portal vein thrombosis. On multivariate analysis, pancreas after simultaneous pancreas-kidney transplantation/solitary pancreatic transplantation, acute rejection, and CT findings of peripancreatic edema and/or inflammatory change were significant risk factors for PAT. Retrospective review of CT scans revealed more grade 1 and 2 thromboses than were initially reported. There was no significant difference in graft or patient survival, postoperative stay, or morbidity of recipients with grade 1 or 2 thrombosis who were or were not anticoagulated. Our data suggest that therapeutic anticoagulation is not necessary for grade 1 and 2 arterial and grade 1 venous thrombosis. The proposed grading system can assist clinicians in decision-making and provide standardized reporting for future studies.

Techniques of pancreas graft salvage/indications for allograft pancreatectomy

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.

Incidence and Indications for Late Allograft Pancreatectomy While on Continued Immunosuppression

BACKGROUND

There are limited data about the incidence and indications for late allograft pancreatectomy while on continued immunosuppression for functional kidney allografts.

METHODS

We analyzed recipients of simultaneous pancreas and kidney and pancreas after kidney transplants between January 1994 and July 2013. Patients with functional kidney but failed pancreas allografts after 90 days were included.

RESULTS

Out of 1022 simultaneous pancreas and kidney or pancreas after kidney recipients, 246 satisfied these criteria. Of these, 50 underwent allograft pancreatectomy (Px) and 196 did not (no-Px). Eleven of these pancreatectomies were performed at the time of repeat transplant and were analyzed separately. None of the basic recipient or donor characteristics differed significantly between the Px (n = 39) and no-Px groups, except for a higher proportion of females in the Px group. The most common presentation in the Px group was abdominal pain. Histopathology of the pancreas varied widely with graft thrombosis as the most common finding. In univariate and multivariate Cox regression analyses, only female recipient was associated with higher risk for allograft pancreatectomy. Px was not associated with kidney allograft survival (P = 0.16).

CONCLUSIONS

Despite the ongoing presence of full immunosuppression for a functioning kidney allograft, the need for Px for symptoms and radiological findings is not rare (39/246, 15.8%).

Arterial Pseudoaneurysm Associated with Pancreas and Kidney Transplantation: A Case Report

Patient: Male, 49

Final Diagnosis: Arterial pseudoaneurysm

Symptoms: Abdominal pain • fever and a pulsatile tumor located in the right iliac fossa

Medication: —

Clinical Procedure: Endovascular and surgical approach

Specialty: Transplantology

Surgical Complications Not Related to the Renal and Pancreatic Grafts After Simultaneous Kidney and Pancreas Transplantation

BACKGROUND

Simultaneous pancreas and kidney transplantation (SPKTx) is the most commonly performed multiorgan transplantation procedure worldwide. Transplanted organs are the main source of complication; however, some postoperative complications are not directly related to the pancreatic or renal grafts. The goal of this study was to evaluate the prevalence, type, and severity of postoperative complications not related to transplanted kidney or pancreas among SPKTx recipients.

METHODS

Complications unrelated to transplanted pancreas and kidneys among 112 SPKTx recipients were analyzed. The cumulative freedom from general surgical complications was assessed, and it was compared with cumulative freedom from complications related to kidney and pancreatic grafts. Severity of complications was classified according to a modified Clavien-Dindo scale.

RESULTS

The general surgery complication rate was 22.2%. Cumulative freedom from general surgical complications at days 60 and 90 after transplantation was 0.89 and 0.87, respectively. Cumulative freedom from general surgical complications was comparable with cumulative freedom from complications related to kidney grafts but significantly higher than cumulative freedom from complications related to pancreatic grafts (log-rank test, P < .001). The rates for grades of severity II, IIIa, IIIb, and IVb were 19.4%, 9.7%, 64.5%, and 6.4%, respectively. The most frequent cause of complications was intra-abdominal hematoma or abscess (25.8%).

CONCLUSIONS

The general surgical complication rate was comparable to the rate of complications originating from the renal grafts but significantly lower than the complication rate related to the transplanted pancreas. The incidence of general surgical complications could be defined as moderate, and the severity of this type of complication was low.

Usefulness of Modified Dindo-Clavien Scale to Evaluate the Correlation Between the Severity of Surgical Complications and Complications Related to the Renal and Pancreatic Grafts After Simultaneous Kidney and Pancreas Transplantation

OBJECTIVE

Simultaneous pancreas and kidney transplantation (spktx) is the multiorgan transplantation. Thus various complications originated from transplanted organs and the complications that are not directly related to pancreatic or renal grafts could be developed at the same recipient.

AIM

The aim of this study is to explore whether there is a correlation between the severity of complications originated from transplanted pancreas, transplanted kidney and general surgical complication developed at the same spktx recipient.

METHODS

Complications which developed among 112 spktx recipients were divided into three groups: related to the pancreatic graft (PTXc), to the renal graft (KTXc) and the general surgical complication (GNc). Severity of postoperative complications using modified Dindo-Clavien scale recipients was evaluated for each group. The correlation of severity of coexisting complications from different complication groups was analyzed.

RESULTS

There were 22 recipients who developed the coexistence of complication between different complication groups. Complication originated from two and three complication groups developed 15 (68.2%) and 7 (31.8%) patients, respectively. There was not found correlation of the complication severity between: KTXc and GNc group, GNc and PTXc group, KTXc and PTXc group. The correlation (r = 0.84) of complication severity in recipients who developed concurrently complication from transplanted kidney, transplanted pancreas and general surgery complication was found.

CONCLUSION

The modified Dindo-Clavien scale is an useful methodology for the correlation description of complication severity in complex multiorgan transplantation such is spktx, especially when the complications originated from different, potentially independent from the pathophysiological point of view, sources.