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A randomized trial in simultaneous pancreas–kidney transplantation: portal versus systemic venous drainage of the pancreas allograft
A Randomized Trial in Simultaneous Pancreas–Kidney Transplantation: Portal Versus Systemic Venous Drainage of the Pancreas Allograft P. Petruzzo, P.G. Konan, L.C. Feitosa, M. Da Silva, D. Touiti, N. Lefranc¸ois, J.M. Dubernard, and X. Martin
A
LTHOUGH combined pancreas– kidney transplantation is currently accepted as a valid therapeutic option for patients with insulin-dependent diabetes mellitus and end-stage diabetic nephropathy, the ideal surgical technique associated with less morbidity remains uncertain. Several procedures have been proposed such as systemic venous and bladder drainage of the exocrine secretions,1 of the pancreas allograft, and, more recently, portal venous and enteric drainage of the exocrine secretions.2,3 The portal drainage of the graft might result in more physiologic insulin delivery and a better carbohydrate and lipid metabolism.4 This report compares a series of uremic diabetic patients who received combined kidney–pancreas allografts with the portal technique and a similar group of patients who underwent transplantation with the systemic venous technique. MATERIALS AND METHODS Forty consecutive simultaneous pancreas– kidney (SPK) transplants were performed. They were randomly assigned to two groups: the first group (SV group) included 19 patients (12 males, 7 females) who received pancreas allograft with systemic drainage of the organ, and the second group (PV group) included 21 patients (11 males, 10 females) who received pancreas allograft with portal drainage. In both groups enteric drainage of the exocrine secretion was performed. A similar immunosuppressive protocol has been performed in all patients.
RESULTS
In the SV group, patient survival was 89.4% at 1 year and 84.21% at 2 and 3 years, and in the PV group patient survival was 90.4% at 1, 2, and 3 years. Pancreas graft survival was defined as freedom from exogenous insulin. Early loss of pancreatic graft due to venous thrombosis occurred in one patient of each group. In the SV group, one pancreas was lost owing to iliac artery thrombosis and one to peripancreatic abscess. In the SV group, one patient presented with colon cancer, which was treated by chemotherapy; at 18 months’ post-Tx he developed a fistula between an infectious iliac artery pseudo-aneurysm and the colon, with graft loss. No kidney loss occurred in the SV group. In the PV group one kidney allograft and one pancreas allograft were lost because of rejection. Excluding
graft lost, at each time point kidney and pancreas functions were similar in both groups. No significant differences were observed concerning fasting insulin, C-peptide, cholesterol and triglyceride levels, all of which were not higher when compared with normal subjects. Several complications such as bowel leaks and occlusions were reported in both groups, and they could be directly attributed to the intestinal drainage of the exocrine secretions. One venous thrombosis occurred in both groups, and the pancreas allografts had to be removed. In the SV group a peripancreatic abscess was evidenced and the pancreatic allograft was removed. Also in the SV group, bleeding from a small arterial vessel in the area of the pancreatic head required surgical exploration. In the PV group, an iliac artery thrombosis determined acute ischemia of the left leg, and a femoro-femoral bypass was performed. In the same group a “double J” was positioned for an ureteral stenosis, and in another patient one ovarian cyst was removed. DISCUSSION
In this randomized study both surgical techniques proved to be feasible and safe: one venous thrombosis occurred in each group, while patient and graft survival as well as other complications were not influenced by the venous drainage procedure. We reported several surgical complications due to the enteric drainage, but no graft failure can be attributed to this procedure. In one patient of the PV group, irreversible pancreas and kidney rejection with loss of both allografts was reported; the other rejection episodes involved only the kidney and occurred at the same incidence as in the PV and SV groups. The data reported herein did not show significant metabolic differences between the PV and SV groups. In conclusion, this study did not allow us to evidence any significant differences between portal and systemic drainage of pancreas allograft; long-term studies are required to show whether portal and systemic drainage in simultaneous From Hopital Edouard Herriot, Lyon, France. Address reprint requests to P. Petruzzo, Service de Chirurgie de la Transplantation, Hopital Edouard Herriot, Lyon, France.
0041-1345/00/$–see front matter PII S0041-1345(00)01879-0
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2776
Transplantation Proceedings, 32, 2776–2777 (2000)
PORTAL VERSUS SYSTEMIC VENOUS DRAINAGE
kidney–pancreas transplantation are or are not equivalent in terms of graft survival and metabolic consequences.
2777 2. Martin X, Dubernard JM, Sanseverino R, et al: Diabetes 38 (suppl 1):16, 1989 3. Tyden G, Tibell A, Groth CG: Clin Transplant 5:36, 1991
REFERENCES 1. Sollinger HW, Knechtle SJ, Reed A, et al: Ann Surg 214:703, 1991
4. Gaber AO, Shokouh-Amiri MH, Hathaway DK, et al: Ann Surg 221:613, 1995
A
LTHOUGH combined pancreas– kidney transplantation is currently accepted as a valid therapeutic option for patients with insulin-dependent diabetes mellitus and end-stage diabetic nephropathy, the ideal surgical technique associated with less morbidity remains uncertain. Several procedures have been proposed such as systemic venous and bladder drainage of the exocrine secretions,1 of the pancreas allograft, and, more recently, portal venous and enteric drainage of the exocrine secretions.2,3 The portal drainage of the graft might result in more physiologic insulin delivery and a better carbohydrate and lipid metabolism.4 This report compares a series of uremic diabetic patients who received combined kidney–pancreas allografts with the portal technique and a similar group of patients who underwent transplantation with the systemic venous technique. MATERIALS AND METHODS Forty consecutive simultaneous pancreas– kidney (SPK) transplants were performed. They were randomly assigned to two groups: the first group (SV group) included 19 patients (12 males, 7 females) who received pancreas allograft with systemic drainage of the organ, and the second group (PV group) included 21 patients (11 males, 10 females) who received pancreas allograft with portal drainage. In both groups enteric drainage of the exocrine secretion was performed. A similar immunosuppressive protocol has been performed in all patients.
RESULTS
In the SV group, patient survival was 89.4% at 1 year and 84.21% at 2 and 3 years, and in the PV group patient survival was 90.4% at 1, 2, and 3 years. Pancreas graft survival was defined as freedom from exogenous insulin. Early loss of pancreatic graft due to venous thrombosis occurred in one patient of each group. In the SV group, one pancreas was lost owing to iliac artery thrombosis and one to peripancreatic abscess. In the SV group, one patient presented with colon cancer, which was treated by chemotherapy; at 18 months’ post-Tx he developed a fistula between an infectious iliac artery pseudo-aneurysm and the colon, with graft loss. No kidney loss occurred in the SV group. In the PV group one kidney allograft and one pancreas allograft were lost because of rejection. Excluding
graft lost, at each time point kidney and pancreas functions were similar in both groups. No significant differences were observed concerning fasting insulin, C-peptide, cholesterol and triglyceride levels, all of which were not higher when compared with normal subjects. Several complications such as bowel leaks and occlusions were reported in both groups, and they could be directly attributed to the intestinal drainage of the exocrine secretions. One venous thrombosis occurred in both groups, and the pancreas allografts had to be removed. In the SV group a peripancreatic abscess was evidenced and the pancreatic allograft was removed. Also in the SV group, bleeding from a small arterial vessel in the area of the pancreatic head required surgical exploration. In the PV group, an iliac artery thrombosis determined acute ischemia of the left leg, and a femoro-femoral bypass was performed. In the same group a “double J” was positioned for an ureteral stenosis, and in another patient one ovarian cyst was removed. DISCUSSION
In this randomized study both surgical techniques proved to be feasible and safe: one venous thrombosis occurred in each group, while patient and graft survival as well as other complications were not influenced by the venous drainage procedure. We reported several surgical complications due to the enteric drainage, but no graft failure can be attributed to this procedure. In one patient of the PV group, irreversible pancreas and kidney rejection with loss of both allografts was reported; the other rejection episodes involved only the kidney and occurred at the same incidence as in the PV and SV groups. The data reported herein did not show significant metabolic differences between the PV and SV groups. In conclusion, this study did not allow us to evidence any significant differences between portal and systemic drainage of pancreas allograft; long-term studies are required to show whether portal and systemic drainage in simultaneous From Hopital Edouard Herriot, Lyon, France. Address reprint requests to P. Petruzzo, Service de Chirurgie de la Transplantation, Hopital Edouard Herriot, Lyon, France.
0041-1345/00/$–see front matter PII S0041-1345(00)01879-0
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2776
Transplantation Proceedings, 32, 2776–2777 (2000)
PORTAL VERSUS SYSTEMIC VENOUS DRAINAGE
kidney–pancreas transplantation are or are not equivalent in terms of graft survival and metabolic consequences.
2777 2. Martin X, Dubernard JM, Sanseverino R, et al: Diabetes 38 (suppl 1):16, 1989 3. Tyden G, Tibell A, Groth CG: Clin Transplant 5:36, 1991
REFERENCES 1. Sollinger HW, Knechtle SJ, Reed A, et al: Ann Surg 214:703, 1991
4. Gaber AO, Shokouh-Amiri MH, Hathaway DK, et al: Ann Surg 221:613, 1995