- Email: [email protected]
Almost 200 Pancreas Transplantations: A Single-Center Experience
Almost 200 Pancreas Transplantations: A Single-Center Experience M. Durlika,b and K. Baumgart-Gryna,b,* a
Department of Surgical Research and Transplantology, Mossakowski Medical Research Centre Polish Academy of Sciences, Warsaw, Poland; and bClinical Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
ABSTRACT Introduction. Pancreas transplantation is the most effective and physiological method of treatment of patients with diabetes. It restores proper insulin secretion and helps to achieve a metabolic balance by eliminating the need for exogenous insulin. It can also prevent lifethreatening diabetic complications. Pancreas transplantation can also reduce cardiovascular risk factors and can prevent the evolution of some of the chronic diabetic complications. Patients and Methods. From November 2004 until September 2017, 193 pancreas transplantations were performed in the Clinical Department of Gastroenterological Surgery and Transplantation in Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw. All medical records of the recipients who underwent pancreas transplantation in our center were retrospectively analyzed. Results. Among 193 transplantations, we performed 159 simultaneous pancreas kidney transplantations (SPK), 25 pancreas transplantations alone (PTA), and 9 pancreas after kidney transplantations (PAK). The overall patient survival was 87% at 1 year and 85% at 3 and 5 years after transplantation. At 1 year after transplantation, 72% patients had a fully functioning pancreas graft; at 3 years, 68%; and at 5 years, 63%. Kidney graft survival was 87% at 1 year and 85% at 3 and 5 years after transplantation. Conclusions. Pancreas transplantation is an established treatment for long-lasting diabetes. It is a complicated procedure, which requires experience and multidisciplinary approach. It is an operation with a relatively high complication rate and should be performed in highly specialized centers.
P
ANCREAS transplantation is an established method in long-lasting treatment of insulin-dependent diabetes mellitus, which provides the patient with the best possible physiological metabolic balance. It not only restores proper insulin secretion and provides the patient with insulin independence, but also can prevent life-threatening diabetic complications such as severe hyperglycemia, which can occur with acidosis and/or coma or hypoglycemia episodes, especially in the absence of awareness or symptoms. It is also proven that pancreas transplantation reduces cardiovascular risk factors and can stop the progression of some of the chronic diabetes complications such as retinopathy and neuropathy as well as lower the incidence of hemostatic abnormalities, cardiocerebrovascular events, and mortality and improve cardiac function, lipid profile, and blood pressure [1].
0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.02.097
2124
PATIENTS AND METHODS From November 2004, when the pancreas transplant program was implemented in the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, to September 2017, 193 patients underwent pancreas transplantation in our department. We analyzed and carried out a retrospective statistical analysis of the available medical records. Patient and graft survival was analyzed using the KaplaneMeier method.
*Address correspondence to Katarzyna Baumgart-Gryn, Clinical Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warsaw, Poland. E-mail: [email protected] ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 2124e2127 (2018)
PANCREAS TRANSPLANTATIONS IN ONE CENTER
2125 Table 2. Basal Characteristics of the Donor
RESULTS
Among 193 transplantations, we performed 159 simultaneous pancreas kidney transplantations (SPK), 25 pancreas transplantations alone (PTA), and 9 pancreas after kidney transplantations (PAK). Our group of patients consisted of 110 men and 83 women with a mean age of 38 years. Most of our patients had diabetes type 1 (99.97%) and the mean time of diabetes evolution was 24.45 years. One patient after transplantation suffered from diabetes type 2 (0.01%). Three patients had diabetes due to previous pancreatectomy (0.02%). Most of our patients already had advanced kidney complications and required dialysis, mainly hemodialysis (61%), for a mean time of 21.83 months; 25% of the patients were treated with peritoneal dialysis and 14% of the treatment was preemptive. The mean body mass index (BMI) of the recipients before the operation was 23.14 kg/m2 (Table 1). All the organs were obtained from heart-beating cadaveric donors, usually in conjunction with multiple organ retrieval. The majority of the donors were men (67%) who had sustained brain injury, with a mean age of 33 years. A summary of the donors’ parameters is provided in Table 2. The vast majority of recipients received induction therapy with thymoglobulin (6e7 mg/kg). Maintenance therapy consisted of mycophenolate mofetil (2 g/d), tacrolimus (0.1 mg/kg per day), and prednisone that was started intraoperatively and was decreased later with time to a 5 mg dose. Antibiotic prophylaxis consisted of piperacillin with tazobaktam and antifungal fluconazole, and later, within 10 to 14 days after surgery, the antiviral ganciclover and cotrimoxazole prophylaxis were administered. Before the operation, the pancreas graft was reconstructed on the back table. The iliac artery bifurcation Y graft was anastomosed with the superior mesenteric and splenic artery. In the great majority of the cases, the portal vein was extended with the donor’s iliac vein [2,3]. Through the longitudinal incision both spaces for the grafts could be achieved. The graft artery was anastomosed end-to-side to the right iliac artery and the graft vein was anastomosed to the left iliac vein. We performed a venous anastomosis with
Feature Sex ratio (M:F) Mean donor age (y) Donor BMI (kg/m2) Cause of death Intracranial hemorrhage Traumatic brain injury Anoxic brain damage Other Mean serum creatinine (mg/dL) Cold ischemic time
Study population N ¼ 193 67%:33% 33 10 25.09 kg/m2 3.79 49% 33% 13% 5% 1.42 mg/dL 1.06 6 h 41 min 2 h 52 min
the inferior vena cava in only 3 cases. The kidney was transplanted in the retroperitoneal left iliac fossa anastomosing the kidney graft vessels to the external iliac vessels of the recipient. The mean time of the SPK transplantation was 176 minutes 44, PAK 142 minutes 30, and PTA 119 minutes 30. In our center we try to ensure the cold ischemia time (CIT) is less than 12 hours. The various complications that may occur due to prolonged CIT, such as graft thrombosis and graft pancreatitis, have been reported by many authors [4,5]. The mean CIT in our center was 6 hours 41 minutes 2 hours 52 minutes. The mean hospital stay after the operation was 27 days 18 days. After release from the hospital, the patient was moved to regular ambulatory care. Mortality rates were 13% at 1 year and 15% at 3 and 5 years respectively after transplantation, and were was most commonly due to infection and septic complications. The inhospital mortality was 62%. In the SPK group the survival rates were 86%, 83%, and 83%, whereas in the PTA group they were 96%, 96%, and 96% at 1, 3, and 5 years after transplantation. We reported no deaths in the PAK group (Fig 1). The most critical period for the survival of the patient and as well as the graft was the first year after transplantation.
Table 1. Basal Characteristics of the Recipient Feature Mean age (y) Sex ratio (M:F) Type of DM
Duration of DM (y after onset) BMI (kg/m2) Type of dialysis Preemptive Peritoneal dialysis Hemodialysis Duration of dialysis (mo)
Study population N ¼ 193 38 8 110 (57%):83 (43%) 99.97% DM type 1 (n ¼ 189) 0.01% DM type 2 (n ¼ 1) 0.02% DM after pancreatectomy (n ¼ 3) 24.45 8.80 23.07 kg/m2 2.98 14% 25% 61% 25 19
Abbreviations: BMI, body mass index; DM, diabetes mellitus.
Fig 1. Patient survival. Abbreviations: PAK, pancreas after kidney transplantation; PTA, pancreas transplantation alone; SPK, simultaneous pancreas kidney transplantation.
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The overall results showed 72% of patients at 1 year after transplantation with a fully functioning pancreas graft, whereas after 3 years 68% of patients were free of the need for exogenous insulin and after 5 years 63%. The inclusion criteria for graft failure were either graftectomy or insulin administration due to graft insufficiency. Two of our patients were administered oral hypoglycemic medication, but were still included in the group with preserved graft function because of good glycemic control without the need for exogenous insulin administration. Patients who died with functioning grafts were also included as graft losses. The graft survival in SPK patients was 71%, 67%, and 63% after 1, 3, and 5 years respectively. We report poor PTA longterm pancreas graft survival: 70% after 1 year and only 40% after 3 and 5 years. However, we report excellent pancreas graft survival in the PAK group: 100% (Fig 2). Kidney graft survival was 87% after 1 year, 85% after 3 years, and 85% after 5 years (Fig 3). In the SPK group the survival rates were 71%, 67%, and 63% and in the PAK group 100% (Fig 3). Most of our patients (63%) required surgical intervention after transplantation. The most common cause of relaparotomy was hemorrhage, as well as intra-abdominal bleeding or hematoma or bleeding from the enteric anastomosis. DISCUSSION
Pancreas transplantation is currently considered a reliable therapeutic option for diabetic patients. However, despite constantly improved results since the first pancreas transplantation in 1966, pancreas grafts are still very susceptible to surgical complications, and graft removal remains a relatively frequent option compared to other organ transplantations [6]. Pancreas graft thrombosis was the most common reason for pancreas graft loss and was a cause of graft failure in 58% of patients with graftectomy in our center. The various risk factors predisposing to graft thrombosis (eg, donor and
Fig 2. Pancreas graft survival. Abbreviations: PAK, pancreas after kidney transplantation; PTA, pancreas transplantation alone; SPK, simultaneous pancreas kidney transplantation.
DURLIK AND BAUMGART-GRYN
Fig 3. Kidney graft survival. Abbreviations: PAK, pancreas after kidney transplantation; SPK, simultaneous pancreas kidney transplantation.
recipient obesity and prolonged CIT) were reported by many authors [4,7]. The usual timing of the graft thrombosis in our center was up to 10 days after the operation. Diabetes is a hypercoagulable state; however, international consensus regarding the anticoagulation protocol in patients after pancreas transplantation is still lacking. In our center we use low molecular weight heparin (LMWH), which is started intraoperatively as a bolus before vascular clamping, 2500 to 3000 units depending on the patient’s weight. We continue to give LMWH boluses after the operation depending on kidney function, either 2500 or 5000 units through the whole hospital stay, and the patient gets a LMWH prescription on release from the hospital. Later on, patients are usually prescribed aspirin. Graft pancreatitis is a common and unavoidable problem after transplantation. It is estimated as the second most common complication after surgery [5]. Of course one should always take in consideration the reperfusion injury of the pancreas after the revascularization; however, the inflammation might evolve and might even lead to graftectomy. In our center 5 patients required pancreas graftectomy due to the severe course of the graft pancreatitis, among whom 2 died. Among 40 patients requiring pancreas graftectomy, 4 patients had to have their graft removed because of arterialgraft duodenal fistula. It is not a very common complication after pancreas transplantation; however, a few such cases were described in other centers [8,9]. It is worth mentioning that gastrointestinal bleeding with concomitant rapid general health state collapse should always lead to a suspicion of an arterio-jejunal fistula during differential diagnosis, with the patient requiring urgent operation. Today, enteric anastomosis is the preferred type of exocrine drainage in most centers. At the time the pancreas transplantation program was set up in our hospital we were performing duodenojejunal anastomosis. In 2007 De Roover et al presented the results of a successful
PANCREAS TRANSPLANTATIONS IN ONE CENTER
duodenoduodenal exocrine anastomosis in several pancreas and kidney recipients [10]. Since 2008 in our center we started changing the surgical technique by performing an exocrine anastomosis with suturing of the donor’s duodenum with the retroperitoneal part of the distal duodenum of the recipient. Of 193 pancreas transplantations we performed 29 (15%) duodenojejunal and 164 (85%) duodenoduodenal anastomoses. Duodenoduodenal anastomosis provides an easy, direct, and noninvasive access to the transplanted duodenum via an endoscope. It is possible to macroscopically evaluate the donor’s and recipient’s duodenums and to examine the anastomosis. When needed, it is extremely useful in endoscopic treatment in suspicion of anastomotic bleeding, so there is no necessity of another operation. We successfully diagnosed and treated endoscopically bleeding from the anastomosis in 21 cases, usually using hemostatic clips and/or adrenalin injections. Poor survival of the pancreatic grafts in patients with PTA may be related to graft rejection. We recorded a series of cases of sudden loss of function, especially in young patients, where within a few weeks the graft underwent a massive fibrotic process. Protocolar graft biopsies may be a possible solution to improve graft survival rates in this group. The great majority of our diabetic patients have diabetes type 1. However, we performed the first operations of its kind in our country: transplantation of the pancreas in a patient with diabetes mellitus type 2 and transplantation of the pancreas in a patient with diabetes after pancreatectomy [11]. CONCLUSION
In conclusion, pancreas transplantation is an established method in the treatment of long-lasting diabetes. It is still a procedure with a high complication rate, which requires experience and a multidisciplinary approach and should be performed in highly specialized centers. From 2013 we qualify each patient in our center, which also enables to
2127
clarify and monitor every aspect of the patient’s preparation for the transplantation. In addition, great care and alertness are especially necessary within the first year after pancreas transplantation, as the risk of graft failure or morbidity is the highest at that time. REFERENCES [1] Boggi U, Rosati CM, Marchetti P. Follow-up of secondary diabetic complications after pancreas transplantation. Curr Opin Organ Transplant 2013;18:102e10. [2] Stratta RJ, Gaber AO, Shokouh-Amiri MH, Egidi MF, Grewal HP, Reddy KS, et al. Experience with portal-enteric pancreas transplant at the University of Tennessee-Memphis. Clin Transpl 1998:239e53. [3] Gill IS, Sindhi R, Jerius JT, Sudan D, Stratta RJ. Bench reconstruction of pancreas for transplantation: experience with 192 cases. Clin Transpl 1997;11:104e9. [4] Farney AC, Rogers J, Stratta RJ. Pancreas graft thrombosis: causes, prevention, diagnosis, and intervention. Curr Opin Organ Transplant 2012;17:87e92. [5] Nadalin S, Girotti P, Königsrainer A. Risk factors for and management of graft pancreatitis. Curr Opin Organ Transplant 2013;18:89e96. [6] Kelly WD, Lillehei RC, Merkel FK, Idezuki Y, Goetz FC. Allotransplantation of the pancreas and duodenum along with the kidney in diabetic nephropathy. Surgery 1967;61:827e35. [7] Gruessner AC, Sutherland DE, Gruessner RW. Long-term outcome after pancreas transplantation. Curr Opin Organ Transplant 2012;17:100e5. [8] Lopez NM, Jeon H, Ranjan D, Johnston TD. Atypical etiology of massive gastrointestinal bleeding: arterio-enteric fistula following enteric drained pancreas transplant. Am Surg 2004;70:529e32. [9] 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 Transpl 2012;26:164e72. [10] De Roover A, Coimbra C, Detry O, Van Kemseke C, Squifflet JP, Honore P, Meurisse M. Pancreas graft drainage in recipient duodenum: preliminary experience. Transplantation 2007;84:795e7. [11] Durlik M, Baumgart K. Pancreas transplantation in a patient after total pancreatectomy due to chronic pancreatitis: the first case in Poland. Pol Przegl Chir 2016;88:106e8.
Department of Surgical Research and Transplantology, Mossakowski Medical Research Centre Polish Academy of Sciences, Warsaw, Poland; and bClinical Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
ABSTRACT Introduction. Pancreas transplantation is the most effective and physiological method of treatment of patients with diabetes. It restores proper insulin secretion and helps to achieve a metabolic balance by eliminating the need for exogenous insulin. It can also prevent lifethreatening diabetic complications. Pancreas transplantation can also reduce cardiovascular risk factors and can prevent the evolution of some of the chronic diabetic complications. Patients and Methods. From November 2004 until September 2017, 193 pancreas transplantations were performed in the Clinical Department of Gastroenterological Surgery and Transplantation in Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw. All medical records of the recipients who underwent pancreas transplantation in our center were retrospectively analyzed. Results. Among 193 transplantations, we performed 159 simultaneous pancreas kidney transplantations (SPK), 25 pancreas transplantations alone (PTA), and 9 pancreas after kidney transplantations (PAK). The overall patient survival was 87% at 1 year and 85% at 3 and 5 years after transplantation. At 1 year after transplantation, 72% patients had a fully functioning pancreas graft; at 3 years, 68%; and at 5 years, 63%. Kidney graft survival was 87% at 1 year and 85% at 3 and 5 years after transplantation. Conclusions. Pancreas transplantation is an established treatment for long-lasting diabetes. It is a complicated procedure, which requires experience and multidisciplinary approach. It is an operation with a relatively high complication rate and should be performed in highly specialized centers.
P
ANCREAS transplantation is an established method in long-lasting treatment of insulin-dependent diabetes mellitus, which provides the patient with the best possible physiological metabolic balance. It not only restores proper insulin secretion and provides the patient with insulin independence, but also can prevent life-threatening diabetic complications such as severe hyperglycemia, which can occur with acidosis and/or coma or hypoglycemia episodes, especially in the absence of awareness or symptoms. It is also proven that pancreas transplantation reduces cardiovascular risk factors and can stop the progression of some of the chronic diabetes complications such as retinopathy and neuropathy as well as lower the incidence of hemostatic abnormalities, cardiocerebrovascular events, and mortality and improve cardiac function, lipid profile, and blood pressure [1].
0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.02.097
2124
PATIENTS AND METHODS From November 2004, when the pancreas transplant program was implemented in the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, to September 2017, 193 patients underwent pancreas transplantation in our department. We analyzed and carried out a retrospective statistical analysis of the available medical records. Patient and graft survival was analyzed using the KaplaneMeier method.
*Address correspondence to Katarzyna Baumgart-Gryn, Clinical Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warsaw, Poland. E-mail: [email protected] ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 2124e2127 (2018)
PANCREAS TRANSPLANTATIONS IN ONE CENTER
2125 Table 2. Basal Characteristics of the Donor
RESULTS
Among 193 transplantations, we performed 159 simultaneous pancreas kidney transplantations (SPK), 25 pancreas transplantations alone (PTA), and 9 pancreas after kidney transplantations (PAK). Our group of patients consisted of 110 men and 83 women with a mean age of 38 years. Most of our patients had diabetes type 1 (99.97%) and the mean time of diabetes evolution was 24.45 years. One patient after transplantation suffered from diabetes type 2 (0.01%). Three patients had diabetes due to previous pancreatectomy (0.02%). Most of our patients already had advanced kidney complications and required dialysis, mainly hemodialysis (61%), for a mean time of 21.83 months; 25% of the patients were treated with peritoneal dialysis and 14% of the treatment was preemptive. The mean body mass index (BMI) of the recipients before the operation was 23.14 kg/m2 (Table 1). All the organs were obtained from heart-beating cadaveric donors, usually in conjunction with multiple organ retrieval. The majority of the donors were men (67%) who had sustained brain injury, with a mean age of 33 years. A summary of the donors’ parameters is provided in Table 2. The vast majority of recipients received induction therapy with thymoglobulin (6e7 mg/kg). Maintenance therapy consisted of mycophenolate mofetil (2 g/d), tacrolimus (0.1 mg/kg per day), and prednisone that was started intraoperatively and was decreased later with time to a 5 mg dose. Antibiotic prophylaxis consisted of piperacillin with tazobaktam and antifungal fluconazole, and later, within 10 to 14 days after surgery, the antiviral ganciclover and cotrimoxazole prophylaxis were administered. Before the operation, the pancreas graft was reconstructed on the back table. The iliac artery bifurcation Y graft was anastomosed with the superior mesenteric and splenic artery. In the great majority of the cases, the portal vein was extended with the donor’s iliac vein [2,3]. Through the longitudinal incision both spaces for the grafts could be achieved. The graft artery was anastomosed end-to-side to the right iliac artery and the graft vein was anastomosed to the left iliac vein. We performed a venous anastomosis with
Feature Sex ratio (M:F) Mean donor age (y) Donor BMI (kg/m2) Cause of death Intracranial hemorrhage Traumatic brain injury Anoxic brain damage Other Mean serum creatinine (mg/dL) Cold ischemic time
Study population N ¼ 193 67%:33% 33 10 25.09 kg/m2 3.79 49% 33% 13% 5% 1.42 mg/dL 1.06 6 h 41 min 2 h 52 min
the inferior vena cava in only 3 cases. The kidney was transplanted in the retroperitoneal left iliac fossa anastomosing the kidney graft vessels to the external iliac vessels of the recipient. The mean time of the SPK transplantation was 176 minutes 44, PAK 142 minutes 30, and PTA 119 minutes 30. In our center we try to ensure the cold ischemia time (CIT) is less than 12 hours. The various complications that may occur due to prolonged CIT, such as graft thrombosis and graft pancreatitis, have been reported by many authors [4,5]. The mean CIT in our center was 6 hours 41 minutes 2 hours 52 minutes. The mean hospital stay after the operation was 27 days 18 days. After release from the hospital, the patient was moved to regular ambulatory care. Mortality rates were 13% at 1 year and 15% at 3 and 5 years respectively after transplantation, and were was most commonly due to infection and septic complications. The inhospital mortality was 62%. In the SPK group the survival rates were 86%, 83%, and 83%, whereas in the PTA group they were 96%, 96%, and 96% at 1, 3, and 5 years after transplantation. We reported no deaths in the PAK group (Fig 1). The most critical period for the survival of the patient and as well as the graft was the first year after transplantation.
Table 1. Basal Characteristics of the Recipient Feature Mean age (y) Sex ratio (M:F) Type of DM
Duration of DM (y after onset) BMI (kg/m2) Type of dialysis Preemptive Peritoneal dialysis Hemodialysis Duration of dialysis (mo)
Study population N ¼ 193 38 8 110 (57%):83 (43%) 99.97% DM type 1 (n ¼ 189) 0.01% DM type 2 (n ¼ 1) 0.02% DM after pancreatectomy (n ¼ 3) 24.45 8.80 23.07 kg/m2 2.98 14% 25% 61% 25 19
Abbreviations: BMI, body mass index; DM, diabetes mellitus.
Fig 1. Patient survival. Abbreviations: PAK, pancreas after kidney transplantation; PTA, pancreas transplantation alone; SPK, simultaneous pancreas kidney transplantation.
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The overall results showed 72% of patients at 1 year after transplantation with a fully functioning pancreas graft, whereas after 3 years 68% of patients were free of the need for exogenous insulin and after 5 years 63%. The inclusion criteria for graft failure were either graftectomy or insulin administration due to graft insufficiency. Two of our patients were administered oral hypoglycemic medication, but were still included in the group with preserved graft function because of good glycemic control without the need for exogenous insulin administration. Patients who died with functioning grafts were also included as graft losses. The graft survival in SPK patients was 71%, 67%, and 63% after 1, 3, and 5 years respectively. We report poor PTA longterm pancreas graft survival: 70% after 1 year and only 40% after 3 and 5 years. However, we report excellent pancreas graft survival in the PAK group: 100% (Fig 2). Kidney graft survival was 87% after 1 year, 85% after 3 years, and 85% after 5 years (Fig 3). In the SPK group the survival rates were 71%, 67%, and 63% and in the PAK group 100% (Fig 3). Most of our patients (63%) required surgical intervention after transplantation. The most common cause of relaparotomy was hemorrhage, as well as intra-abdominal bleeding or hematoma or bleeding from the enteric anastomosis. DISCUSSION
Pancreas transplantation is currently considered a reliable therapeutic option for diabetic patients. However, despite constantly improved results since the first pancreas transplantation in 1966, pancreas grafts are still very susceptible to surgical complications, and graft removal remains a relatively frequent option compared to other organ transplantations [6]. Pancreas graft thrombosis was the most common reason for pancreas graft loss and was a cause of graft failure in 58% of patients with graftectomy in our center. The various risk factors predisposing to graft thrombosis (eg, donor and
Fig 2. Pancreas graft survival. Abbreviations: PAK, pancreas after kidney transplantation; PTA, pancreas transplantation alone; SPK, simultaneous pancreas kidney transplantation.
DURLIK AND BAUMGART-GRYN
Fig 3. Kidney graft survival. Abbreviations: PAK, pancreas after kidney transplantation; SPK, simultaneous pancreas kidney transplantation.
recipient obesity and prolonged CIT) were reported by many authors [4,7]. The usual timing of the graft thrombosis in our center was up to 10 days after the operation. Diabetes is a hypercoagulable state; however, international consensus regarding the anticoagulation protocol in patients after pancreas transplantation is still lacking. In our center we use low molecular weight heparin (LMWH), which is started intraoperatively as a bolus before vascular clamping, 2500 to 3000 units depending on the patient’s weight. We continue to give LMWH boluses after the operation depending on kidney function, either 2500 or 5000 units through the whole hospital stay, and the patient gets a LMWH prescription on release from the hospital. Later on, patients are usually prescribed aspirin. Graft pancreatitis is a common and unavoidable problem after transplantation. It is estimated as the second most common complication after surgery [5]. Of course one should always take in consideration the reperfusion injury of the pancreas after the revascularization; however, the inflammation might evolve and might even lead to graftectomy. In our center 5 patients required pancreas graftectomy due to the severe course of the graft pancreatitis, among whom 2 died. Among 40 patients requiring pancreas graftectomy, 4 patients had to have their graft removed because of arterialgraft duodenal fistula. It is not a very common complication after pancreas transplantation; however, a few such cases were described in other centers [8,9]. It is worth mentioning that gastrointestinal bleeding with concomitant rapid general health state collapse should always lead to a suspicion of an arterio-jejunal fistula during differential diagnosis, with the patient requiring urgent operation. Today, enteric anastomosis is the preferred type of exocrine drainage in most centers. At the time the pancreas transplantation program was set up in our hospital we were performing duodenojejunal anastomosis. In 2007 De Roover et al presented the results of a successful
PANCREAS TRANSPLANTATIONS IN ONE CENTER
duodenoduodenal exocrine anastomosis in several pancreas and kidney recipients [10]. Since 2008 in our center we started changing the surgical technique by performing an exocrine anastomosis with suturing of the donor’s duodenum with the retroperitoneal part of the distal duodenum of the recipient. Of 193 pancreas transplantations we performed 29 (15%) duodenojejunal and 164 (85%) duodenoduodenal anastomoses. Duodenoduodenal anastomosis provides an easy, direct, and noninvasive access to the transplanted duodenum via an endoscope. It is possible to macroscopically evaluate the donor’s and recipient’s duodenums and to examine the anastomosis. When needed, it is extremely useful in endoscopic treatment in suspicion of anastomotic bleeding, so there is no necessity of another operation. We successfully diagnosed and treated endoscopically bleeding from the anastomosis in 21 cases, usually using hemostatic clips and/or adrenalin injections. Poor survival of the pancreatic grafts in patients with PTA may be related to graft rejection. We recorded a series of cases of sudden loss of function, especially in young patients, where within a few weeks the graft underwent a massive fibrotic process. Protocolar graft biopsies may be a possible solution to improve graft survival rates in this group. The great majority of our diabetic patients have diabetes type 1. However, we performed the first operations of its kind in our country: transplantation of the pancreas in a patient with diabetes mellitus type 2 and transplantation of the pancreas in a patient with diabetes after pancreatectomy [11]. CONCLUSION
In conclusion, pancreas transplantation is an established method in the treatment of long-lasting diabetes. It is still a procedure with a high complication rate, which requires experience and a multidisciplinary approach and should be performed in highly specialized centers. From 2013 we qualify each patient in our center, which also enables to
2127
clarify and monitor every aspect of the patient’s preparation for the transplantation. In addition, great care and alertness are especially necessary within the first year after pancreas transplantation, as the risk of graft failure or morbidity is the highest at that time. REFERENCES [1] Boggi U, Rosati CM, Marchetti P. Follow-up of secondary diabetic complications after pancreas transplantation. Curr Opin Organ Transplant 2013;18:102e10. [2] Stratta RJ, Gaber AO, Shokouh-Amiri MH, Egidi MF, Grewal HP, Reddy KS, et al. Experience with portal-enteric pancreas transplant at the University of Tennessee-Memphis. Clin Transpl 1998:239e53. [3] Gill IS, Sindhi R, Jerius JT, Sudan D, Stratta RJ. Bench reconstruction of pancreas for transplantation: experience with 192 cases. Clin Transpl 1997;11:104e9. [4] Farney AC, Rogers J, Stratta RJ. Pancreas graft thrombosis: causes, prevention, diagnosis, and intervention. Curr Opin Organ Transplant 2012;17:87e92. [5] Nadalin S, Girotti P, Königsrainer A. Risk factors for and management of graft pancreatitis. Curr Opin Organ Transplant 2013;18:89e96. [6] Kelly WD, Lillehei RC, Merkel FK, Idezuki Y, Goetz FC. Allotransplantation of the pancreas and duodenum along with the kidney in diabetic nephropathy. Surgery 1967;61:827e35. [7] Gruessner AC, Sutherland DE, Gruessner RW. Long-term outcome after pancreas transplantation. Curr Opin Organ Transplant 2012;17:100e5. [8] Lopez NM, Jeon H, Ranjan D, Johnston TD. Atypical etiology of massive gastrointestinal bleeding: arterio-enteric fistula following enteric drained pancreas transplant. Am Surg 2004;70:529e32. [9] 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 Transpl 2012;26:164e72. [10] De Roover A, Coimbra C, Detry O, Van Kemseke C, Squifflet JP, Honore P, Meurisse M. Pancreas graft drainage in recipient duodenum: preliminary experience. Transplantation 2007;84:795e7. [11] Durlik M, Baumgart K. Pancreas transplantation in a patient after total pancreatectomy due to chronic pancreatitis: the first case in Poland. Pol Przegl Chir 2016;88:106e8.