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Enteric versus bladder drainage for solitary pancreas transplants— a registry report
Enteric Versus Bladder Drainage for Solitary Pancreas Transplants— A Registry Report A.C. Gruessner, D.E.R. Sutherland, and R.W.G. Gruessner
O
VER THE LAST 4 years, the number of solitary pancreas transplants has increased significantly; in 1999, they accounted for 17% of all pancreas transplants.1 Of solitary transplants, pancreas after kidney (PAK) transplants are more than twice as common as pancreas transplants alone (PTA). Debate continues over the optimal technique for exocrine pancreas drainage. Bladder drainage (BD) has been the most widely used technique over the last 15 years. But more recently, enteric drainage (ED) has resulted in equivalent outcome for recipients of simultaneous pancreas-kidney (SPK) transplants. For SPK (but not solitary pancreas) recipients, serum creatinine levels can be used to diagnose rejection, because rejection of the kidney usually precedes rejection of the pancreas. For solitary pancreas recipients, who experience rejection more frequently than do SPK recipients, BD allows monitoring for rejection by following urinary amylase levels. Another advantage of BD over ED has been its lower technical complication rate. But the disadvantages of BD include urologic and metabolic complications, such as urinary tract infections, metabolic acidosis and dehydration, hematuria, reflux pancreatitis, and bladder stones; such complications require conversion operations (from BD to ED) for 5% to 10% of recipients at 1 year posttransplant.1 The advantages of ED include the absence of urologic and metabolic complications and a more physiologic drainage of pancreatic enzymes. But the disadvantages of ED are the inability to monitor graft exocrine function and, in the past, a higher technical complication rate. Lately, ED has been used increasingly for both SPK and solitary pancreas recipients (PAK, PTA). The purpose of our report was to study the outcome of BD versus ED for solitary pancreas recipients. METHODS AND PATIENTS Between January 1, 1996 and May 31, 2000, 753 solitary pancreas transplants were reported to UNOS and the International Pancreas Transplant Registry (IPTR). Of those, 537 (71%) were in the PAK (325 BD, 212 ED) and 260 (29%) in the PTA (128 BD, 88 ED) category (Fig 1). In the PAK category, we found no difference between BD and ED in recipient age, gender distribution (male preponderance), number of retransplants, preservation time, or donor age; however, the number of HLA mismatches was higher for ED (3.8 ⫾ 1.4) versus BD (3.4 ⫾ 1.3) (P ⫽ .001). In the PTA category, we found no difference in recipient age, gender distribu0041-1345/01/$–see front matter PII S0041-1345(00)02638-5
tion (female preponderance), number of retransplants, or preservation time; however, donor age was lower for ED (23 ⫾ 10 years) versus BD (28 ⫾ 12 years) (P ⫽ .003), and the number of HLA mismatches was higher for ED (4.4 ⫾ 1.4) versus BD (2.9 ⫾ 1.3) (P ⫽ .001).
RESULTS
Patient survival rates for BD and ED in both the PAK and PTA categories were not different and exceeded 95% at 1 year. However, graft survival was significantly better for BD versus ED: in the PAK category, 1-year graft survival rates (primary and retransplants) were 77% for BD and 66% for ED (P ⫽ .003); in the PTA category, 1-year graft survival rates were 75% for BD and 66% for ED (P ⫽ .02) (Fig 2). In univariate analyses, this difference in graft survival was not due to a higher rejection rate but rather to a higher technical failure rate for ED in both categories. The 1-year graft loss rate from rejection in the PAK category was 7% for BD and 6% for ED (P ⫽ .94); in the PTA category, 8% for BD and 10% for ED (P ⫽ .31). The overall technical failure rate was significantly higher for ED: in the PAK category, 7.0% for ED versus 15.0% for BD (P ⫽ .003); in the PTA category, 3.9% for BD versus 14.8% for ED (P ⫽ .04). Our analysis also showed that the difference in the technical failure rate was due to a higher incidence of graft thrombosis for ED: in the PAK category, 4.9% for BD versus 11.5% for ED (P ⫽ .006); in the PTA category, 3.5% for BD versus 14.9% for ED (P ⫽ .004). Of note, the incidence of graft loss from late thrombosis (⬎1 month posttransplant) was higher for ED in both the PAK and PTA categories. The incidence of graft loss from infection, pancreatitis, and bleeding was not different for BD versus ED in both the PAK and PTA categories; the incidence of graft loss from anastomotic leakage was slightly higher for ED, but did not reach statistical significance. Systemic drainage was used in 99% of all BD transplants and portal drainage in 31% of all ED transplants; we found no difference in the technical failure rate for BD versus ED in From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA. Address reprint requests to Dr A. Gruessner, University of Minnesota, Department of Surgery, MMC 90, 420 Delaware Street SE, Minneapolis, MN 55455. © 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
1678
Transplantation Proceedings, 33, 1678–1680 (2001)
ENTERIC VS BLADDER DRAINAGE
Fig 1.
1679
Duct management techniques in (a) PAK and (b) PTA.
both the PAK and PTA categories. For ED, the use of a Roux-en-Y loop did not have a significant impact on graft survival or on the incidence of graft loss from technical failure. According to a multivariate analysis of technical failure for ED, immunologic causes (ie, rejection) contributed to less favorable outcome for ED, indicating that some of the
losses due to late thrombosis in fact could have been caused by rejection. Since the pathology results of pancreas grafts that are removed for (technical) failure are not reported to the registry, this observation warrants comprehensive single-center analysis to clearly identify the cause of graft loss from thrombosis.
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GRUESSNER, SUTHERLAND, AND GRUESSNER
Fig 2.
(a) PAK and (b) PTA graft function by duct management.
DISCUSSION AND SUMMARY
In summary, pancreas graft survival is higher for BD versus ED in both the PAK and PTA categories. Although the difference is due to a higher technical failure rate from thrombosis, the higher incidence of late thrombosis for ED could have been secondary to rejection rather than to technical failure. Interestingly, neither portal drainage nor
the use of a Roux-en-Y loop had an impact on outcome. In conclusion, for solitary pancreas recipients (PAK, PTA), BD (versus ED) is still associated with a significantly higher graft survival rate and a significantly lower technical failure rate. REFERENCE 1. Gruessner A, Sutherland DER: Clinical Transplants 1999:51, 2000
O
VER THE LAST 4 years, the number of solitary pancreas transplants has increased significantly; in 1999, they accounted for 17% of all pancreas transplants.1 Of solitary transplants, pancreas after kidney (PAK) transplants are more than twice as common as pancreas transplants alone (PTA). Debate continues over the optimal technique for exocrine pancreas drainage. Bladder drainage (BD) has been the most widely used technique over the last 15 years. But more recently, enteric drainage (ED) has resulted in equivalent outcome for recipients of simultaneous pancreas-kidney (SPK) transplants. For SPK (but not solitary pancreas) recipients, serum creatinine levels can be used to diagnose rejection, because rejection of the kidney usually precedes rejection of the pancreas. For solitary pancreas recipients, who experience rejection more frequently than do SPK recipients, BD allows monitoring for rejection by following urinary amylase levels. Another advantage of BD over ED has been its lower technical complication rate. But the disadvantages of BD include urologic and metabolic complications, such as urinary tract infections, metabolic acidosis and dehydration, hematuria, reflux pancreatitis, and bladder stones; such complications require conversion operations (from BD to ED) for 5% to 10% of recipients at 1 year posttransplant.1 The advantages of ED include the absence of urologic and metabolic complications and a more physiologic drainage of pancreatic enzymes. But the disadvantages of ED are the inability to monitor graft exocrine function and, in the past, a higher technical complication rate. Lately, ED has been used increasingly for both SPK and solitary pancreas recipients (PAK, PTA). The purpose of our report was to study the outcome of BD versus ED for solitary pancreas recipients. METHODS AND PATIENTS Between January 1, 1996 and May 31, 2000, 753 solitary pancreas transplants were reported to UNOS and the International Pancreas Transplant Registry (IPTR). Of those, 537 (71%) were in the PAK (325 BD, 212 ED) and 260 (29%) in the PTA (128 BD, 88 ED) category (Fig 1). In the PAK category, we found no difference between BD and ED in recipient age, gender distribution (male preponderance), number of retransplants, preservation time, or donor age; however, the number of HLA mismatches was higher for ED (3.8 ⫾ 1.4) versus BD (3.4 ⫾ 1.3) (P ⫽ .001). In the PTA category, we found no difference in recipient age, gender distribu0041-1345/01/$–see front matter PII S0041-1345(00)02638-5
tion (female preponderance), number of retransplants, or preservation time; however, donor age was lower for ED (23 ⫾ 10 years) versus BD (28 ⫾ 12 years) (P ⫽ .003), and the number of HLA mismatches was higher for ED (4.4 ⫾ 1.4) versus BD (2.9 ⫾ 1.3) (P ⫽ .001).
RESULTS
Patient survival rates for BD and ED in both the PAK and PTA categories were not different and exceeded 95% at 1 year. However, graft survival was significantly better for BD versus ED: in the PAK category, 1-year graft survival rates (primary and retransplants) were 77% for BD and 66% for ED (P ⫽ .003); in the PTA category, 1-year graft survival rates were 75% for BD and 66% for ED (P ⫽ .02) (Fig 2). In univariate analyses, this difference in graft survival was not due to a higher rejection rate but rather to a higher technical failure rate for ED in both categories. The 1-year graft loss rate from rejection in the PAK category was 7% for BD and 6% for ED (P ⫽ .94); in the PTA category, 8% for BD and 10% for ED (P ⫽ .31). The overall technical failure rate was significantly higher for ED: in the PAK category, 7.0% for ED versus 15.0% for BD (P ⫽ .003); in the PTA category, 3.9% for BD versus 14.8% for ED (P ⫽ .04). Our analysis also showed that the difference in the technical failure rate was due to a higher incidence of graft thrombosis for ED: in the PAK category, 4.9% for BD versus 11.5% for ED (P ⫽ .006); in the PTA category, 3.5% for BD versus 14.9% for ED (P ⫽ .004). Of note, the incidence of graft loss from late thrombosis (⬎1 month posttransplant) was higher for ED in both the PAK and PTA categories. The incidence of graft loss from infection, pancreatitis, and bleeding was not different for BD versus ED in both the PAK and PTA categories; the incidence of graft loss from anastomotic leakage was slightly higher for ED, but did not reach statistical significance. Systemic drainage was used in 99% of all BD transplants and portal drainage in 31% of all ED transplants; we found no difference in the technical failure rate for BD versus ED in From the Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA. Address reprint requests to Dr A. Gruessner, University of Minnesota, Department of Surgery, MMC 90, 420 Delaware Street SE, Minneapolis, MN 55455. © 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
1678
Transplantation Proceedings, 33, 1678–1680 (2001)
ENTERIC VS BLADDER DRAINAGE
Fig 1.
1679
Duct management techniques in (a) PAK and (b) PTA.
both the PAK and PTA categories. For ED, the use of a Roux-en-Y loop did not have a significant impact on graft survival or on the incidence of graft loss from technical failure. According to a multivariate analysis of technical failure for ED, immunologic causes (ie, rejection) contributed to less favorable outcome for ED, indicating that some of the
losses due to late thrombosis in fact could have been caused by rejection. Since the pathology results of pancreas grafts that are removed for (technical) failure are not reported to the registry, this observation warrants comprehensive single-center analysis to clearly identify the cause of graft loss from thrombosis.
1680
GRUESSNER, SUTHERLAND, AND GRUESSNER
Fig 2.
(a) PAK and (b) PTA graft function by duct management.
DISCUSSION AND SUMMARY
In summary, pancreas graft survival is higher for BD versus ED in both the PAK and PTA categories. Although the difference is due to a higher technical failure rate from thrombosis, the higher incidence of late thrombosis for ED could have been secondary to rejection rather than to technical failure. Interestingly, neither portal drainage nor
the use of a Roux-en-Y loop had an impact on outcome. In conclusion, for solitary pancreas recipients (PAK, PTA), BD (versus ED) is still associated with a significantly higher graft survival rate and a significantly lower technical failure rate. REFERENCE 1. Gruessner A, Sutherland DER: Clinical Transplants 1999:51, 2000