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Our experience with pancreatic graft extraperitoneal placement
ELSEVIER
Our Experience With Pancreatic Graft Extraperitoneal Placement M. Adamec and F. Saudek
C
OMBINED kidney and pancreas transplantation is a therapeutic option for some types of uremic diabetics, as a means of normalizing glucose metabolism and preventing or delaying degenerative complications of diabetes. In our department, pancreas transplantation has a tradition of 13 years, characterized by a search for an optimal surgical technique and tactics of whole procedure.
MATERIALS
AND
METHODS
Over the past 3 years, we have performed 38 pancreas transplantations, 36 combined kidney and pancreas transplantations, and 2 pancreas after kidney transplantations, all from cadaveric donors. The pancreatic graft was placed extraperitoneally and exocrine secretions were drained into the bladder by side-to-side duodenocystostomy. Emphasis was laid on a short cold ischemia time, which was why typing was omitted. Quadruple-drug transplant immunosuppression with azathioprine, prednisone, cyclosporine (CyA), and antithymocyte globulin (ATG) was used. Low-molecular heparin was administered for 3 weeks, which was replaced by aspirin to prevent graft thrombosis. Those receiving combined transplants included 22 men and 16 women. Their mean age was 41.8 2 6.3 years. They had been suffering from diabetes for a mean of 27.2 2 6.9 years, and 22 had been on dialysis for a mean of 10.1 months.
RESULTS
In all the 38 recipients, the pancreatic graft started to function immediately and insulin therapy was stopped. The l-year survival rates of recipients, pancreatic and renal grafts were 90%, 78%, and 80%, respectively. Three patients died within the first years from the following causes. One recipient died of pulmonary embolism not related to the functioning pancreatic transplant. Another two patients had surgical revisions for duodenovesical leaks and died of myocardial infarction and sepsis, respectively. Surgical complications were the cause of pancreatic graft loss in four patients. Graftectomy was undertaken for graft thrombosis and duodenovesical leak in two cases each. There was one case of pancreatic graft rejection leading to graft loss.
0041-1345/97/$17.00 PII SO041 -1345(97)00727-6 2914
DISCUSSION The numbers of combined pancreatic and renal transplantations have been rising and their results are almost comparable to those of transplantations of the other organs.’ Despite its long-standing history, the surgical technique and tactics of pancreas transplantation are not uniform. The current standard is to transplant the whole pancreas with a duodenal segment and urinary bladder draining, with the pancreatic graft placed intraperitoneally. Some transplant centers prefer to place the pancreatic graft outside the peritoneal cavity.2 Judging by our experience gained to date, extraperitoneal placement offers several advantages: The surgical procedure places less stress on the patient. Rehabilitation and enteral nutrition can be initiated very early in the postoperative period. Ultrasound visualization of the pancreatic graft including the diagnosis of possible surgical complications is easy and very informative. Extraperitoneal graft placement allows easy and safe biopsies to be performed. Surgical complications may prolong hospitalization but do not significantly raise the mortality rates. Moreover, the danger of an intraperitoneal infection developing is excluded. Complications due to duodenocystoanastomosis can be managed by duct obliteration.
REFERENCES
1. Sutherland DER: In Mckeehan DA (ed). International Pancreas Transplant Registry Newsletter. Minneapolis, Minn: University of Minnesota, 1994 2. Barrou B, Bitker MO, Mouquet C: Transplant Proc 27:1755, 1995
From the KKTCH IKEM, Prague, Czech Republic. Supported by the Grant Agency of the Czech Republic. Address reprint requests to Dr Milos Adamec, KKTCH IKEM, Videnska 800, Prague 4, 149 00, Czech Republic.
0 1997 by Elsevier Science
Inc.
655 Avenue of the Americas, New York, NY 10010 Transplantation
Proceedings,
29, 2914 (1997)
Our Experience With Pancreatic Graft Extraperitoneal Placement M. Adamec and F. Saudek
C
OMBINED kidney and pancreas transplantation is a therapeutic option for some types of uremic diabetics, as a means of normalizing glucose metabolism and preventing or delaying degenerative complications of diabetes. In our department, pancreas transplantation has a tradition of 13 years, characterized by a search for an optimal surgical technique and tactics of whole procedure.
MATERIALS
AND
METHODS
Over the past 3 years, we have performed 38 pancreas transplantations, 36 combined kidney and pancreas transplantations, and 2 pancreas after kidney transplantations, all from cadaveric donors. The pancreatic graft was placed extraperitoneally and exocrine secretions were drained into the bladder by side-to-side duodenocystostomy. Emphasis was laid on a short cold ischemia time, which was why typing was omitted. Quadruple-drug transplant immunosuppression with azathioprine, prednisone, cyclosporine (CyA), and antithymocyte globulin (ATG) was used. Low-molecular heparin was administered for 3 weeks, which was replaced by aspirin to prevent graft thrombosis. Those receiving combined transplants included 22 men and 16 women. Their mean age was 41.8 2 6.3 years. They had been suffering from diabetes for a mean of 27.2 2 6.9 years, and 22 had been on dialysis for a mean of 10.1 months.
RESULTS
In all the 38 recipients, the pancreatic graft started to function immediately and insulin therapy was stopped. The l-year survival rates of recipients, pancreatic and renal grafts were 90%, 78%, and 80%, respectively. Three patients died within the first years from the following causes. One recipient died of pulmonary embolism not related to the functioning pancreatic transplant. Another two patients had surgical revisions for duodenovesical leaks and died of myocardial infarction and sepsis, respectively. Surgical complications were the cause of pancreatic graft loss in four patients. Graftectomy was undertaken for graft thrombosis and duodenovesical leak in two cases each. There was one case of pancreatic graft rejection leading to graft loss.
0041-1345/97/$17.00 PII SO041 -1345(97)00727-6 2914
DISCUSSION The numbers of combined pancreatic and renal transplantations have been rising and their results are almost comparable to those of transplantations of the other organs.’ Despite its long-standing history, the surgical technique and tactics of pancreas transplantation are not uniform. The current standard is to transplant the whole pancreas with a duodenal segment and urinary bladder draining, with the pancreatic graft placed intraperitoneally. Some transplant centers prefer to place the pancreatic graft outside the peritoneal cavity.2 Judging by our experience gained to date, extraperitoneal placement offers several advantages: The surgical procedure places less stress on the patient. Rehabilitation and enteral nutrition can be initiated very early in the postoperative period. Ultrasound visualization of the pancreatic graft including the diagnosis of possible surgical complications is easy and very informative. Extraperitoneal graft placement allows easy and safe biopsies to be performed. Surgical complications may prolong hospitalization but do not significantly raise the mortality rates. Moreover, the danger of an intraperitoneal infection developing is excluded. Complications due to duodenocystoanastomosis can be managed by duct obliteration.
REFERENCES
1. Sutherland DER: In Mckeehan DA (ed). International Pancreas Transplant Registry Newsletter. Minneapolis, Minn: University of Minnesota, 1994 2. Barrou B, Bitker MO, Mouquet C: Transplant Proc 27:1755, 1995
From the KKTCH IKEM, Prague, Czech Republic. Supported by the Grant Agency of the Czech Republic. Address reprint requests to Dr Milos Adamec, KKTCH IKEM, Videnska 800, Prague 4, 149 00, Czech Republic.
0 1997 by Elsevier Science
Inc.
655 Avenue of the Americas, New York, NY 10010 Transplantation
Proceedings,
29, 2914 (1997)