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Pancreas Retransplantation: Outcomes of 20 Cases
Pancreas Retransplantation: Outcomes of 20 Cases T. Genzini, F. Crescentini, F.C.M. Torricelli, I. Antunes, A. Hayashi, N.J. Kim, E.R. Belieacqua, H. Noujaim, J.R. de Sa, and M. Perosa ABSTRACT The objective of this paper was to evaluate our initial experience with pancreas retransplantation. From January 26, 1996 to February 2005, 285 pancreas transplantations were performed, including 20 (7%) retransplants. The causes of primary graft loss were graft thrombosis in 11 (55%, 7 venous and 4 arterial); 4 (20%) chronic rejections; 2 (10%) ischemia/reperfusion injury; 1 severe graft pancreatitis; 1 primary nonfunction; and 1 sepsis. Venous drainage was placed in the iliac vessels in 14 (70%), vena cava in 5 (25%), and portal drainage in 1. The exocrine drainage was vesical in 16 (80%) and enteric in 4 (20%). In 14 cases (70%), the primary graft was removed before and in 6 (30%) at the time of retransplantation. Immunosuppression was based on antilymphocyte induction, tacrolimus, mycophenolate mofetil, and steroids in all patients. One-year patient and graft survivals were 95% and 85%. In conclusion, pancreas retransplants were feasible with results comparable to a primary pancreas transplantation.
P
ANCREAS RETRANSPLANTATION (PRT) is a procedure of higher risk than a primary transplant. According to the International Register of Pancreas Transplants (IPTR), graft survival after PRT from January 1999 to May 2003 was worse when compared with primary transplantation (PT) for all categories of pancreas transplantation: 69% versus 84% for simultaneous pancreas kidney transplant (SPK), 73% versus 78% for pancreas after kidney transplant (PAK), and 77% versus 78% for pancreas transplant alone (PTA), mainly due to technical loss (19% in the PRT vs 9% in PT). However, with the significant growth in the number of pancreas transplants performed throughout the world and subsequent increase in the absolute number of graft losses, retransplants have become more frequent with gradually improving results. In this paper we present our experience with PRT in patients previously undergoing SPK, PAK, or PTA.
been previously removed, and in 6 (30%) this was performed at the same time as the retransplant. Venous drainage was placed on the iliac vessels in 14 (70%), vena cava in 5 (25%), and portal system in 1. The exocrine drainage was vesical in 16 (80%) and enteric in 4 (20%) cases. Immunosuppression was based on antilymphocyte preparations for 7 to 10 days with maintenance treatment using tacrolimus, mycophenolate mofetil, and steroids in all patients.
MATERIALS AND METHODS
DISCUSSION
From January 26, 1996 to February 2005, 285 pancreas transplants were performed, including 20 (7%) retransplants. In the RTP group, the recipient mean age was 34.3 years (range, 24 –51), and the mean interval between first graft loss and retransplant was 19.3 months (range, 3.9 –76.7). Among retransplanted patients, 14 (70%) had initially undergone SPK, 3 (15%) PAK, and 3 (15%) PTA. The causes of primary graft loss were graft thrombosis in 11 (55%, 7 venous and 4 arterial); 4 (20%) chronic rejection; 2 (10%) ischemia/reperfusion injury; 1 severe graft pancreatitis; 1 primary nonfunction; and 1 sepsis. In 14 cases (70%), the primary graft had
Pancreas transplantation is the most effective treatment to provide a cure for diabetes with sustained insulin-independent normoglycemia. It guarantees stabilization or regression of
RESULTS
There was one surgical complication (venous thrombosis) and one patient died because of sepsis. Three grafts were lost: one venous thrombosis, one arterial thrombosis in the same patient that died from sepsis, and one chronic rejection. Mean follow-up was 24 months (range, 4 –52). Oneyear patient and graft survivals were 95% and 85%. There was no additional risk when the primary graft was removed at the time of retransplant.
From HEPATO, Hepatology and Organ Transplantation Department, Albert Einstein Hospital, São Paulo, Brazil. Address reprint requests to Fábio C.M. Torricelli, Rua Vieira de Morais #74 ap. 111-A - Campo Belo, São Paulo, CEP 04617000, Brasil. E-mail: [email protected]
© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.06.055
Transplantation Proceedings, 38, 1937–1938 (2006)
1937
1938
secondary complications on long-term follow-up. According to the IPTR, approximately 20,000 pancreas transplants were reported through June 2003. The graft survival rates at 1 year (IPTR n ⫽ 5129) were 98.4%, 95%, and 94.9% for PTA, SPK, and PKA, respectively. Lower survival rates have been reported among retransplants by several authors, namely, around 90% for recipients and 61% for grafts. There was no relation between these results and the primary cause of graft loss.1,2 Others reports have shown a higher incidence of technical failures when compared to PT due to surgical difficulty, necessity of primary graft removal, and more extensive dissection.3 In our experience with 285 transplants, vascular thrombosis was the main cause of graft failure and PRT, like others have already published.4,5 However, PRT was not followed by higher rates of technical failure, showing the same late outcomes as PT. In conclusion, PRT is feasible, showing comparable results to PT. The removal of the pancreatic graft can be
GENZINI, CRESCENTINI, TORRICELLI ET AL
performed during the secondary transplantation without decreased success. These results encourage this treatment for diabetic patients who have lost their first pancreatic graft.
REFERENCES 1. Stratta RJ, Lowell JA, Sudan D, et al: Retransplantation in the diabetic patient with a pancreas allograft. Am J Surg 174:759, 1997 2. Sutherland DE, Gruessner RW, Dunn DL, et al: Lessons learned from more than 1,000 pancreas transplants at a single institution. Ann Surg 233:463, 2001 3. Humar A, Kandaswamy R, Drangstveit MB, et al: Surgical risks and outcome of pancreas retransplants. Surgery 127:634, 2000 4. Sansalone CV, Aseni P, Follini ML, et al: Early pancreas retransplantation for vascular thrombosis in simultaneous pancreaskidney transplants. Transplant Proc 30:253, 1998 5. Stratta RJ, Taylor RJ, Sudan D, et al: Experience with pancreas retransplantation. Transplant Proc 27:3020, 1995
P
ANCREAS RETRANSPLANTATION (PRT) is a procedure of higher risk than a primary transplant. According to the International Register of Pancreas Transplants (IPTR), graft survival after PRT from January 1999 to May 2003 was worse when compared with primary transplantation (PT) for all categories of pancreas transplantation: 69% versus 84% for simultaneous pancreas kidney transplant (SPK), 73% versus 78% for pancreas after kidney transplant (PAK), and 77% versus 78% for pancreas transplant alone (PTA), mainly due to technical loss (19% in the PRT vs 9% in PT). However, with the significant growth in the number of pancreas transplants performed throughout the world and subsequent increase in the absolute number of graft losses, retransplants have become more frequent with gradually improving results. In this paper we present our experience with PRT in patients previously undergoing SPK, PAK, or PTA.
been previously removed, and in 6 (30%) this was performed at the same time as the retransplant. Venous drainage was placed on the iliac vessels in 14 (70%), vena cava in 5 (25%), and portal system in 1. The exocrine drainage was vesical in 16 (80%) and enteric in 4 (20%) cases. Immunosuppression was based on antilymphocyte preparations for 7 to 10 days with maintenance treatment using tacrolimus, mycophenolate mofetil, and steroids in all patients.
MATERIALS AND METHODS
DISCUSSION
From January 26, 1996 to February 2005, 285 pancreas transplants were performed, including 20 (7%) retransplants. In the RTP group, the recipient mean age was 34.3 years (range, 24 –51), and the mean interval between first graft loss and retransplant was 19.3 months (range, 3.9 –76.7). Among retransplanted patients, 14 (70%) had initially undergone SPK, 3 (15%) PAK, and 3 (15%) PTA. The causes of primary graft loss were graft thrombosis in 11 (55%, 7 venous and 4 arterial); 4 (20%) chronic rejection; 2 (10%) ischemia/reperfusion injury; 1 severe graft pancreatitis; 1 primary nonfunction; and 1 sepsis. In 14 cases (70%), the primary graft had
Pancreas transplantation is the most effective treatment to provide a cure for diabetes with sustained insulin-independent normoglycemia. It guarantees stabilization or regression of
RESULTS
There was one surgical complication (venous thrombosis) and one patient died because of sepsis. Three grafts were lost: one venous thrombosis, one arterial thrombosis in the same patient that died from sepsis, and one chronic rejection. Mean follow-up was 24 months (range, 4 –52). Oneyear patient and graft survivals were 95% and 85%. There was no additional risk when the primary graft was removed at the time of retransplant.
From HEPATO, Hepatology and Organ Transplantation Department, Albert Einstein Hospital, São Paulo, Brazil. Address reprint requests to Fábio C.M. Torricelli, Rua Vieira de Morais #74 ap. 111-A - Campo Belo, São Paulo, CEP 04617000, Brasil. E-mail: [email protected]
© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.06.055
Transplantation Proceedings, 38, 1937–1938 (2006)
1937
1938
secondary complications on long-term follow-up. According to the IPTR, approximately 20,000 pancreas transplants were reported through June 2003. The graft survival rates at 1 year (IPTR n ⫽ 5129) were 98.4%, 95%, and 94.9% for PTA, SPK, and PKA, respectively. Lower survival rates have been reported among retransplants by several authors, namely, around 90% for recipients and 61% for grafts. There was no relation between these results and the primary cause of graft loss.1,2 Others reports have shown a higher incidence of technical failures when compared to PT due to surgical difficulty, necessity of primary graft removal, and more extensive dissection.3 In our experience with 285 transplants, vascular thrombosis was the main cause of graft failure and PRT, like others have already published.4,5 However, PRT was not followed by higher rates of technical failure, showing the same late outcomes as PT. In conclusion, PRT is feasible, showing comparable results to PT. The removal of the pancreatic graft can be
GENZINI, CRESCENTINI, TORRICELLI ET AL
performed during the secondary transplantation without decreased success. These results encourage this treatment for diabetic patients who have lost their first pancreatic graft.
REFERENCES 1. Stratta RJ, Lowell JA, Sudan D, et al: Retransplantation in the diabetic patient with a pancreas allograft. Am J Surg 174:759, 1997 2. Sutherland DE, Gruessner RW, Dunn DL, et al: Lessons learned from more than 1,000 pancreas transplants at a single institution. Ann Surg 233:463, 2001 3. Humar A, Kandaswamy R, Drangstveit MB, et al: Surgical risks and outcome of pancreas retransplants. Surgery 127:634, 2000 4. Sansalone CV, Aseni P, Follini ML, et al: Early pancreas retransplantation for vascular thrombosis in simultaneous pancreaskidney transplants. Transplant Proc 30:253, 1998 5. Stratta RJ, Taylor RJ, Sudan D, et al: Experience with pancreas retransplantation. Transplant Proc 27:3020, 1995