- Email: [email protected]
Preservation of the pancreas for transplantation
Preservation of the Pancreas for Transplantation R. Riege, M. Bu¨sing, and W. Kozuschek
D
URING the last two decades the number of pancreas transplantations has increased, not only in the United States but also in Europe. Developments of surgical techniques of organ procurement, transplantation, and organ preservation and the discovery of new immunosuppressive agents have yielded an improved outcome of patient survival and graft survival. Since 1976 a modified solution of Collins has been used for kidney transplantation in Europe, known as Euro-Collins Solution (EC solution).1,2 With regard to the different metabolism of the procured organs for transplantation, two other solutions for hypothermic storage have succeeded during the last few years: the University of Wisconsin solution (UW) by Belzer3,4 and the histidintryptophan-ketoglutarate solution (HTK) by Bretschneider.5–7 Due to the utilization of all available organs for transplantation and the clinical outcome of organ function, the UW solution is applied primarily for the intraabdominal organs, especially for the pancreas. The aim of employment is to prolong the time of preservation as long as will be needed without greater loss of viability to offer an organ to the best-matched patient concerning the criteria of organ division, including the time for the transport, for tissue matching, and for the reconstruction of blood supply. In the Eurotransplant community (ET) in most cases of multiorgan donors the liver and the pancreas have been harvested simultaneously, often by the transplantation team for the liver. Commonly, after preparation and decontamination of the duodenum the perfusion is done in situ by flushing the aorta and the vena portae with cold perfusion solution. At the same time the surface of the organs is cooled with topical ice slush. The celiac axis is retained with the liver graft and the superior mesenteric artery with the pancreas. The donor iliac artery bifurcation is taken for the reconstruction of the pancreatic blood supply. After separation and removal of the organs, the pancreas and the kidney will be stored with UW perfusion solution at 4°C. In the period from June 1994 until December 1997 we performed 100 simultaneous pancreas-kidney transplantations. In 83 cases the organs were harvested from transplantation teams in other centers, 9 pancreas-kidney grafts were procured from our team in related hospitals, and in 8 cases the organs were procured in our own center. The mean age of the donors was 27 years (10 to 53 years), nearly 45% of the donors died by traumatic disease of the brain. The UW
Table 1. Results of Early Pancreatic and Renal Function with UW-/HTK Solution UW Solution (number)
HTK Solution (number)
95 0 7 1 3
5 0 0 1 0
Immediate insulin independence Primary nonfunction Vascular thrombosis Graft pancreatitis Hemodialysis
solution was used in the preservation of 95 pancreas-kidney grafts and HTK solution in the preservation of 5 pancreas kidney grafts. The average cold-storage time for the pancreas was approximately 14 hours and 13.5 hours for the kidney (maximum: 23/22 hours). Placing the pancreas graft on the right side of the abdomen after reconstruction of the blood supply8 51 solid pancreas transplants were performed in bladder drainage and 49 in enteric drainage. Postoperative organ function results are shown in Table 1. Fasting blood glucose levels were normal immediately after pancreas transplantation in most patients. In these 100 pancreas grafts we registered no case of primary nonfunction but there were seven patients with vascular thrombosis (8%) in the early postoperative period, and the need of postoperative dialysis was 3%. Table 2 shows the pancreas graft survival in the early function and after 1 year according to the preservation time. Just one (1%) graft loss of 32 transplants were mentioned in the group of pancreas transplants stored up to 12 hours, 6 of 62 (6%), and 0 of 6 in the group of storage time between 12 to 18 hours and 18 to 24 Table 2. Pancreas Graft Survival Rates in the Early Function and After 1 Year According to the Preservation Time Preservation time (h) Early function (n ⫽ 100) After 1 year (n ⫽ 57)
⬍12 31/32 (99%) 16/21 (76%)
12–18 56/62 (90%) 25/34 (74%)
18 –24 6/6 (100%) 3/4 (75%)
From the Knappschaffs-Krankenhaus, Chirurgische Klinik, Ruhr-Universita¨t Bochum, Bochum, Germany. Address reprint requests to Knappschaffs-Krankenhaus, Chirurgische Klinik, Ruhr-Universita¨t Bochum, In der Schornau 23, 44892 Bochum, Germany.
© 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/99/$–see front matter PII S0041-1345(99)00273-0
Transplantation Proceedings, 31, 2095–2096 (1999)
2095
2096
hours, respectively. There was no case of pancreas transplantation with a cold storage of more than 24 hours. Retrospectively, 1-year survival rates of the pancreas grafts concerning the different groups of cold storage time are 76%, 74%, and 75%. The patient survival rate after 1 year is 93%. This results were comparable to those reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR).9 Due to the data that are shown it seems to be that the preservation time hasn’t been an influence in the longer outcome of pancreas transplant grafts. But it should be mentioned that the donors used for pancreas transplants were highly selected. We have noticed that the constellation of younger donors and short preservation time may be a good prediction for the pancreas graft outcome.
RIEGE, BU¨SING AND KOZUSCHEK
REFERENCES 1. Collins GM, Brava-Shugarman M, Treasaki PL: Lancet 2:1219, 1969 2. Dreikorn K, Horsch R, Ro ¨hl L: Eur Urol 6:221, 1980 3. Belzer FO, Southard JH: Transplantation 45:673, 1988 4. Ploeg R, Goossens JD, Sollinger HW, et al: Transplant Proc 21:1378, 1989 5. Kalayoglu M, Sollinger HW, D’Alessandro AM, et al: Lancet 1:617, 1988 6. Bretschneider HJ, Helmchen U, Kehrer G: Klin Wochenschr 66:817, 1988 7. Ho ¨ lscher M, Groenewoud AF: Transplant Proc 23:2334, 1991 8. Bu ¨sin M, Ko ¨veker G, Hopt UT, et al: Chirurgie 65:1130, 1994 9. Gruessner A, Sutherland DE: Clin Transpl 47, 1996
D
URING the last two decades the number of pancreas transplantations has increased, not only in the United States but also in Europe. Developments of surgical techniques of organ procurement, transplantation, and organ preservation and the discovery of new immunosuppressive agents have yielded an improved outcome of patient survival and graft survival. Since 1976 a modified solution of Collins has been used for kidney transplantation in Europe, known as Euro-Collins Solution (EC solution).1,2 With regard to the different metabolism of the procured organs for transplantation, two other solutions for hypothermic storage have succeeded during the last few years: the University of Wisconsin solution (UW) by Belzer3,4 and the histidintryptophan-ketoglutarate solution (HTK) by Bretschneider.5–7 Due to the utilization of all available organs for transplantation and the clinical outcome of organ function, the UW solution is applied primarily for the intraabdominal organs, especially for the pancreas. The aim of employment is to prolong the time of preservation as long as will be needed without greater loss of viability to offer an organ to the best-matched patient concerning the criteria of organ division, including the time for the transport, for tissue matching, and for the reconstruction of blood supply. In the Eurotransplant community (ET) in most cases of multiorgan donors the liver and the pancreas have been harvested simultaneously, often by the transplantation team for the liver. Commonly, after preparation and decontamination of the duodenum the perfusion is done in situ by flushing the aorta and the vena portae with cold perfusion solution. At the same time the surface of the organs is cooled with topical ice slush. The celiac axis is retained with the liver graft and the superior mesenteric artery with the pancreas. The donor iliac artery bifurcation is taken for the reconstruction of the pancreatic blood supply. After separation and removal of the organs, the pancreas and the kidney will be stored with UW perfusion solution at 4°C. In the period from June 1994 until December 1997 we performed 100 simultaneous pancreas-kidney transplantations. In 83 cases the organs were harvested from transplantation teams in other centers, 9 pancreas-kidney grafts were procured from our team in related hospitals, and in 8 cases the organs were procured in our own center. The mean age of the donors was 27 years (10 to 53 years), nearly 45% of the donors died by traumatic disease of the brain. The UW
Table 1. Results of Early Pancreatic and Renal Function with UW-/HTK Solution UW Solution (number)
HTK Solution (number)
95 0 7 1 3
5 0 0 1 0
Immediate insulin independence Primary nonfunction Vascular thrombosis Graft pancreatitis Hemodialysis
solution was used in the preservation of 95 pancreas-kidney grafts and HTK solution in the preservation of 5 pancreas kidney grafts. The average cold-storage time for the pancreas was approximately 14 hours and 13.5 hours for the kidney (maximum: 23/22 hours). Placing the pancreas graft on the right side of the abdomen after reconstruction of the blood supply8 51 solid pancreas transplants were performed in bladder drainage and 49 in enteric drainage. Postoperative organ function results are shown in Table 1. Fasting blood glucose levels were normal immediately after pancreas transplantation in most patients. In these 100 pancreas grafts we registered no case of primary nonfunction but there were seven patients with vascular thrombosis (8%) in the early postoperative period, and the need of postoperative dialysis was 3%. Table 2 shows the pancreas graft survival in the early function and after 1 year according to the preservation time. Just one (1%) graft loss of 32 transplants were mentioned in the group of pancreas transplants stored up to 12 hours, 6 of 62 (6%), and 0 of 6 in the group of storage time between 12 to 18 hours and 18 to 24 Table 2. Pancreas Graft Survival Rates in the Early Function and After 1 Year According to the Preservation Time Preservation time (h) Early function (n ⫽ 100) After 1 year (n ⫽ 57)
⬍12 31/32 (99%) 16/21 (76%)
12–18 56/62 (90%) 25/34 (74%)
18 –24 6/6 (100%) 3/4 (75%)
From the Knappschaffs-Krankenhaus, Chirurgische Klinik, Ruhr-Universita¨t Bochum, Bochum, Germany. Address reprint requests to Knappschaffs-Krankenhaus, Chirurgische Klinik, Ruhr-Universita¨t Bochum, In der Schornau 23, 44892 Bochum, Germany.
© 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/99/$–see front matter PII S0041-1345(99)00273-0
Transplantation Proceedings, 31, 2095–2096 (1999)
2095
2096
hours, respectively. There was no case of pancreas transplantation with a cold storage of more than 24 hours. Retrospectively, 1-year survival rates of the pancreas grafts concerning the different groups of cold storage time are 76%, 74%, and 75%. The patient survival rate after 1 year is 93%. This results were comparable to those reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR).9 Due to the data that are shown it seems to be that the preservation time hasn’t been an influence in the longer outcome of pancreas transplant grafts. But it should be mentioned that the donors used for pancreas transplants were highly selected. We have noticed that the constellation of younger donors and short preservation time may be a good prediction for the pancreas graft outcome.
RIEGE, BU¨SING AND KOZUSCHEK
REFERENCES 1. Collins GM, Brava-Shugarman M, Treasaki PL: Lancet 2:1219, 1969 2. Dreikorn K, Horsch R, Ro ¨hl L: Eur Urol 6:221, 1980 3. Belzer FO, Southard JH: Transplantation 45:673, 1988 4. Ploeg R, Goossens JD, Sollinger HW, et al: Transplant Proc 21:1378, 1989 5. Kalayoglu M, Sollinger HW, D’Alessandro AM, et al: Lancet 1:617, 1988 6. Bretschneider HJ, Helmchen U, Kehrer G: Klin Wochenschr 66:817, 1988 7. Ho ¨ lscher M, Groenewoud AF: Transplant Proc 23:2334, 1991 8. Bu ¨sin M, Ko ¨veker G, Hopt UT, et al: Chirurgie 65:1130, 1994 9. Gruessner A, Sutherland DE: Clin Transpl 47, 1996