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Simultaneous Pancreas-Kidney Transplantation From Living Donor Using Hand-Assisted Laparoscopic Donor Surgery: Single-Center Experience
Simultaneous Pancreas-Kidney Transplantation From Living Donor Using Hand-Assisted Laparoscopic Donor Surgery: Single-Center Experience K.-T. Parka, H. Junb, M.-G. Kimc, Y.J. Boob, and C.W. Jungb,* a Department of Surgery, National Medical University of Mongolia, Ulaanbaatar, Mongolia; bDepartment of Surgery, Korea University Anam Hospital, Seoul, Korea; and cDepartment of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
ABSTRACT Background. Simultaneous pancreas-kidney (SPK) transplantation has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency. Most pancreas transplantations are dependent on deceased donors, yet the waiting time for SPK transplantation from deceased donors is significantly long in Asian countries. Methods. In 3 cases, living-donor SPK transplantation was performed with the use of handassisted laparoscopic donor surgery (HALS). Three cases of patients who underwent SPK transplantation from living donors (LDSPK) with the use of HALS at Korea University Anam Hospital from 2012 to 2013 were retrospectively reviewed regarding patient characteristics and clinical outcomes of donors and recipients. For the donors, the pancreas and renal function had been well preserved postoperatively. Results. One donor had a pancreatic fistula, which was controlled with conservative management. Of the 3 cases of recipient operation, 1 case was performed by ABO incompatibility donor. The levels of creatinine, serum insulin, and C-peptide of recipients were normalized and remained stable at the last follow-up. Conclusions. LDSPK can be an efficient alternative in cases in which the deceased donor is not present at the proper time, depending on the degree of completion in the operator’s skill.
D
IABETES mellitus is one of the leading chronic diseases of childhood and adolescence [1]. Simultaneous pancreas-kidney transplantation (SPK) has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency [2]. Most pancreas transplantations are dependent on deceased donors. However, the use of pancreas from live donors is a good alternative with several advantages and comparable results [3,4]. Furthermore, many countries are without law establishment regarding brain death. Living donors remain the only source. Living-donor SPK transplantation (LDSPK) was performed for the first time in March 1994 [5]. Since then, this procedure has become more popular; more than 155 cases have been performed globally [6]. Despite the fact that the pancreas was the first extra-renal solid organ for which a live donor was successfully used [7], pancreas transplantation from living donors has not become
as widespread as kidney or liver transplantation because of the lack of significant donors, recipient morbidity, and technical difficulty [6]. Most important is the safety of a living donor hemi-pancreatectomy and minimization of the risk of becoming diabetic [6]. Herein, 3 cases of LDSPK with the use of hand-assisted laparoscopic donor surgery (HALS) are reported. MATERIALS AND METHODS Three patients who underwent LDSPK with the use of HALS at Korea University Anam Hospital from 2012 to 2013 were retrospectively reviewed regarding patient characteristics and clinical outcomes of
*Address correspondence to Cheol Woong Jung, Inchon-ro 73, Seongbuk-Gu, Seoul 136-705, Republic of Korea. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.10.063
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
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Transplantation Proceedings, 47, 1096e1098 (2015)
SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION
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Table 1. Patient Characteristics and Clinical Outcomes of Donors and Recipients
Donor Age/sex Body mass index HbA1c, %/total Hb C-peptide(basal), uIU/mL Hospital stay, days Complication, postoperatively Recipient Age/sex Relation to donor ABO donor/recipient Duration of type 1 DM Duration of dialysis Amount of insulin, (iu/day), preop POD 1M Hb A1c, preop POD 1M C-peptide, preop POD 1M Creatinine, preop POD 1M Hospital stay, days Complication
Case 1
Case 2
Case 3
31 Male 22.0 4.5 1.30 8 None
31 Female 26.5 5.6 1.48 7
41 Female 21.1 5.1 1.58 7 None
28 Female Brother Aþ/Aþ 13 years 5 years (HD) 30 None 8.5 4.5 9.50 1.78 10.05 0.46 14 None
38 Male Husband Aþ/Bþ 18 years 1 year (PD) 64 metformin 30 mg 6.9 5.4 9.46 2.61 12.20 0.92 23 None
33 Female Sister Aþ/Aþ 13 years 2 years (HD) 30 None 5.7 5.4 6.89 1.93 14.41 0.91 28 Post-op bleeding
Abbreviations: DM, diabetes mellitus; HD, hemodialysis; PD, peritoneal dialysis; POD, postoperative day.
donors and recipients (Table 1). Regarding the donor’s operation, the entire procedure is performed with the patient in a full lateral decubitus position on the flexed operating table. The incision for the hand port was made in midline, just above the umbilicus. The first 11-mm port was inserted at the midclavicular line on the margin of the rectus muscle through hand guidance. Another12-mm port that was placed lateral to the previous port. A 5-mm trocar was placed at the costal margin on the mid-clavicular line (Fig 1). For the recipient’s operation, an end-to-side anastomosis of the donor splenic vein to the recipient common iliac vein and the splenic artery to the external iliac artery were performed. The pancreatic graft was anastomosed to a Roux-en-Y segment of recipient bowel that was created at the time. For immunosuppression, anti-thymocyte globulin was used for induction, and steroid withdrawal was done at postoperative day 7. If there was no active bleeding after operation, anti-coagulation therapy was routinely performed with the use of intravenous heparin from postoperative day 1.
RESULTS
For the donors, the pancreas and renal function had been well preserved postoperatively. One donor had a pancreatic
fistula, which was controlled with conservative management. Of 3 cases of recipient operation, 1 case was performed with the use of an ABO-incompatible donor. One recipient had significant postoperative bleeding that required a transfusion of 10 pints of packed red blood cells for 3 days because of the routine anti-coagulation therapy to prevent the vascular thrombosis. However, bleeding was controlled with conservative management. In all recipients, the kidney and pancreas graft function were immediate. There was no rejection episode. The levels of creatinine, serum insulin, and C-peptide of recipients were normalized and remained stable at the last follow-up (Table 1). DISCUSSION
Diabetes mellitus is one of the leading chronic diseases of childhood and adolescence [1]. The crude prevalence of total diabetes was estimated at 1.82 cases per 1000 youths in the United States [1]. The average age at diagnosis was 8.4 years, and the cumulative prevalence of micro-albuminuria,
Fig 1. (A, B) Laparoscopy port placement for left nephrectomy and pancreatectomy with the use of a low transverse incision of the hand-assisted port.
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which is the earliest sign of diabetic nephropathy, was 26% after 10 years of diabetes and 51% after 19 years of diabetes [1,8]. Unmanaged diabetes can cause significant long-term microvascular complications, such as retinopathy, neuropathy, and nephropathy [1,8,9]. Nephropathy is one of the most life-threatening complications, culminating in endstage renal disease) [1,2,8]. Even though tight glycemic control can slow the progress and reduce the risk of developing complications, it cannot sustain normoglycemia and stop the progression of diabetic complications [10]. SPK has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency [2]. Most pancreas transplantations are dependent on deceased donors (DDs). The first livingdonor (LD) pancreas transplant that used a segmental graft was performed at the University of Minnesota Hospital on June 20, 1979 [11]. LDSPK was performed for the first time in March 1994 [5]. There are many advantages of the use of living donors for pancreas transplants. Most of all, it eliminates waiting time and obviates the high mortality rate of waiting for a DD [3,4,6]. In addition, an LD provides the only realistic opportunity for pancreas transplant in highly sensitized recipients through pre-conditioning. This also enables the transplantation of two organs from an LD during one operation, with minimal preservation injury [3,4,9]. LD pancreas transplants had high technical failure rates at the beginning, but, presently, rates are less than that with DDs [4]. In recent data, the patients and graft survival also did not differ significantly between LD and DD groups and was even better in early graft functions shown in an HLA-identical LD group [9]. Donor safety has been the most important consideration in the conduction of LDSPK. There is no doubt that the evaluation of the outcome of LDSPK should be focused not only on the recipient but also on the donor. Potential complications of the donor operation, with its large incision and long recovery time, reduce the number of donations [3]. In this respect, less-invasive HALS procedures are expected to increase the donor pool. Surgical complications, such as intra-operative or postoperative bleeding, pancreatic leak, and pancreatic fistula, are fewer than 5%, and no donor mortality has been reported [4]. However, most of these complications frequently require an invasive procedure and a prolonged hospital stay. In our cases, one donor had a pancreatic fistula, which, fortunately, was controlled with conservative management. To diminish surgical complications, meticulous hemostasis and selective ligation of the main pancreatic duct are required [6]. Metabolic complications for LDs are also significant issues. The donor selection criteria should optimize the quality of the donated organ and protect the donor [12]. Donors must undergo a thorough pre-transplant endocrinologic workup to minimize the risk of metabolic
PARK, JUN, KIM ET AL
complications [6]. Donors with high body mass index must be avoided for pancreas donation [12,13]. CONCLUSIONS
LDSPK can be an efficient alternative in cases in which a DD is not present at the proper time, depending on the degree of completion in the operator’s skill. It also can be safely performed on both donors and recipients with results comparable to DDs. To determine the donor safety, future long-term follow-up studies are mandatory. REFERENCES [1] SEARCH for Diabetes in Youth Group, Liese AD, D’Agostino Jr RB, Hamman RF, et al. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006;118:1510e8. [2] Sutherland DE, Gruessner RW, Dunn DL, et al. Lessons learned from more than 1,000 pancreas transplants at a single institutions. Ann Surg 2001;233:463e501. [3] Zielinski D, Nazarewski S, Bogetti D, et al. Simultaneous pancreas-kidney transplant from living related donor: a single center experience. Transplantation 2003;76:547e52. [4] Sutherland DE, Radosevich D, Gruessner RW, et al. Pushing the envelope: living donor pancreas transplantation. Curr Opin Organ Transplant 2012;17:106e15. [5] Gruessner RW, Leone JP, Sutherland DE. Combined kidney and pancreas transplants from living donors. Transplant Proc 1998;30:282. [6] Reynoso JF, Gruessner CE, Sutherland DE, Gruessner RW. Short- and long-term outcome for living pancreas donors. J Hepatobiliary Pancreat Sci 2010;17:92e6. [7] Sutherland DE, Goetz FC, Najarian JS. Living-related donor segmental pancreatectomy for transplantation. Transplant Proc 1980;12:19e25. [8] Amin R, Widmer B, Prevost AT, et al. Risk of microalbuminuria and progression to macroalbuminuria in a cohort with childhood onset type 1 diabetes: prospective observational study. BMJ 2008;336:697e701. [9] Rayhill SC, D’Alessandro AM, Odorico JS, et al. Simultaneous pancreas-kidney transplantation and living related donor renal transplantation in patients with diabetes: is there a difference in survival? Ann Surg 2000;231:417e23. [10] Jiang AT, BHSc, Rowe N, et al. Simultaneous pancreaskidney transplantation: the role in the treatment of type 1 diabetes and end-stage renal disease. Can Urol Assoc J 2014;8: 135e8. [11] Sutherland DE, Goetz FC, Najarian JS. Report of twelve clinical cases of segmental pancreas transplantation at the University of Minnesota. Transplant Proc 1980;12:33e9. [12] Matsumoto I, Shinzeki M, Asari S, et al. Evaluation of glucose metabolism after distal pancreatectomy according to the donor criteria of the living donor pancreas transplantation guidelines proposed by the Japanese Pancreas and Islet Transplantation Association. Transplant Proc 2014;46:958e62. [13] Robertson RP, Lanz KJ, Sutherland DE, Seaquist ER. Relationship between diabetes and obesity 9 to 18 years after hemipancreatectomy and transplantation in donors and recipients. Transplantation 2002;73:736e41.
ABSTRACT Background. Simultaneous pancreas-kidney (SPK) transplantation has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency. Most pancreas transplantations are dependent on deceased donors, yet the waiting time for SPK transplantation from deceased donors is significantly long in Asian countries. Methods. In 3 cases, living-donor SPK transplantation was performed with the use of handassisted laparoscopic donor surgery (HALS). Three cases of patients who underwent SPK transplantation from living donors (LDSPK) with the use of HALS at Korea University Anam Hospital from 2012 to 2013 were retrospectively reviewed regarding patient characteristics and clinical outcomes of donors and recipients. For the donors, the pancreas and renal function had been well preserved postoperatively. Results. One donor had a pancreatic fistula, which was controlled with conservative management. Of the 3 cases of recipient operation, 1 case was performed by ABO incompatibility donor. The levels of creatinine, serum insulin, and C-peptide of recipients were normalized and remained stable at the last follow-up. Conclusions. LDSPK can be an efficient alternative in cases in which the deceased donor is not present at the proper time, depending on the degree of completion in the operator’s skill.
D
IABETES mellitus is one of the leading chronic diseases of childhood and adolescence [1]. Simultaneous pancreas-kidney transplantation (SPK) has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency [2]. Most pancreas transplantations are dependent on deceased donors. However, the use of pancreas from live donors is a good alternative with several advantages and comparable results [3,4]. Furthermore, many countries are without law establishment regarding brain death. Living donors remain the only source. Living-donor SPK transplantation (LDSPK) was performed for the first time in March 1994 [5]. Since then, this procedure has become more popular; more than 155 cases have been performed globally [6]. Despite the fact that the pancreas was the first extra-renal solid organ for which a live donor was successfully used [7], pancreas transplantation from living donors has not become
as widespread as kidney or liver transplantation because of the lack of significant donors, recipient morbidity, and technical difficulty [6]. Most important is the safety of a living donor hemi-pancreatectomy and minimization of the risk of becoming diabetic [6]. Herein, 3 cases of LDSPK with the use of hand-assisted laparoscopic donor surgery (HALS) are reported. MATERIALS AND METHODS Three patients who underwent LDSPK with the use of HALS at Korea University Anam Hospital from 2012 to 2013 were retrospectively reviewed regarding patient characteristics and clinical outcomes of
*Address correspondence to Cheol Woong Jung, Inchon-ro 73, Seongbuk-Gu, Seoul 136-705, Republic of Korea. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.10.063
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1096
Transplantation Proceedings, 47, 1096e1098 (2015)
SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION
1097
Table 1. Patient Characteristics and Clinical Outcomes of Donors and Recipients
Donor Age/sex Body mass index HbA1c, %/total Hb C-peptide(basal), uIU/mL Hospital stay, days Complication, postoperatively Recipient Age/sex Relation to donor ABO donor/recipient Duration of type 1 DM Duration of dialysis Amount of insulin, (iu/day), preop POD 1M Hb A1c, preop POD 1M C-peptide, preop POD 1M Creatinine, preop POD 1M Hospital stay, days Complication
Case 1
Case 2
Case 3
31 Male 22.0 4.5 1.30 8 None
31 Female 26.5 5.6 1.48 7
41 Female 21.1 5.1 1.58 7 None
28 Female Brother Aþ/Aþ 13 years 5 years (HD) 30 None 8.5 4.5 9.50 1.78 10.05 0.46 14 None
38 Male Husband Aþ/Bþ 18 years 1 year (PD) 64 metformin 30 mg 6.9 5.4 9.46 2.61 12.20 0.92 23 None
33 Female Sister Aþ/Aþ 13 years 2 years (HD) 30 None 5.7 5.4 6.89 1.93 14.41 0.91 28 Post-op bleeding
Abbreviations: DM, diabetes mellitus; HD, hemodialysis; PD, peritoneal dialysis; POD, postoperative day.
donors and recipients (Table 1). Regarding the donor’s operation, the entire procedure is performed with the patient in a full lateral decubitus position on the flexed operating table. The incision for the hand port was made in midline, just above the umbilicus. The first 11-mm port was inserted at the midclavicular line on the margin of the rectus muscle through hand guidance. Another12-mm port that was placed lateral to the previous port. A 5-mm trocar was placed at the costal margin on the mid-clavicular line (Fig 1). For the recipient’s operation, an end-to-side anastomosis of the donor splenic vein to the recipient common iliac vein and the splenic artery to the external iliac artery were performed. The pancreatic graft was anastomosed to a Roux-en-Y segment of recipient bowel that was created at the time. For immunosuppression, anti-thymocyte globulin was used for induction, and steroid withdrawal was done at postoperative day 7. If there was no active bleeding after operation, anti-coagulation therapy was routinely performed with the use of intravenous heparin from postoperative day 1.
RESULTS
For the donors, the pancreas and renal function had been well preserved postoperatively. One donor had a pancreatic
fistula, which was controlled with conservative management. Of 3 cases of recipient operation, 1 case was performed with the use of an ABO-incompatible donor. One recipient had significant postoperative bleeding that required a transfusion of 10 pints of packed red blood cells for 3 days because of the routine anti-coagulation therapy to prevent the vascular thrombosis. However, bleeding was controlled with conservative management. In all recipients, the kidney and pancreas graft function were immediate. There was no rejection episode. The levels of creatinine, serum insulin, and C-peptide of recipients were normalized and remained stable at the last follow-up (Table 1). DISCUSSION
Diabetes mellitus is one of the leading chronic diseases of childhood and adolescence [1]. The crude prevalence of total diabetes was estimated at 1.82 cases per 1000 youths in the United States [1]. The average age at diagnosis was 8.4 years, and the cumulative prevalence of micro-albuminuria,
Fig 1. (A, B) Laparoscopy port placement for left nephrectomy and pancreatectomy with the use of a low transverse incision of the hand-assisted port.
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which is the earliest sign of diabetic nephropathy, was 26% after 10 years of diabetes and 51% after 19 years of diabetes [1,8]. Unmanaged diabetes can cause significant long-term microvascular complications, such as retinopathy, neuropathy, and nephropathy [1,8,9]. Nephropathy is one of the most life-threatening complications, culminating in endstage renal disease) [1,2,8]. Even though tight glycemic control can slow the progress and reduce the risk of developing complications, it cannot sustain normoglycemia and stop the progression of diabetic complications [10]. SPK has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency [2]. Most pancreas transplantations are dependent on deceased donors (DDs). The first livingdonor (LD) pancreas transplant that used a segmental graft was performed at the University of Minnesota Hospital on June 20, 1979 [11]. LDSPK was performed for the first time in March 1994 [5]. There are many advantages of the use of living donors for pancreas transplants. Most of all, it eliminates waiting time and obviates the high mortality rate of waiting for a DD [3,4,6]. In addition, an LD provides the only realistic opportunity for pancreas transplant in highly sensitized recipients through pre-conditioning. This also enables the transplantation of two organs from an LD during one operation, with minimal preservation injury [3,4,9]. LD pancreas transplants had high technical failure rates at the beginning, but, presently, rates are less than that with DDs [4]. In recent data, the patients and graft survival also did not differ significantly between LD and DD groups and was even better in early graft functions shown in an HLA-identical LD group [9]. Donor safety has been the most important consideration in the conduction of LDSPK. There is no doubt that the evaluation of the outcome of LDSPK should be focused not only on the recipient but also on the donor. Potential complications of the donor operation, with its large incision and long recovery time, reduce the number of donations [3]. In this respect, less-invasive HALS procedures are expected to increase the donor pool. Surgical complications, such as intra-operative or postoperative bleeding, pancreatic leak, and pancreatic fistula, are fewer than 5%, and no donor mortality has been reported [4]. However, most of these complications frequently require an invasive procedure and a prolonged hospital stay. In our cases, one donor had a pancreatic fistula, which, fortunately, was controlled with conservative management. To diminish surgical complications, meticulous hemostasis and selective ligation of the main pancreatic duct are required [6]. Metabolic complications for LDs are also significant issues. The donor selection criteria should optimize the quality of the donated organ and protect the donor [12]. Donors must undergo a thorough pre-transplant endocrinologic workup to minimize the risk of metabolic
PARK, JUN, KIM ET AL
complications [6]. Donors with high body mass index must be avoided for pancreas donation [12,13]. CONCLUSIONS
LDSPK can be an efficient alternative in cases in which a DD is not present at the proper time, depending on the degree of completion in the operator’s skill. It also can be safely performed on both donors and recipients with results comparable to DDs. To determine the donor safety, future long-term follow-up studies are mandatory. REFERENCES [1] SEARCH for Diabetes in Youth Group, Liese AD, D’Agostino Jr RB, Hamman RF, et al. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006;118:1510e8. [2] Sutherland DE, Gruessner RW, Dunn DL, et al. Lessons learned from more than 1,000 pancreas transplants at a single institutions. Ann Surg 2001;233:463e501. [3] Zielinski D, Nazarewski S, Bogetti D, et al. Simultaneous pancreas-kidney transplant from living related donor: a single center experience. Transplantation 2003;76:547e52. [4] Sutherland DE, Radosevich D, Gruessner RW, et al. Pushing the envelope: living donor pancreas transplantation. Curr Opin Organ Transplant 2012;17:106e15. [5] Gruessner RW, Leone JP, Sutherland DE. Combined kidney and pancreas transplants from living donors. Transplant Proc 1998;30:282. [6] Reynoso JF, Gruessner CE, Sutherland DE, Gruessner RW. Short- and long-term outcome for living pancreas donors. J Hepatobiliary Pancreat Sci 2010;17:92e6. [7] Sutherland DE, Goetz FC, Najarian JS. Living-related donor segmental pancreatectomy for transplantation. Transplant Proc 1980;12:19e25. [8] Amin R, Widmer B, Prevost AT, et al. Risk of microalbuminuria and progression to macroalbuminuria in a cohort with childhood onset type 1 diabetes: prospective observational study. BMJ 2008;336:697e701. [9] Rayhill SC, D’Alessandro AM, Odorico JS, et al. Simultaneous pancreas-kidney transplantation and living related donor renal transplantation in patients with diabetes: is there a difference in survival? Ann Surg 2000;231:417e23. [10] Jiang AT, BHSc, Rowe N, et al. Simultaneous pancreaskidney transplantation: the role in the treatment of type 1 diabetes and end-stage renal disease. Can Urol Assoc J 2014;8: 135e8. [11] Sutherland DE, Goetz FC, Najarian JS. Report of twelve clinical cases of segmental pancreas transplantation at the University of Minnesota. Transplant Proc 1980;12:33e9. [12] Matsumoto I, Shinzeki M, Asari S, et al. Evaluation of glucose metabolism after distal pancreatectomy according to the donor criteria of the living donor pancreas transplantation guidelines proposed by the Japanese Pancreas and Islet Transplantation Association. Transplant Proc 2014;46:958e62. [13] Robertson RP, Lanz KJ, Sutherland DE, Seaquist ER. Relationship between diabetes and obesity 9 to 18 years after hemipancreatectomy and transplantation in donors and recipients. Transplantation 2002;73:736e41.