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Synchronous Pancreas–Kidney Transplantation With Portal Venous and Enteric Exocrine Drainage: Outcome in 70 Consecutive Cases
Synchronous Pancreas–Kidney Transplantation With Portal Venous and Enteric Exocrine Drainage: Outcome in 70 Consecutive Cases D.S. Bruce, K.A. Newell, E.S. Woodle, D.C. Cronin, H.P. Grewal, J.M. Millis, M. Ruebe, M.A. Josephson, and J.R. Thistlethwaite, Jr
S
YNCHRONOUS pancreas– kidney (SPK) transplantation with portal venous and enteric exocrine drainage (P/E)1,2 has been advocated to avoid the hyperinsulinemia, dehydration, cystitis, and metabolic acidosis seen with systemic venous and bladder exocrine drainage (S/B).3 However, P/E SPK precludes monitoring of urine amylase and incurs the theoretic risk of enteric leakage. Additionally, entering the gastrointestinal tract during a transplant procedure might conceivably increase the risk of perioperative intra-abdominal sepsis. This study examines patient and graft survival rates, technical complications, reoperations, infections, graft function, and days of hospitalization in 70 consecutive P/E SPK performed between January 1992 and August 1997. PATIENTS AND METHODS Seventy P/E SPK were performed between January 1992 and August 1997 using a technique described previously.4 Briefly, the kidney and pancreas allografts were both placed in intraperitoneal sites via a midline laparotomy. The pancreas was revascularized via the recipient’s right common iliac artery and superior mesenteric vein, and exocrine drainage was provided by a Roux-en-Y jejunal limb anastomosed to the allograft duodenum. These 70 consecutive P/E SPK were compared to 70 consecutive S/B SPK performed between January 1987 and November 1994. These groups were similar with respect to age (P/E, 39 6 8 years, S/B 35 6 8 y), sex (P/E, 46 males/24 females; S/B, 44 males/26 females), and HLA mismatches (P/E, 4.3 6 1.5; S/B, 3.8 6 1.5). Kaplan–Meier survival curves were compared using the logrank and Wilcoxon tests, while other variables were compared using a non-paired t-test.
RESULTS
One-year patient, pancreas, and kidney survival were 88%, 78%, and 79% for the P/E SPK group versus 94%, 88%, and 92% for the S/B SPK group; actuarial survival was not statistically significantly different by either the logrank or Wilcoxon test. To assess for a “learning curve” effect, survival curves were constructed for the initial and subsequent groups of 35 patients within the P/E group. One-year patient, pancreas, and kidney survival were 83%, 71%, and 80% for the first 35 P/E SPK versus 97%, 87%, and 85% for the last 35 P/E SPK; although there was a clear trend toward improved survival in the latter group, these values were also not statistically significantly different. Early ve0041-1345/98/$19.00 PII S0041-1345(97)01259-1 270
nous thrombosis led to the loss of three pancreata in the P/E group (4.2%) and six pancreata in the S/B group (8.4%; P 5 NS). Five pancreata in each group were lost to rejection; one pancreas in the P/E group was lost to isolated pancreas rejection. Two P/E pancreata were lost to late (10 months and 15 months) perforation of the allograft duodenum; there were no anastomotic leaks. In the S/B group, there were three exocrine leaks, none of which led to graft loss. One patient in the P/E group required operative drainage of an intra-abdominal abscess in the absence of exocrine leakage. First-year reoperation related to the pancreas allograft was required much less commonly in the P/E group relative to the S/B group (P/E, 14/70 patients [20%] versus S/B, 33/70 patients [47%]; P , .0005). Conversion to enteric drainage was done in 15 S/B patients (21%); the conversion operations in the S/B group accounted for much of the difference in reoperation rates between the two groups. First-year hospitalization was also decreased in the P/E group (37 6 28 days versus 62 6 40 days; P , .0005). The two groups were similar at 1 year with respect to serum creatinine (P/E 1.4 6 0.5 mg/dL versus S/B 1.6 6 0.6 mg/dL) and fasting glucose (P/E 94 6 12 mg/dL versus S/B 86 6 14 mg/dL). DISCUSSION
P/E and S/B SPK result in similar graft and patient survival. There was a statistically insignificant trend toward lowered graft and patient survival in P/E SPK, as well as a trend toward improved graft and patient survival later in the series, suggesting a “learning curve” effect. The data in this report address several concerns frequently raised concerning the P/E technique. First, the incidence of allograft thrombosis was lower in the P/E group (4.2%) than in the S/B group (8.4%). Second, there were no enteric anastomotic leaks in the P/E group. However, the two duodenal From the Section of Transplantation, Department of Surgery (D.S.B., K.A.N., E.S.W., D.C.C., H.P.G., J.M.M., M.R., J.R.T.), and Section of Nephrology, Department of Medicine (M.A.J.), University of Chicago, Chicago, Illinois, USA. Address reprint requests to Dr David S. Bruce, Section of Transplantation, M.C. 5026, Department of Surgery, University of Chicago, 5841 S. Maryland Avenue, Chicago, Illinois 60637. © 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 270–271 (1998)
SYNCHRONOUS PANCREAS–KIDNEY TRANSPLANTATION
perforations in the P/E group both led to graft loss, whereas none of the S/B allografts were lost due to exocrine leakage. Third, there was only one significant intraabdominal perioperative infection in the P/E group, arguing that entering the small bowel is not a major risk. Fourth, only one pancreas was lost to isolated rejection, which implies that the inability to monitor urine amylase is not a serious objection to this technique. Importantly, both total hospitalization and need for reoperation were substantially decreased in the P/E group. Given the well-known limitations of retrospective studies using
271
historical controls, a prospective trial comparing these techniques is warranted. REFERENCES 1. Gaber AO, Shokouh-Amiri H, Grewal HP, et al: Surg Gynecol Obstet 177:417, 1993 2. Gaber AO, Shokouh-Amiri MH, Hathaway DK, et al: Ann Surg 221:613, 1995 3. Nghiem DD, Corry RJ: Am J Surg 153:405, 1987 4. Newell KA, Bruce DS, Cronin DC, et al: Transplantation 62:1353, 1996
S
YNCHRONOUS pancreas– kidney (SPK) transplantation with portal venous and enteric exocrine drainage (P/E)1,2 has been advocated to avoid the hyperinsulinemia, dehydration, cystitis, and metabolic acidosis seen with systemic venous and bladder exocrine drainage (S/B).3 However, P/E SPK precludes monitoring of urine amylase and incurs the theoretic risk of enteric leakage. Additionally, entering the gastrointestinal tract during a transplant procedure might conceivably increase the risk of perioperative intra-abdominal sepsis. This study examines patient and graft survival rates, technical complications, reoperations, infections, graft function, and days of hospitalization in 70 consecutive P/E SPK performed between January 1992 and August 1997. PATIENTS AND METHODS Seventy P/E SPK were performed between January 1992 and August 1997 using a technique described previously.4 Briefly, the kidney and pancreas allografts were both placed in intraperitoneal sites via a midline laparotomy. The pancreas was revascularized via the recipient’s right common iliac artery and superior mesenteric vein, and exocrine drainage was provided by a Roux-en-Y jejunal limb anastomosed to the allograft duodenum. These 70 consecutive P/E SPK were compared to 70 consecutive S/B SPK performed between January 1987 and November 1994. These groups were similar with respect to age (P/E, 39 6 8 years, S/B 35 6 8 y), sex (P/E, 46 males/24 females; S/B, 44 males/26 females), and HLA mismatches (P/E, 4.3 6 1.5; S/B, 3.8 6 1.5). Kaplan–Meier survival curves were compared using the logrank and Wilcoxon tests, while other variables were compared using a non-paired t-test.
RESULTS
One-year patient, pancreas, and kidney survival were 88%, 78%, and 79% for the P/E SPK group versus 94%, 88%, and 92% for the S/B SPK group; actuarial survival was not statistically significantly different by either the logrank or Wilcoxon test. To assess for a “learning curve” effect, survival curves were constructed for the initial and subsequent groups of 35 patients within the P/E group. One-year patient, pancreas, and kidney survival were 83%, 71%, and 80% for the first 35 P/E SPK versus 97%, 87%, and 85% for the last 35 P/E SPK; although there was a clear trend toward improved survival in the latter group, these values were also not statistically significantly different. Early ve0041-1345/98/$19.00 PII S0041-1345(97)01259-1 270
nous thrombosis led to the loss of three pancreata in the P/E group (4.2%) and six pancreata in the S/B group (8.4%; P 5 NS). Five pancreata in each group were lost to rejection; one pancreas in the P/E group was lost to isolated pancreas rejection. Two P/E pancreata were lost to late (10 months and 15 months) perforation of the allograft duodenum; there were no anastomotic leaks. In the S/B group, there were three exocrine leaks, none of which led to graft loss. One patient in the P/E group required operative drainage of an intra-abdominal abscess in the absence of exocrine leakage. First-year reoperation related to the pancreas allograft was required much less commonly in the P/E group relative to the S/B group (P/E, 14/70 patients [20%] versus S/B, 33/70 patients [47%]; P , .0005). Conversion to enteric drainage was done in 15 S/B patients (21%); the conversion operations in the S/B group accounted for much of the difference in reoperation rates between the two groups. First-year hospitalization was also decreased in the P/E group (37 6 28 days versus 62 6 40 days; P , .0005). The two groups were similar at 1 year with respect to serum creatinine (P/E 1.4 6 0.5 mg/dL versus S/B 1.6 6 0.6 mg/dL) and fasting glucose (P/E 94 6 12 mg/dL versus S/B 86 6 14 mg/dL). DISCUSSION
P/E and S/B SPK result in similar graft and patient survival. There was a statistically insignificant trend toward lowered graft and patient survival in P/E SPK, as well as a trend toward improved graft and patient survival later in the series, suggesting a “learning curve” effect. The data in this report address several concerns frequently raised concerning the P/E technique. First, the incidence of allograft thrombosis was lower in the P/E group (4.2%) than in the S/B group (8.4%). Second, there were no enteric anastomotic leaks in the P/E group. However, the two duodenal From the Section of Transplantation, Department of Surgery (D.S.B., K.A.N., E.S.W., D.C.C., H.P.G., J.M.M., M.R., J.R.T.), and Section of Nephrology, Department of Medicine (M.A.J.), University of Chicago, Chicago, Illinois, USA. Address reprint requests to Dr David S. Bruce, Section of Transplantation, M.C. 5026, Department of Surgery, University of Chicago, 5841 S. Maryland Avenue, Chicago, Illinois 60637. © 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 270–271 (1998)
SYNCHRONOUS PANCREAS–KIDNEY TRANSPLANTATION
perforations in the P/E group both led to graft loss, whereas none of the S/B allografts were lost due to exocrine leakage. Third, there was only one significant intraabdominal perioperative infection in the P/E group, arguing that entering the small bowel is not a major risk. Fourth, only one pancreas was lost to isolated rejection, which implies that the inability to monitor urine amylase is not a serious objection to this technique. Importantly, both total hospitalization and need for reoperation were substantially decreased in the P/E group. Given the well-known limitations of retrospective studies using
271
historical controls, a prospective trial comparing these techniques is warranted. REFERENCES 1. Gaber AO, Shokouh-Amiri H, Grewal HP, et al: Surg Gynecol Obstet 177:417, 1993 2. Gaber AO, Shokouh-Amiri MH, Hathaway DK, et al: Ann Surg 221:613, 1995 3. Nghiem DD, Corry RJ: Am J Surg 153:405, 1987 4. Newell KA, Bruce DS, Cronin DC, et al: Transplantation 62:1353, 1996