|
1
|
Bharadwaj HR, Tan JK, Ali SH, Shah MH, Nicholas A, Ahmed KAHM, Irfan K, Dalal P, Mehta A, Awuah WA, Dhali A. Exploring the current provision of pancreatic transplantations in low- and middle-income countries: Current landscape, challenges, future prospects. World J Gastrointest Pathophysiol 2024; 15:94590. [DOI: 10.4291/wjgp.v15.i6.94590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 10/06/2024] [Accepted: 10/22/2024] [Indexed: 11/19/2024] Open
Abstract
This comprehensive review addresses the global health challenge of disparities in pancreas transplant access, particularly in low- and middle-income countries (LMICs) compared to high-income countries. Despite advancements in surgical techniques and immunosuppression for procedures like simultaneous pancreas-kidney, pancreas-after-kidney, and pancreas-transplant alone, LMICs face significant challenges, including limited infrastructure, financial constraints, and a shortage of skilled medical professionals. Donation after brain death remains constrained by sociocultural barriers. Region-specific analyses highlight progress in Latin America, Asia, Russia, and South Africa, showcasing the regional disparities in access and outcomes. Future prospects involve minimally invasive surgeries, telemedicine for enhanced post-operative care, international collaborations with organizations like the European Union of Medical Specialists, and robust funding networks to improve organ availability. In conclusion, the review underscores the importance of multifaceted strategies to address economic, sociocultural, and infrastructural barriers, aiming to improve accessibility, quality, and effectiveness of pancreas transplantation services in LMICs.
Collapse
Affiliation(s)
- Hareesha Rishab Bharadwaj
- Faculty of Biology Medicine and Health, University of Manchester, Manchester M13 9PL, United Kingdom
| | - Joecelyn Kirani Tan
- Faculty of Medicine, University of St Andrews, St Andrews KY16 9AJ, United Kingdom
| | - Syed Hasham Ali
- Faculty of Medicine, Dow Medical College, Karachi 74200, Pakistan
| | - Muhammad Hamza Shah
- School of Medicine, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - Aderinto Nicholas
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Ogbomosho 210214, Oyo, Nigeria
| | | | - Khansa Irfan
- School of Medicine, University of Central Lancashire, Preston PR2 1SG, United Kingdom
| | - Priyal Dalal
- School of Medicine, University of Central Lancashire, Preston PR2 1SG, United Kingdom
| | - Aashna Mehta
- Faculty of Medicine and Surgery, University of Debrecen, Debrecen 4032, Hungary
| | | | - Arkadeep Dhali
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom
- School of Medicine and Population Health, University of Sheffield, Sheffield S10 2HQ, United Kingdom
- Deanery of Clinical Sciences, The University of Edinburgh, Edinburgh EH16 4SB, United Kingdom
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9LN, United Kingdom
| |
Collapse
|
|
2
|
Khubutiya MS, Dmitriev IV, Zhuravel NS, Balkarov AG, Storozhev RV, Anisimov YA, Kondrashkin AS, Shmarina NV. Retroperitoneal pancreas transplantation with a Roux-en-Y duodenojejunostomy for exocrine drainage. BMC Surg 2024; 24:357. [PMID: 39538165 PMCID: PMC11562524 DOI: 10.1186/s12893-024-02658-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 11/05/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Pancreatic transplantation is the only definitive surgical treatment for diabetes mellitus. Currently, most transplant centers use enteric exocrine drainage of pancreatic secretions; however, experts disagree on which part of the gastrointestinal tract is preferable for enteric anastomosis. We analyzed the outcomes of retroperitoneal pancreatic transplantation with enteric drainage of pancreatic secretions. MATERIALS AND METHODS We evaluated the outcomes of 60 simultaneous retroperitoneal pancreas-kidney transplantations. Based on the type of enteric anastomosis, the patients were divided into two groups: the study group consisted of 10 patients who underwent enteric drainage via Roux-en-Y duodenojejunostomy, and the control group included 50 patients who underwent exocrine drainage via duodenoduodenal anastomosis. No statistically significant differences were observed between the groups in terms of the main parameters. RESULTS The rate of surgical complications did not differ significantly between the groups (p > 0.05). Clavien IVb complications occurred only in the control group (n = 4.8%). The in-hospital pancreatic graft survival rate in both groups was 80%, whereas the recipient survival rates were 90% and 84%, in the study and control groups, respectively (p < 0.05). CONCLUSION Retroperitoneal pancreatic transplantation with exocrine drainage via a Roux-en-Y duodenojejunostomy is an effective alternative technique that reduces the rate of severe surgical complications.
Collapse
Affiliation(s)
- Mogeli Sh Khubutiya
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
- Chair of Transplantology and Artificial Organs, The Russian University of Medicine, Moscow, Russia
| | - Ilya V Dmitriev
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
- Chair of Transplantology and Artificial Organs, Department of Continuous Medical Education , Pirogov Russian National Research Medical University, Moscow, Russia
| | - Nikita S Zhuravel
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia.
- Chair of Transplantology and Artificial Organs, The Russian University of Medicine, Moscow, Russia.
| | - Aslan G Balkarov
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
- Chair of Transplantology and Artificial Organs, Department of Continuous Medical Education , Pirogov Russian National Research Medical University, Moscow, Russia
- Research Institute for Healthcare Organization and Medical Management of Moscow Health Department, Moscow, Russia
| | - Roman V Storozhev
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
| | - Yuri A Anisimov
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
- Chair of Transplantology and Artificial Organs, The Russian University of Medicine, Moscow, Russia
| | - Alexander S Kondrashkin
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
- Chair of Transplantology and Artificial Organs, The Russian University of Medicine, Moscow, Russia
| | - Nonna V Shmarina
- Department of Kidney and Pancreas transplantation, N.V. Sklifosovsky Research Institute for Emergency Medicine of Moscow Health Department, Moscow, Russia
- Chair of Transplantology and Artificial Organs, Department of Continuous Medical Education , Pirogov Russian National Research Medical University, Moscow, Russia
| |
Collapse
|
|
3
|
Ray S, Hobeika C, Norgate A, Sawicka Z, Schiff J, Sapisochin G, McGilvray ID, Selzner M, Reichman TW, Shwaartz C. Evolving Trends in the Management of Duodenal Leaks After Pancreas Transplantation: A Single-Centre Experience. Transpl Int 2024; 37:13302. [PMID: 39376730 PMCID: PMC11456492 DOI: 10.3389/ti.2024.13302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 09/06/2024] [Indexed: 10/09/2024]
Abstract
Duodenal leaks (DL) contribute to most graft losses following pancreas transplantation. However, there is a paucity of literature comparing graft preservation approach versus upfront graft pancreatectomy in these patients. We reviewed all pancreas transplants performed in our institution between 2000 and 2020 and identified the recipients developing DL to compare based on their management: percutaneous drainage vs. operative graft preservation vs. upfront pancreatectomy. Of the 595 patients undergoing pancreas transplantation, 74 (12.4%) developed a duodenal leak with a median follow up of 108 months. Forty-five (61%) were managed by graft preservation strategies, with the rest being treated with upfront graft pancreatectomy. DL managed by graft preservation strategies had similar graft survival rates at 1 and 5-year compared to the matched cohort of population without DL (95% and 59% vs. 91% and 62%; p = 0.78). Multivariate analysis identified male recipient (OR: OR: 6.18; CI95%: 1.26-41.09; p = 0.04) to have higher odds of undergoing an upfront graft pancreatectomy. In appropriately selected recipients with DL, graft preservation strategies utilizing either interventional radiology guided percutaneous drainage or laparotomy with/without repair of leak can achieve comparable long-term graft survival rates compared to recipients without DL.
Collapse
Affiliation(s)
- Samrat Ray
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Hobeika
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, Paris-Cité University, Clichy, France
| | - Andrea Norgate
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Zaneta Sawicka
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jeffrey Schiff
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ian D. McGilvray
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Trevor W. Reichman
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Chaya Shwaartz
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
|
4
|
Ray S, Parmentier C, Kawamura M, Ganesh S, Nogueira E, Novoa FC, Hobeika C, Chu T, Kalimuthu SN, Selzner M, Reichman TW. Reanimating Pancreatic Grafts Subjected to Prolonged Cold Ischemic Injury Using Normothermic Ex Vivo Perfusion. Transplant Direct 2024; 10:e1620. [PMID: 38617463 PMCID: PMC11013695 DOI: 10.1097/txd.0000000000001620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 02/08/2024] [Accepted: 02/10/2024] [Indexed: 04/16/2024] Open
Abstract
Background Pancreas transplant volumes are limited because of poor utilization of "extended criteria grafts." Prolonged cold ischemia is a risk factor associated with poor allograft survival. We aimed to establish the feasibility of transplantation using grafts subjected to prolonged cold ischemia and determine whether these grafts could be optimized using normothermic ex vivo perfusion (NEVP) in a porcine model. Methods The study population consisted of 35 to 40 kg male Yorkshire pigs in an allotransplantation model with a 3-d survival plan for recipients. Control grafts were subjected to cold storage (CS) in a University of Wisconsin solution for 21 to 24 h (n = 6), whereas the test group received an additional 3 h NEVP after CS of 21 h (n = 5). Results The 3-d survival was 60% in the NEVP arm versus 0% in the control arm (P = 0.008; log rank). Graft parenchyma was 60% to 70% preserved in the NEVP arm at necropsy on gross appearance. In addition, the islet function was well preserved, and both the pancreas (including the islets) and the duodenal morphology were maintained histologically. The intravenous glucose tolerance test on the day of euthanasia was in the normoglycemic range for 80% of cases in the NEVP arm. Conclusions Optimization of pancreas grafts exposed to extended CS with NEVP seems promising at rescuing and reanimating these grafts for transplantation, resulting in significantly improved survival in a porcine pancreas transplant model.
Collapse
Affiliation(s)
- Samrat Ray
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Catherine Parmentier
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Masataka Kawamura
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sujani Ganesh
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Emmanuel Nogueira
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Francisco Calderon Novoa
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christian Hobeika
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tunpang Chu
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sangeetha N. Kalimuthu
- Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto, ON, Canada
| | - Markus Selzner
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Trevor W. Reichman
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
|
5
|
Betancur V, Zughul R, Ivanovic A, Madrazo BL, Castillo P, Casillas J, Alessandrino F. Ultrasound of pancreatic transplant complications: a primer for radiologists. Clin Radiol 2023; 78:861-871. [PMID: 37679209 DOI: 10.1016/j.crad.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/10/2023] [Accepted: 08/13/2023] [Indexed: 09/09/2023]
Abstract
Pancreatic transplantation is an established treatment for patients with type 1 diabetes patients and select type 2 diabetes patients, with excellent survival rates as graft health is evaluated through regular imaging and early detection of complications. Amongst the various imaging methods that may aid in diagnosis of pancreatic transplant complications, ultrasound is a widely available, quick, portable, and cost-effective technique, often used as the sole method to assess for pancreatic transplant complications. When assessing a patient with a pancreatic transplant, the radiologist should be methodical in assessing the vasculature, the pancreatic parenchyma, and the peripancreatic regions. Complications can be categorised based on time from transplant and type of complications, and include vascular, parenchymal, and enteric/anastomotic complications. Doppler has a major role in the diagnosis of vascular complications including arterial and venous thrombosis, arterial stenosis, pseudoaneurysms, and haematomas. Pancreatic complications include rejections and pancreatitis, and are often diagnosed through a combination of clinical, laboratory, and imaging findings, such as pancreatic heterogeneity or the presence of pancreatic pseudocysts. Enteric/anastomotic complications include leaks and bowel obstructions, and may require cross-sectional imaging in addition to ultrasound. This review covers the most common and high-impact vascular, parenchymal, and enteric/anastomotic complications that should be considered in every radiologist's search pattern when assessing a pancreatic graft, as well as their respective postoperative timeframes.
Collapse
Affiliation(s)
- V Betancur
- Leonard M. Miller School of Medicine, University of Miami, FL, USA
| | - R Zughul
- Department of Radiology, Jackson Memorial Hospital, Miami, FL, USA
| | - A Ivanovic
- Department of Diagnostic Imaging, Faculty of Medicine, Center for Radiology and MRI, Clinical Center of Serbia, Belgrade, Serbia
| | - B L Madrazo
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - P Castillo
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - J Casillas
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - F Alessandrino
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA.
| |
Collapse
|
|
6
|
Fleetwood VA, Falls C, Ohman J, Aziz A, Stalter L, Leverson G, Welch B, Kaufman DB, Al-Adra DP, Odorico JS. Post-pancreatic transplant enteric leaks: The role of the salvage operation. Am J Transplant 2022; 22:2052-2063. [PMID: 35593379 DOI: 10.1111/ajt.17094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 01/25/2023]
Abstract
Enteric drainage in pancreas transplantation is complicated by an enteric leak in 5%-8%, frequently necessitating pancreatectomy. Pancreatic salvage outcomes are not well studied. Risk factors for enteric leak were examined and outcomes of attempted graft salvage were compared to immediate pancreatectomy. Pancreas transplants performed between 1995 and 2018 were reviewed. Donor, recipient, and organ variables including demographics, donor type, ischemic time, kidney donor profile index, and pancreas donor risk index were analyzed. Among 1153 patients, 33 experienced enteric leaks (2.9%). Donors of allografts that developed leak were older (37.9y vs. 29.0y, p = .001), had higher KDPI (37% vs. 24%, p < .001), higher pancreas donor risk index (1.83 vs. 1.32, p < .001), and longer cold ischemic time (16.5 vs. 14.8 h, p = .03). Intra-abdominal abscess and higher blood loss decreased the chance of successful salvage. Enteric leak increased 6-month graft loss risk (HR 13.9[CI 8.5-22.9], p < .001). However, 50% (n = 12) of allografts undergoing attempted salvage survived long-term. After 6 months of pancreas graft survival, salvage and non-leak groups had similar 5-year graft survival (82.5% vs. 81.5%) and mortality (90.9% vs. 93.5%). Enteric leaks remain a challenging complication. Pancreatic allograft salvage can be attempted in suitable patients and accomplished in 50% of cases without significantly increased graft failure or mortality risk.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri, USA.,Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Cody Falls
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jakob Ohman
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Antony Aziz
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bridget Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David P Al-Adra
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
|
7
|
Aida N, Ito T, Kurihara K, Hiratsuka I, Shibata M, Suzuki A, Kenmochi T. Evaluation of the Efficacy and Effects of Common Hepatic Artery Reconstruction in Pancreas Transplantation: A Randomized Controlled Trial. J Clin Med 2022; 11:jcm11082258. [PMID: 35456349 PMCID: PMC9024615 DOI: 10.3390/jcm11082258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/14/2022] [Accepted: 04/16/2022] [Indexed: 02/07/2023] Open
Abstract
Maintenance of postoperative graft flow is important in pancreas transplantation. In Japan, reconstruction of the common hepatic artery is performed primarily to increase perfusion in the pancreatic head. We investigated the effects of common hepatic artery reconstruction on patient and graft survival and endocrine functions. Twenty-nine cases of pancreas transplantation were registered in the clinical trial. Of the 29 cases, four were excluded because of the risk of ischemia without reconstruction or complicated reconstruction due to a narrow artery. A total of 25 cases were randomized into two groups: 13 in the non-reconstructed group and 12 in the reconstructed group. The 1-year patient survival and graft survival rates of the non-reconstructed and reconstructed groups were 92.3% and 83.3%, and 91.7% and 82.5%, respectively. The incidence of complications in the two groups was comparable, with 38.5% (5/13 cases) in the non-reconstructed group and 33.3% (4/12 cases) in the reconstructed group. The results of the glucagon stimulation test and oral glucose tolerance test at 1 month and 1 year post-transplantation were comparable. Common hepatic artery reconstruction is not essential unless there is risk of ischemia. This study was registered at the University Hospital Medical Information Network Clinical Trials Registry under UMIN000027213.
Collapse
Affiliation(s)
- Naohiro Aida
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (T.I.); (K.K.); (T.K.)
- Correspondence: ; Tel.: +81-0562-93-2111; Fax: +81-0562-93-5125
| | - Taihei Ito
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (T.I.); (K.K.); (T.K.)
| | - Kei Kurihara
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (T.I.); (K.K.); (T.K.)
| | - Izumi Hiratsuka
- Department of Endocrinology, Diabetes and Metabolism, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (I.H.); (M.S.); (A.S.)
| | - Megumi Shibata
- Department of Endocrinology, Diabetes and Metabolism, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (I.H.); (M.S.); (A.S.)
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (I.H.); (M.S.); (A.S.)
| | - Takashi Kenmochi
- Department of Transplantation and Regenerative Medicine, School of Medicine, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan; (T.I.); (K.K.); (T.K.)
| |
Collapse
|
|
8
|
Ryu JH, Ko HJ, Shim JR, Lee TB, Yang KH, Kim T, Choi BH. Technical factors that minimize the occurrence of early graft failure in pancreas transplantation. Clin Transplant 2021; 35:e14455. [PMID: 34390276 DOI: 10.1111/ctr.14455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022]
Abstract
Pancreatic transplantation is the only treatment for insulin-dependent diabetes resulting in long-term euglycemia without exogenous insulin. However, pancreatic transplantation has become debatable following the improvements in the results of islet transplantation and artificial pancreas. Therefore, surgeons who perform pancreas transplants require the best surgical technique that can minimize technical failure. We aimed to report our experiences with pancreatic transplantations. We transplanted 65 pancreatic grafts between 2015 and 2020. Except for one death due to hypoxic brain damage after surgery, no postoperative technical failure was observed. We usually perform duodeno-duodenal anastomosis using the transperitoneal approach, with retrocolic placement of the graft pancreas. There was no leakage from the duodenum even after immunologic graft failure. To prevent venous thrombosis, which is the most common cause of technical failure, we used the inferior vena cava for anastomosis and added graft venoplasty with a patch of donor vena cava or aortic interposition graft to the bench procedure; subsequently, there were no cases of technical failure due to thrombosis post-transplantation. Therefore, the 1-year graft survival (insulin-free) rate was more than 95%. The improving the surgical technique will maintain pancreatic transplantation as the best treatment for insulin-dependent diabetes. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyo Jung Ko
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae Ryong Shim
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Kwang Ho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Taeun Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| |
Collapse
|
|
9
|
Tomimaru Y, Eguchi H, Doki Y, Ito T, Kenmochi T. Current state of pancreas transplantation in Japan based on the nationwide registry. Ann Gastroenterol Surg 2021; 5:494-501. [PMID: 34337298 PMCID: PMC8316743 DOI: 10.1002/ags3.12423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/08/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022] Open
Abstract
In Japan, 437 pancreas transplantations (PTx) were carried out between 2000 and 2019. Clinical data for all PTx cases are registered in the Japan Pancreas Transplant Registry of the Japan Society for Pancreas and Islet Transplantation. Here we analyzed the registry data to describe the current status of PTx in Japan. The 437 PTx included 410 from deceased donors (407 from brain-dead and 3 from non-heart-beating donors) and 27 from living donors. We investigated the clinical characteristics of the 410 PTx from deceased donors. The rate of marginal donors using expanded donor criteria was higher in Japan than in other countries. At 1/5/10 years post-PTx, the overall survival rates were 95.8%/94.2%/88.7%, and the graft survival rates were 85.9%/76.2%/67.4% for pancreas and 93.2%/90.8%/78.2% for kidney (non-censored for death). These rates were comparable to those in other countries. When stratified by PTx category, survival was significantly better following simultaneous pancreas-kidney transplantation (SPK) compared to pancreas-after-kidney transplantation (PAK) or PTx alone (PTA). Immunological rejection was more frequently the cause of graft loss in PAK/PTA cases than in SPK cases, potentially contributing to the poorer survival in PAK/PTA. These outcomes highlight two main concerns: substantial incidence of pancreas graft loss, and inferior outcomes after PAK/PTA. Overall, PTx outcome is favorable in Japan, despite the high rate of marginal donors. To improve outcomes, it is important to prevent and manage each cause of pancreas graft loss. Overcoming the poorer survival in PAK/PTA may require new immunosuppressive protocols or allogenic islet transplantation.
Collapse
Affiliation(s)
- Yoshito Tomimaru
- Japan Society for Pancreas & Islet TransplantationThe Japan Pancreas Transplant RegistrySuitaJapan
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Hidetoshi Eguchi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Toshinori Ito
- Japan Society for Pancreas & Islet TransplantationThe Japan Pancreas Transplant RegistrySuitaJapan
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan
| | - Takashi Kenmochi
- Japan Society for Pancreas & Islet TransplantationThe Japan Pancreas Transplant RegistrySuitaJapan
- Department of Transplantation and Regenerative MedicineSchool of MedicineFujita Health UniversityToyoakeJapan
| |
Collapse
|
|
10
|
Shapey IM, Summers A, Khambalia H, Yiannoullou P, Fullwood C, Hanley NA, Augustine T, Rutter MK, van Dellen D. Donor insulin therapy in intensive care predicts early outcomes after pancreas transplantation. Diabetologia 2021; 64:1375-1384. [PMID: 33665687 PMCID: PMC8099796 DOI: 10.1007/s00125-021-05411-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Abstract
AIMS/HYPOTHESIS Approximately 50% of organ donors develop hyperglycaemia in intensive care, which is managed with insulin therapy. We aimed to determine the relationships between donor insulin use (DIU) and graft failure in pancreas transplantation. METHODS UK Transplant Registry organ donor data were linked with national data from the UK solid pancreas transplant programme. All pancreas transplants performed between 2004 and 2016 with complete follow-up data were included. Logistic regression models determined associations between DIU and causes of graft failure within 3 months. Area under the receiver operating characteristic curve (aROC) and net reclassification improvement (NRI) assessed the added value of DIU as a predictor of graft failure. RESULTS In 2168 pancreas transplant recipients, 1112 (51%) donors were insulin-treated. DIU was associated with a higher risk of graft loss from isolated islet failure: OR (95% CI), 1.79 (1.05, 3.07), p = 0.03, and this relationship was duration/dose dependent. DIU was also associated with a higher risk of graft loss from anastomotic leak (2.72 [1.07, 6.92], p = 0.04) and a lower risk of graft loss from thrombosis (0.62 [0.39, 0.96], p = 0.03), although duration/dose-dependent relationships were only identified in pancreas transplant alone/pancreas after kidney transplant recipients with grafts failing due to thrombosis (0.86 [0.74, 0.99], p = 0.03). The relationships between donor insulin characteristics and isolated islet failure remained significant after adjusting for potential confounders: DIU 1.75 (1.02, 2.99), p = 0.04; duration 1.08 (1.01, 1.16), p = 0.03. In multivariable analyses, donor insulin characteristics remained significant predictors of lower risk of graft thrombosis in pancreas transplant alone/pancreas after kidney transplant recipients: DIU, 0.34 (0.13, 0.90), p = 0.03; insulin duration/dose, 0.02 (0.001, 0.85), p = 0.04. When data on insulin were added to models predicting isolated islet failure, a significant improvement in discrimination and risk reclassification was observed in all models: no DIU aROC 0.56; DIU aROC 0.57, p = 0.86; NRI 0.28, p < 0.00001; insulin duration aROC 0.60, p = 0.47; NRI 0.35, p < 0.00001. CONCLUSIONS/INTERPRETATION DIU predicts graft survival in pancreas transplant recipients. This assessment could help improve donor selection and thereby improve patient and graft outcomes.
Collapse
Affiliation(s)
- Iestyn M Shapey
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK.
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Angela Summers
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Hussein Khambalia
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Petros Yiannoullou
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Catherine Fullwood
- Department of Research and Innovation (Medical Statistics), Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Neil A Hanley
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
| | - Titus Augustine
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Martin K Rutter
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - David van Dellen
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK
- Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
|
11
|
Nawabi A, Kahle AC, Baral P, King CD, Nawabi P. Lymphangiography with lipiodol as a diagnostic and therapeutic approach for Chyle Leak ascites following Simultaneous Pancreas-Kidney Transplant. J Surg Case Rep 2021; 2021:rjab029. [PMID: 33747430 PMCID: PMC7955963 DOI: 10.1093/jscr/rjab029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022] Open
Abstract
Chylous ascites (CA) is the leakage of triglyceride-rich fluid into the peritoneal cavity. This most commonly occurs due to trauma of the lymphatic system. Recently, lymphangiography with lipiodol have been used with promising results in managing refractory postoperative CA. We present the case of a 35-year-old man who developed massive refractory CA post simultaneous pancreas-kidney (SPK) transplant. After conservative management with diet modifications failed, the patient underwent lymphangiography and lymph angioembolization using lipiodol. In this case report, we describe the use of lymphangiography as both a diagnostic and therapeutic approach to successfully manage large volume CA following SPK.
Collapse
Affiliation(s)
- Atta Nawabi
- The University of Kansas, Department of Surgery, 3901 Rainbow Blvd, M/S 2005, Kansas City, KS 66160, USA
| | - Adam C Kahle
- The University of Kansas, Department of Surgery, 3901 Rainbow Blvd, M/S 2005, Kansas City, KS 66160, USA
| | - Perel Baral
- The University of Kansas, Department of Surgery, 3901 Rainbow Blvd, M/S 2005, Kansas City, KS 66160, USA
| | - Clay D King
- Kansas City University, Kansas City, MO 64106, USA
| | | |
Collapse
|
|
12
|
Ferrer-Fàbrega J, Cano-Vargas B, Ventura-Aguiar P, Cárdenas G, García-Criado Á, López-Boado MA, Rull R, García R, Cuatrecasas M, Esmatjes E, Diekmann F, Fondevila C, Ricart MJ, Fernández-Cruz L, Fuster J, García-Valdecasas JC. Early intestinal complications following pancreas transplantation: lessons learned from over 300 cases - a retrospective single-center study. Transpl Int 2020; 34:139-152. [PMID: 33084117 DOI: 10.1111/tri.13775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/27/2020] [Accepted: 10/16/2020] [Indexed: 01/15/2023]
Abstract
Enteric complications remain a major cause of morbidity in the post-transplant period of pancreas transplantation despite improvements surgical technique. The aim of this single-center study was to analyze retrospectively the early intestinal complications and their potential relation with vascular events. From 2000 to 2016, 337 pancreas transplants were performed with systemic venous drainage. For exocrine secretion, intestinal drainage was done with hand-sewn anastomosis duodenojejunostomy. Twenty-three patients (6.8%) had early intestinal complications. Median age was 39 years (male: 65.2%). Median cold ischemia time was 11 h [IQR: 9-12.4]. Intestinal complications were intestinal obstruction (n = 7); paralytic ileus (n = 5); intestinal fistula without anastomotic dehiscence (n = 3); ischemic graft duodenum (n = 3); dehiscence of duodenojejunostomy (n = 4); and anastomotic dehiscence in jejunum after pancreas transplantectomy (n = 1). Eighteen cases required relaparotomy: adhesiolysis (n = 6); repeated laparotomy without findings (n = 1); transplantectomy (n = 6); primary leak closure (n = 3); re-positioning of the graft (n = 1); and intestinal resection (n = 1). Of the intestinal complications, 4 were associated with vascular thrombosis, resulting in two pancreatic graft losses. Enteric drainage with duodenum-jejunum anastomosis is safe and feasible, with a low rate of intra-abdominal complications. Vascular thrombosis associated with intestinal complications presents a risk factor for the viability of pancreatic grafts, so prevention and early detection is vital.
Collapse
Affiliation(s)
- Joana Ferrer-Fàbrega
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Brenda Cano-Vargas
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pedro Ventura-Aguiar
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Gabriel Cárdenas
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Miguel Angel López-Boado
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ramón Rull
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Rocío García
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miriam Cuatrecasas
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Department of Pathology, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Barcelona, Spain
| | - Enric Esmatjes
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Diabetes Unit, Department of Endocrinology and Nutrition, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Constantino Fondevila
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Barcelona, Spain
| | - Mª José Ricart
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Laureano Fernández-Cruz
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Josep Fuster
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Barcelona, Spain
| | - Juan Carlos García-Valdecasas
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Department of Surgery, Institute Clínic of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.,Network for Biomedical Research in Hepatic and Digestive Diseases (CIBERehd), Barcelona, Spain
| |
Collapse
|
|
13
|
Pinchuk AV, Dmitriev IV, Storozhev RV, Balkarov AG, Anisimov YA, Kondrashkin AS. [Pancreas transplantation followed by stumpless duodenal exocrine drainage]. Khirurgiia (Mosk) 2019:89-95. [PMID: 30855597 DOI: 10.17116/hirurgia201902189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreas transplantation followed by stumpless duodenal exocrine drainage was performed in 2 patients. Primary kidney and pancreas graft function was noted in both cases. Two procedures of pancreas transplantation followed by stumpless duodenal exocrine drainage were carried out for the first time. Perhaps, absent donor duodenal stump has several advantages for the further course of postoperative period that may be confirmed in prospective trials.
Collapse
Affiliation(s)
- A V Pinchuk
- Department of Pancreas and Kidney Transplantation of Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - I V Dmitriev
- Department of Pancreas and Kidney Transplantation of Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - R V Storozhev
- Department of Pancreas and Kidney Transplantation of Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - A G Balkarov
- Department of Pancreas and Kidney Transplantation of Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - Yu A Anisimov
- Department of Pancreas and Kidney Transplantation of Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - A S Kondrashkin
- Department of Pancreas and Kidney Transplantation of Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| |
Collapse
|
|
14
|
Retroperitoneal Pancreas Transplantation With the Use of Duodenal Drainage via "Button Technique": First Clinical Practice (Case Report). Transplant Proc 2018; 49:2347-2351. [PMID: 29198675 DOI: 10.1016/j.transproceed.2017.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The persistent relative high incidence of duodenum-associated surgical complications significantly reduces pancreas grafts' (PG) and recipients' survival rates. A 31-year-old female patient underwent retroperitoneal pancreas transplantation with the use of PG exocrine drainage into the recipient's duodenum via the "button technique" approach. An uncomplicated postoperative period with satisfactory function of both transplants (pancreas and kidney) was noted. This was the 1st time ever that the transplantation was performed with the use of retroperitoneal placement of the pancreas transplant and duodenal drainage via the "button technique" approach. It is possible that the absence of the duodenal stump in the donor's transplant has a number of benefits in the postoperative period, which can be confirmed during the follow-up observations.
Collapse
|
|
15
|
Pieroni E, Napoli N, Lombardo C, Marchetti P, Occhipinti M, Cappelli C, Caramella D, Consani G, Amorese G, De Maria M, Vistoli F, Boggi U. Duodenal graft complications requiring duodenectomy after pancreas and pancreas-kidney transplantation. Am J Transplant 2018; 18:1388-1396. [PMID: 29205793 DOI: 10.1111/ajt.14613] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/02/2017] [Accepted: 11/21/2017] [Indexed: 01/25/2023]
Abstract
Duodenal graft complications are poorly reported complications of pancreas transplantation that can result in graft loss. Excluding patients with early graft failure, after a median follow-up period of 126 months (range 23-198) duodenectomy was required in 14 of 312 pancreas transplants (4.5%). All patients were insulin-independent at the time of diagnosis. Reasons for duodenectomy included delayed duodenal graft perforation (n = 10, 71.5%) and refractory duodenal graft bleeding (n = 4, 28.5%). In patients with duodenal graft bleeding, a total duodenectomy was performed. In patients with duodenal graft perforation, preservation of a duodenal segment was possible in five patients but completion duodenectomy was necessary in one patient. After total duodenectomy, immediate enteric duct drainage was feasible in seven patients. In two patients, a pancreaticocutaneous fistula was created that was subsequently converted to enteric drainage in one patient. In the other patient, enteric fistulization occurred as a consequence of silent pressure perforation of the draining catheter on the ascending colon. After a mean follow-up period of 52 months (21-125), all patients were alive, well, and insulin-independent. An aggressive and timely surgical approach may permit graft rescue in patients with severe duodenal graft complications occurring after pancreas transplantation. Generalization of these results remains to be established.
Collapse
Affiliation(s)
- Erica Pieroni
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Carlo Lombardo
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Piero Marchetti
- Division of Metabolism and Cell Transplantation, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Margherita Occhipinti
- Division of Metabolism and Cell Transplantation, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Carla Cappelli
- Division of Radiology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Davide Caramella
- Division of Radiology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Giovanni Consani
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Maurizio De Maria
- Division of Urology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| |
Collapse
|
|
16
|
Abstract
PURPOSE OF REVIEW The surgical techniques of pancreas transplantation have been evolving and significantly improved over time. This article discusses different current techniques and their modifications. RECENT FINDING At this time, the most commonly used technique is systemic venous drainage (for venous outflow) and enteric drainage (for management of exocrine pancreatic secretions). However, new modifications of established techniques such as gastric or duodenal exocrine drainage and venous drainage to the inferior vena cava continue to be introduced. SUMMARY This article provides a state-of the-art review of the most prevalent up-to-date surgical techniques as well as a synopsis of their specific risks and benefits. The article also provides the most current registry data regarding utilization of different surgical techniques in the United State and worldwide.
Collapse
|
|
17
|
Techniques of pancreas graft salvage/indications for allograft pancreatectomy. Curr Opin Organ Transplant 2017; 21:405-11. [PMID: 27058314 DOI: 10.1097/mot.0000000000000318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite improvements in pancreas allograft outcome, graft complications remain a significant cause of morbidity and mortality. This review analyses the issues involved in the management of conditions that may require graft pancreatectomy, including the indications and techniques for graft salvage. RECENT FINDINGS With early recognition of graft complications, liberal use of radiological interventions, improved infection control, access to critical care and innovative surgical techniques, graft salvage is now feasible in many circumstances where graft pancreatectomy would previously have been necessary. SUMMARY The outcome of pancreas transplantation continues to improve with advances in the management of graft-threatening complications.
Collapse
|
|
18
|
Simultaneous Kidney-Pancreas Transplantation With an Original "Transverse Pancreas" Technique: Initial 9 Years' Experience With 56 Cases. Transplant Proc 2017; 49:1879-1882. [PMID: 28923641 DOI: 10.1016/j.transproceed.2017.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 04/07/2017] [Accepted: 04/27/2017] [Indexed: 11/22/2022]
Abstract
An innovative technique for pancreas transplantation is described. The main aspect consists of the horizontal positioning of the pancreas, which allows a better venous outflow, thus preventing thrombosis and graft loss. The program of pancreas transplantation in this national reference center for pancreatic and liver surgery was started in 2007; the initial results were considered poor, resulting in the loss of half of the grafts due to venous thrombosis. After analyzing the possible causes, this technique was proposed and successfully implemented, reducing the postoperative complications, particularly the problem of venous thrombosis. A detailed description of the new surgical technique is provided. The main clinical and demographic characteristics of the 56 patients who underwent the surgery are analyzed. The incidence of venous thrombosis was 5.3% (3 patients) and graft loss was 3.5% (2 patients). Due to the good results, this technique became the standard surgery for transplantation of the pancreas in our center. The technique proved to be safe and successful. Due to the unique pancreas graft implantation, we called it "transverse pancreas surgery."
Collapse
|
|
19
|
Al-Adra D, McGilvray I, Goldaracena N, Spetzler V, Laurence J, Norgate A, Marquez M, Greig P, Sapisochin G, Schiff J, Singh S, Selzner M, Cattral M. Preserving the Pancreas Graft: Outcomes of Surgical Repair of Duodenal Leaks in Enterically Drained Pancreas Allografts. Transplant Direct 2017; 3:e179. [PMID: 28706982 PMCID: PMC5498020 DOI: 10.1097/txd.0000000000000698] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/16/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Duodenal leak remains a major cause of morbidity and graft loss in pancreas transplant recipients. The role and efficacy of surgical and image-guided interventions to salvage enterically drained grafts with a duodenal leak has yet to be defined. METHODS We investigated the incidence, treatment, and outcome of duodenal leak in 426 pancreas transplantation recipients from 2000 to 2015. RESULTS Duodenal leak developed in 33 (7.8%) recipients after a median follow-up of 5.3 (range, 0.5-15.2) years. Most leaks occurred during the first year (n = 22; 67%), and most were located near the proximal and distal duodenal staple line. Graft pancreatectomy was performed in 8 patients as primary therapy because of unfavorable local and/or systemic conditions. Salvage was attempted in 25 patients using percutaneous drainage (n = 4), surgical drainage (n = 4), or surgical repair (n = 17). Percutaneous or surgical drainage failed to control the leak in 7 of these 8 patients, and all 7 ultimately required graft pancreatectomy for persistent leak and sepsis. Surgical repair salvaged 14 grafts, and 13 grafts continue to function after a median follow-up of 2.9 (range, 1.1-6.3) years after repair. CONCLUSIONS Our study shows that in selected patients a duodenal leak can be repaired successfully and safely in enterically drained grafts.
Collapse
Affiliation(s)
- David Al-Adra
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian McGilvray
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicolas Goldaracena
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vinzent Spetzler
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jerome Laurence
- Royal Prince Alfred Institute of Academic Surgery, University of Sydney, Sydney, Australia
| | - Andrea Norgate
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Max Marquez
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Greig
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sunita Singh
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
|
20
|
Amin I, Butler AJ, Defries G, Russell NK, Harper SJF, Jah A, Saeb-Parsy K, Pettigrew GJ, Watson CJE. A single-centre experience of Roux-en-Y enteric drainage for pancreas transplantation. Transpl Int 2017; 30:410-419. [DOI: 10.1111/tri.12920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/11/2016] [Accepted: 01/17/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Irum Amin
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Andrew J. Butler
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Gail Defries
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Neil K. Russell
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Simon J. F. Harper
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Asif Jah
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Kourosh Saeb-Parsy
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | - Gavin J. Pettigrew
- Department of Surgery; Addenbrooke's Hospital; University of Cambridge; Cambridge UK
| | | |
Collapse
|
|
21
|
Kumar S, Singh S, Kenwar DB, Rathi M, Bhadada S, Sharma A, Gupta V, Bhansali A, Lal A, Minz M. Management of Graft Duodenal Leak in Simultaneous Pancreas Kidney Transplant-a Case Report from India and Review of Literature. Indian J Surg 2016; 78:402-406. [PMID: 27994337 DOI: 10.1007/s12262-016-1548-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 08/14/2016] [Indexed: 11/30/2022] Open
Abstract
Pancreatic transplantation is currently the only effective cure for Type 1 diabetes mellitus. It allows long-term glycemic control without exogenous insulin and amelioration of secondary diabetic complications. In India, pancreas transplant has not yet established with only a single successful transplant reported so far in the literature. We report a 24-year-old Type 1 diabetic patient with renal failure who underwent a simultaneous pancreas kidney transplant. On postoperative day 15, he had leak from the graft duodenal stump for which a tube duodenostomy and proximal diversion enterostomy was done. He had a high output pancreatic fistula following the procedure which was managed conservatively. The tube duodenostomy was removed at three and half months and enterostomy closure with restoration of bowel continuity was done at 6 months. After a follow up of 7 months, patient is doing well with a serum creatinine of 0.8 mg/dl and normal blood sugars, not requiring any exogenous insulin or oral hypoglycemic drugs. Managing patients with graft duodenal complications after pancreas transplant is challenging. Tube duodenostomy is a safe option in management of duodenal leak, although can lead to a persistent pancreatic fistula. A proximal diversion enterostomy allows early oral feeding and avoids the cost as well as the long term complications associated with parenteral nutrition.
Collapse
Affiliation(s)
- Sunil Kumar
- Department of Renal Transplant Surgery, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Sarbpreet Singh
- Department of Renal Transplant Surgery, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Deepesh Benjamin Kenwar
- Department of Renal Transplant Surgery, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Manish Rathi
- Department of Nephrology, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Sanjay Bhadada
- Department of Endocrinology, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Vikas Gupta
- Department of General Surgery, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Anil Bhansali
- Department of Endocrinology, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Anupam Lal
- Department of Radiodiagnosis, Post graduate institute of medical education and research, Chandigarh, 160012 India
| | - Mukut Minz
- Department of Renal Transplant Surgery, Post graduate institute of medical education and research, Chandigarh, 160012 India
| |
Collapse
|