Bladder vs enteric drainage in simultaneous pancreas-kidney transplantation.

BACKGROUND: As a valid therapeutic option for patients with type 1 diabetes mellitus (IDDM) and secondary diabetic nephropathy, simultaneous pancreas-kidney (SPK) transplantation remains more undeveloped than other solid organ transplantations due to restrictions of surgical techniques, especially modes of exocrine pancreatic secretion. Enteric drainage (ED) has recently been increasingly popular due to the long-term complications with bladder drainage (BD). Objectives. Compare results of SPK transplants with enteric vs bladder exocrine drainage since the beginning of our experience with this type of transplantation. METHODS: From March 1998 to October 2004, 53 SPK transplants were performed, consisting of 30 with bladder drainage (BD) and 23 with enteric drainage (ED). Induction therapy included antilymphocyte globulin (ALG) or anti-CD25 monoclonal antibody. Maintenance regimen consisted of tacrolimus (TAC)/cyclosporine (CsA), mycophenolate mofetil (MMF) and steroids. RESULTS: Mean age of recipients was 39+/-7 in both groups. No anastomosis leakage occurred in either group. Surgical complications were not significantly different between the two groups. Incidence of acute rejection, major infections and cytomegalovirus disease were also similar. However, the BD group was characterized by a slight increase in number of urologic complications, metabolic acidosis and dehydration. The length of initial hospital stay was likewise comparable. All patients with a functional graft no longer required exogenous insulin. BD actuarial patient survival and graft three-year survival were 96 and 86%, respectively. For ED, the respective results were 97 and 91%, respectively. CONCLUSION: Compared with BD, perioperative morbidity is not increased by ED, and ED is not associated with increased long-term pancreas graft failure. These data suggest that ED is superior to BD and should be considered as the preferred technique for simultaneous pancreas-kidney transplants.     

Hospital charges following simultaneous kidney–pancreas transplantation: enteric drainage versus bladder drainage

Background. Enteric drainage (ED) is associated with reduced morbidity compared with bladder drainage (BD) after simultaneous kidney–pancreas transplantation (SKPT) and is becoming increasingly common (more than 50% of SKPTs done in the US in 1998 were performed with enteric drainage). Although several studies have reported the morbidity and graft survival of ED compared with BD previously, there are limited data available comparing the length of stay and hospital charges between these two drainage procedures.
Methods. Fourteen SKPTs were performed during the period January 1995–May 1998 using BD and 20 during June 1998–August 1999 using ED. Hospital charges analyzed included the following categories: pharmacy, inpatient room, laboratory, operating room, medical–surgical supply, radiology/nuclear medicine, and miscellaneous. Organ acquisition charges and professional fees were not included in this analysis.
Results. The mean hospital stay for patients with ED was 7.8±2.2 d (range 5–12 d; median 7.5 d) compared with 15.9±7 d (range 8–38 d; median 15 d) for patients with BD (p=0.002). The mean hospital charges during initial hospitalization for the ED group were $36 582±11 424 compared with $64 555±29 054 for the BD group (p=0.005). There was a significant decrease in the charges relating to pharmacy, inpatient room, laboratory, radiology/nuclear medicine, and miscellaneous category in the ED group compared with the BD group, while the charges relating to operating room and medical–surgical supply were no different between the two groups. One‐year actuarial kidney and pancreas graft survival rates were 83% and 93%, respectively, for the BD group and 90% and 80%, respectively, for the ED group (p=NS).
Conclusions. SKPT patients with ED had a 43% reduction in hospital charges and equivalent pancreas and kidney graft survival rates compared with SKPT patients with BD. A shorter hospital stay and a reduction in pharmacy, radiology/nuclear medicine, and laboratory charges contributed to the decreased hospital charges in SKPT patients with ED.     

Pancreas-kidney transplantations with primary bladder drainage followed by enteric conversion: graft survival and outcomes

BACKGROUND: In the Leiden University Medical Centre, a two-step approach is routinely used in simultaneous pancreas-kidney (SPK) transplantations: primary bladder drainage (BD) followed by elective enteric conversion. The rationale for this approach is to prevent the short-term disadvantages of primary enteric drainage (intra-abdominal abscesses, pancreas graft loss) and the long-term urological complications related to bladder drainage. Aim of the present study is to evaluate survival and (urological) complications of this approach compared to enteric drainage (ED). METHODS: Patient records of all 98 SPK transplantations in the period 1997-2004 were reviewed for complications during the initial hospitalization until 30 days after discharge, and to assess urological complications and graft survival until the last hospital visit. Median duration of follow-up was 4.3 years for pancreas graft survival, 4.7 years for kidney graft survival, and 4.8 years for patient survival. RESULTS: Patient survival was significantly better in BD patients than in ED patients (chi2=9.89 P<0.01). Pancreas graft survival was also better in BD patients after adjustment for the longer pancreas warm ischemia time in BD patients (P=0.05). The survival rates in our patient population seem higher than reported by the International Pancreas Transplant Registry, particularly in BD patients. Urological complications occurred in nine BD patients (10.3%), comparable to the rates reported for enteric-drained grafts. CONCLUSIONS: This two-step approach of SPK transplantation results in excellent survival rates, with urological complication rates comparable to those reported for enteric-drained grafts, and may thus be viewed as a safe and effective procedure of SPK transplantation.     

A prospective comparison of bladder versus enteric drainage in vascularized pancreas transplantation

Although the number of pancreas transplants has increased significantly in previous years, debate continues concerning the optimum technique for exocrine pancreas drainage. Enteric drainage (ED) has recently been increasingly popular due to the long-term complications with bladder drainage (BD). We prospectively assigned 40 consecutive pancreas transplant recipients to either bladder (n = 20) or enteric (n = 20) drainage. Patient, kidney, and pancreas graft survival rates at 1 year after simultaneous kidney-pancreas transplantation were 95%, 95%, 85%, for BD group and 90%, 85%, 85% for ED group, respectively. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections, and CMV disease were similar between groups. The length of the initial hospital stay was likewise comparable. However, the BD group showed a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Based on the results of our study, patient and graft survivals were excellent irrespective of technique.     

A prospective comparison of bladder versus enteric drainage in vascularized pancreas transplantation

In previous years, the number of pancreas transplants has increased significantly. Debate continues over the optimum technique for exocrine drainage. Enteric drainage (ED) has recently been increasingly popular owing to the long-term complications of bladder drainage (BD). We prospectively evaluated 40 consecutive pancreas transplant recipients undergoing either bladder (n = 20) or enteric (n = 20) drainage. After simultaneous kidney-pancreas transplantation 1-year patient, kidney, and pancreas graft survival rates were 95%, 95%, 85% for the BD group, and 90%, 85%, 85%, for the ED group. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections and cytomegalovirus disease were also similar. The length of the initial hospital stay was likewise comparable. However, the BD group was characterized by a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Our results suggest excellent patient and graft survival irrespective of the drainage technique.     

An Evidence-Based Analysis of Simultaneous Pancreas-Kidney and Pancreas Transplantation Alone

While pancreas transplantation has evolved within two decades from a frustrating and poorly-accepted therapeutic option to a highly successful procedure, the respective benefits of the successive surgical and immunosuppressive developments have remained unclear. The aim of this study was to determine using an evidence-based methodology, which novel approaches have contributed to the current results and whether pancreas transplantation is cost-effective. Out of 2481 articles, 102 analyzed either surgical or immunosuppressive aspects of pancreas transplantation. Urological complications were more frequent in bladder over enteric drainage (range: 62-63% vs. 12-20%, p = 0.0001), but without significant difference in patient or graft survival. Portal drainage was associated with a trend toward fewer complications and better hyperinsulinemia control over systemic drainage in retrospective studies. Immunosuppression combining induction therapy, a calcineurin inhibitor, mycophenolate mophetil (MMF) and corticosteroids were associated with a 40% decreased incidence of rejection (p = 0.01) and an increase in graft survival above 90% at 1 year (p < 0.05). Pancreas transplantation is highly cost-effective compared to conservative alternatives. We conclude that despite a paucity of large studies, enteric drainage should be recommended but the benefits of portal venous drainage remain debated. Quadruple immunosuppression protocols including induction therapy should be the standard regimen.     

Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of June 2004

As of December 31, 2004, more than 23,000 pancreas transplant had been reported to the IPTR, >17,000 in the US and almost 6000 from outside the US. An analysis of US pancreas transplants performed between 1988 and 2003 showed a progressive improvement in outcome, with pancreas transplant graft survival rates (GSRs) going from 75% at 1 yr for 1988/1989 to 85% for 2002/2003 simultaneous pancreas-kidney (SPK) cases, from 55 to 78% for pancreas after kidney (PAK) cases, and from 45 to 77% for pancreas transplants alone (PTA) cases. The improvements were due both to decreases in technical failure (TF) rates (from 12 to 6% in SPK, 13-8% in PAK, and 24-7% in PTA) and immunological failure rates (going from 7 to 2% for SPK, from 28 to 7% for PAK, and from 38 to 8% for PTA cases). These results are even more impressive under the aspect that during the same time the rate of potential risk factors increased and the duct management techniques changed from bladder to enteric drainage. The improvement in outcome allowed also an increase in the number of solitary pancreas transplants from initially 12% to now 35%. Contemporary primary deceased donor pancreas transplant outcomes were calculated separately for 2000-2004 US and non-US cases. The US patient survival rates at 1 yr were >95% in each recipient category, with 1 yr primary pancreas GSRs of 85% for SPK, 78% for PAK, and 76% for PTA (p < 0.0001). The immunological graft failure rates for 2000-2004 technically successful (TS) SPK, PAK, and PTA cases were 2, 8, and 10% at 1 yr (p = 0.0001). In the majority of all transplants ED was used for duct management (81% of SPK, 67% of PAK, and 56% for PTA cases). Of the ED transplants, venous drainage via the portal system was used for 20% of SPK, 23% of PAK, and 35% of PTA cases. Duct management technique did not have a significant impact on overall pancreas graft function in the univariate or the multivariate model. The outcomes of ED and BD transplants are comparable with 85 vs. 87% at 1 yr for SPK, 77 vs. 80% for PAK, and 72 vs. 79% for PTA. The overall TF rate was higher in ED pancreas transplants but this difference did reach significance only in SPK. In addition, in technically successful PTA the immunological graft loss rate was higher in ED vs. BD transplants (15 vs. 5% at 1 yr). The different vascular management techniques did not seem to have an impact on the outcome of the pancreas transplants. Kidney GSRs were not significantly different for ED vs. BD SPK cases, 93 and 91% at 1 yr (p = 0.24). The overall conversion rate from BD to ED was 9% at 1 yr and 17% at 3 yr post-transplant. The most influential factor for patient survival in SPK and PAK in the multivariate and the univariate models was the status of the transplanted organ. The hazard ratio (HR) for a failed kidney was 14.99 in SPK and 9.17 in PAK (p = 0.0001). The HR for a failed pancreas graft was 3.51 in SPK and 4.17 for PAK (p = 0.0001). In PTA a failed pancreas graft did not have a direct impact on patient survival. SPK and PAK patients older than 44 yr at the time of transplants also showed an increased mortality risk, but at the same time the risk of immunological graft loss was significantly decreased for those patients. TAC&MMF remained the dominant maintenance immunosuppressant for 2000-2004 US cases (approximately two-third) in all three categories and with this regime 1-year GSRs were > or =80% in all three recipient categories. The results were comparable (> or =83% 1-year GSR) for patients (approximately 10%) treated with Sirolimus (SIR) under various protocols. In regard to non-US pancreas transplants, even for 2000-2004 the overwhelming majority continued to be in the SPK category (91%), with 1-year patient, kidney and pancreas survival rates of 94, 92, and 87%. Solitary transplants are still very rarely done outside the US. Non-US PAK GSR at 1 yr was 85%, non-US PTA GSR at 1 yr was 76%. In summary, with the new advancements in immunosuppression and changes in surgical techniques the outcomes in patient survival and pancreas transplant graft function continue to improve even with an increasing proportion of high risk patients in all three categories.     

Enteric conversion after pancreatic transplantation: resolution of symptoms and long-term results

Kleespies A, Mikhailov M, Khalil PN, Preissler G, Rentsch M, Arbogast H, Illner W‐D, Bruns CJ, Jauch K‐W, Angele MK. Enteric conversion after pancreatic transplantation: resolution of symptoms and long‐term results.
Clin Transplant 2011: 25: 549–560. © 2010 John Wiley & Sons A/S. Abstract: Purpose: Bladder drainage (BD) of pancreatic transplants is associated with a unique set of complications. We intended to analyze the incidence, indications, complications and long‐term results of enteric conversion procedures (EC). Methods: Using a prospective database, 32 EC patients out of 433 simultaneous pancreas–kidney‐transplant (SPK) recipients were identified. Graft and patient survival rates were compared with those after primary enteric drainage (ED). Results: The mean SPK‐EC interval was 5.0 yr, and the mean patient follow‐up was 13.8 yr. Indications for EC were genitourinary symptoms (62.5%), duodenal complications (15.6%), graft pancreatitis (12.5%), pyelonephritis (6.3%), and metabolic acidosis (3.1%). All patients reported significant long‐term resolution of symptoms. Surgical complications, reoperations, early graft loss, and 30‐d mortality occurred in 31.3%, 25.0%, 6.3%, and 3.1% of cases, respectively. Pancreatic graft and patient survival rates at 1, 5, and 10 yr after SPK were comparable between EC patients and ED patients at the same institution. Conclusion: For the treatment of symptoms associated with BD, EC results in excellent long‐term graft function and significant resolution of symptoms even years after SPK. Postoperative morbidity after EC including early reoperation and graft loss, however, has to be considered.     

Experience with 53 portal–duodenal drained solitary pancreas transplants

Systemic–enteric drainage is currently the most common technique for pancreas transplantation (PT). A novel alternative technique, portal–duodenal drainage (PDD), has potential physiological benefits and provides improved monitoring of the pancreatic graft. The current study describes 53 solitary PT procedures (43 pancreas after kidney and 10 pancreas transplant alone) using the PDD technique over the last three yr. This method resulted in one‐yr patient survival at 96% and 83% graft survival. There were five cases (9.4%) of thrombosis, in which transplantectomy and two‐layer closure of the native duodenum were performed. No fistulas were observed. Here, we demonstrate that the PDD technique in PT was as safe and effective as current techniques in clinical use.     

Diagnosis, Management, and Outcome of Late Duodenal Complications in Portal–Enteric Pancreas Transplantation: Case Reports

Background: Enteric drainage (ED) of pancreas allografts is an alternative to the bladder drainage (BD) technique and eliminates unique metabolic complications seen in the BD pancreas transplant recipients. Little longterm data has been reported in ED pancreas transplants.

Study Design: Of 53 patients who underwent pancreas transplantations performed with ED drainage of the exocrine secretion to a Roux-en-Y limb, who had more than 6 months graft function, four patients were identified with late duodenal segment complications (more than 6 months after transplantation) and are presented as case reports.

Results: The duodenal segment complications occurred between 8 and 48 months after simultaneous pancreas–kidney transplantation. Three patients were diagnosed with leakage from the duodenal segment. All were managed operatively. The fourth patient developed a distal stricture of the transplant duodenum occluding the anastomosis between the duodenum and the Roux-en-Y limb and also had a pancreatic pseudocyst. Drainage via a cyst-jejunostomy resulted in graft salvage. The mean followup after operative management of the duodenal-related complications was 15 months (range, 3–24 months). The patient, pancreas and kidney graft survival are 100%.

Conclusions: Late duodenal complications occurred in 8% of pancreas transplant recipients with ED. Operative intervention in all four patients resulted in excellent graft and patient outcome and is recommended for these complications.     

The case for pancreas after kidney transplantation

Abstract:  Pancreas after kidney (PAK) transplantation has historically demonstrated inferior pancreas allograft survival compared to simultaneous pancreas and kidney (SPK) transplantation. Under our current immunosuppression protocol, we have noted excellent outcomes and rare immunological graft loss. The goal of this study was to compare pancreas allograft survival in PAK and SPK recipients using this regimen. This was a single center retrospective review of all SPK and PAK transplants performed between January 2003 and November 2007. All transplants were performed with systemic venous drainage and enteric exocrine drainage. Immunosuppression included induction with rabbit anti-thymocyte globulin (thymoglobulin), early steroid withdrawal, and maintenance with tacrolimus and sirolimus or mycophenolate mofetil. Study end points included graft and patient survival and immunosuppression related complications. Transplants included PAK 61 (30%) and SPK 142 (70%). One-yr patient survival was PAK 98% and SPK 95% (p = 0.44) and pancreas graft survival was PAK 95% and SPK 90% (p = 0.28). Acute cellular rejection was uncommon with 2% requiring treatment in each group. Survival for PAK using thymoglobulin induction, early steroid withdrawal and tacrolimus-based immunosuppression is at least comparable to SPK and should be pursued in the recipient with a potential living donor.     

Prognostic risk factors for graft failure following pancreas transplantation: results of multivariate analysis of data from the International Pancreas Transplant Registry

Abstract. A multivariate analysis of prognostic factors for graft failure was performed on patients in the International Pancreas Transplant Registry. The analysis was restricted to the period January 1978 to June 1987 and included 764 patients. All patients had at least 1 year of follow-up. The following variables were studied: transplant year, continent (N. America, Europe, others), type of donor (cadaver, living related mismatched, living related HLA-identical), donor mismatch at the HLA A, B loci, donor mismatch at the DR loci, preservation time, kidney association (pancreas transplant alone, simultaneous pancreas and kidney transplant, pancreas after kidney transplant), whole versus segmental pancreatic transplant, graft duct management technique (polymer injection, enteric drainage, stomach drainage, bladder drainage), and immunosuppression. By stepwise, logistic regression analysis, we found that the following factors were predictive for 1-year graft function: donor mismatch at the DR loci ( P = 0. 0003), kidney association ( P < 0. 0001), type of donor ( P = 0. 04), and immunosuppression ( P = 0. 0002). For donor mismatch at the DR loci, we found an odds ratio for success of 2. 2 for 0 versus 2 mismatches. The odds for success were 2. 9 for simultaneous pancreas and kidney transplant versus pancreas transplant alone. The best results-79% 1-year graft survival-were obtained for the combination of 0 mismatches at the DR loci, pancreas after kidney transplant, living related HLA-identical donor, and the immunosuppressive regimen consisting of cyclosporin, azathioprine, and prednisone. Patients receiving a pancreas transplant alone with 0 mismatches at the DR loci, living related HLA-identical donor, and triple immunosuppressive regimen had a predicted 1-year graft survival of 71%.     

Experience with 500 simultaneous pancreas-kidney transplants.

METHODS: From December 1985 to October 1997, 500 simultaneous pancreas-kidney transplants (SPKs) were performed at the University of Wisconsin. Bladder drainage (BD) was used in 388 and enteric drainage (ED) in 112. All pancreas transplants were preserved in UW solution. RESULTS: Patient survival at 1, 5, and 10 years was 96.4%, 88.6%, and 76.3%; kidney function, 88.6%, 80.3%, and 66.6%; and pancreas function, 87.5%, 78.1%, and 67.2%. Thrombosis of the pancreas occurred in three to four (0.6% to 0.8%) and primary nonfunction in one (0.2%). There was a 4.2% acute tubular necrosis rate for the kidney. Conversion from BD to ED was required in 24% of cases. Primary indications for enteric conversion (EC) were leak (14%), urethritis and extravasation (7%), and chronic hematuria (3%). No graft was lost as a result of EC. There was no difference in 1-year graft survival between ED and BD. Leading causes of pancreas loss were rejection in 45 patients and death with a functioning graft in 27 patients. Since June 1995, mycophenolate mofetil was used for immunosuppression (n = 109). One-year survival rates with mycophenolate mofetil are patient, 98.1 %; kidney, 94.2%; and pancreas, 93.1%. Steroid-resistant rejections decreased from 48% to 15%. CONCLUSIONS: This series represents the world's largest experience with SPK, including the longest follow-up for BD pancreatic transplants. Ten-year graft survival rates exceed those of all other transplants, with the exception of HLA-identical living-related grafts. This series confirms that SPK is a highly successful procedure for selected diabetic patients with renal failure.     

The use of low dose octreotide prophylaxis in pancreatic transplants with enteric drainage. Results of a prospective randomized single center trial

AIM: The aim of this study was to investigate the effect of octreotide in the perioperative course of pancreas transplants drained into the bowel in terms of fistula formation, pancreatitis, hemorrhage and thrombosis, and to compare the results to patients not receiving octreotide in a prospectively, randomized single center trial. PATIENTS AND METHODS: Forty pancreas transplant recipients were prospectively randomized to either receive or not to receive octreotide 0.1 mg subcutaneously at the time of operation and 3x/d there after until post-operative day 7. The incidence of pancreatic leakage from the anastomosis and the content of peritoneal fluid drainage regarding amylase and lipase concentrations collected by abdominal drains were registered on day 0-10. Both groups were comparable for age, sex, onset of diabetes, surgical procedure and immunosuppressive regimen. RESULTS: There were 35 simultaneous pancreas-kidney transplants and five solitary pancreas transplants, two in the octreotide and three in the control group two pancreas after kidney, one pancreas after liver pancreas, one pancreas after simultaneous pancreas kidney transplantation, one pancreas transplant alone. All had enteric drainage. Twenty patients received octreotide and 20 did not. In one patient, receiving octreotide the pancreas had to be removed for septic complications because of an enteric fistula arising from the anastomosis (1/20 = 5%). The incidence in patients on octreotide vs. non-octreotide was 1 vs. 0 for pancreatitis, 2 vs. 3 for hemorrhage, 2 vs. 1 for thrombosis and 2 vs. 0 for pancreatic fistulae resulting in an actual overall 12 months patient survival of 100% in both groups and a pancreas survival of 85% vs. 95%. For primary simulaneous pancreas kidney the pancreas graft survival was 93%. The amylase and lipase concentrations of fluid collections drained into the peritoneum on day 0 to 10 post-operatively indicating pancreatic fistulization was comparable in both groups. CONCLUSION: The use of octreotide following pancreas transplantation did not prevent pancreatic fistula formation from the anastomosis neither from the pancreatic capsule in pancreas transplantation with enteric drainage. Further studies are required to finally evaluate the benefit of this prophylactic treatment.     

Duodenoduodenostomy in pancreas transplantation

Enteric drainage (ED) using duodenojejunostomy (DJ) is an established technique in pancreatic transplantation. Duodenoduodenostomy (DD), an alternative ED technique, may provide unique advantages over DJ. We compared our experience with these two types of ED through a retrospective review of all pancreas transplants performed at our institution from November 2007 to November 2009. The allograft duodenum was anastomosed to the recipient jejunum or duodenum. Duodenal drainage was performed by a stapled or hand-sewn technique. Patient demographics, operative times, major post-operative complications, and graft survival data were analyzed. Of 57 pancreas transplants, DJ was performed in 36 patients, stapled DD in 14 patients, and hand-sewn DD in seven patients. Two DD grafts (9.5%) thrombosed compared with no DJ grafts (p = NS). Enteric leak and small-bowel obstruction occurred in 3 of 36 DJ patients and in two DD patients (p = NS). Gastrointestinal bleeding occurred more frequently in stapled DD compared with DJ (4 vs. 0, p < 0.015). In conclusion, DD is technically feasible with no increase in operative time or enteric complications. GI bleeding rates appear to be higher following DD (stapled) technique. Potential complications of DD should be balanced against the benefits conferred by this technique.     

Pancreas Transplantation From Living Donors: A Single Center Experience of 20 Cases

Living donor pancreas transplantation (LDPT) has several advantages over deceased donor pancreas transplantation (DDPT), including better HLA matching, shorter ischemic time, and shorter waiting time. It remains an attractive option for diabetes mellitus (DM) patients with end stage renal disease. We reviewed 20 cases of LDPT performed in Asan Medical Center between October 1992 and March 2015. Six cases (30%) were pancreas transplantation alone (PTA), and the rest (70%) were simultaneous pancreas and kidney transplantation (SPK). Relations of donor and recipient were parents in 7 (35%), siblings in 6 (30%), spouse in 6 (30%), and cousin in 1 (5%). Graft survival in SPK at 1, 3, 5, and 10 years was 91.7%, 83.3%, 83.3%, and 83.3%, respectively, and that in PTA recipients was 50%, 33.3%, 16.7%, and 16.7%, respectively (p = 0.005). Causes of graft failure in SPK were thrombosis (one case), and rejection (one case), whereas those in PTA were noncompliance (two cases), thrombosis (one case), reflux pancreatitis (one case), and chronic rejection (one case). In terms of pancreas exocrine drainage, two grafts (25%) maintained their function in bladder drainage, while all grafts maintained in enteric drainage p < 0.05). Seven (35%) donors experienced minor pancreatic juice leakage and one underwent reoperation due to postoperative hematoma. Most donors maintained normoglycemia and normal renal function. However, two donors developed DM (at 1 and 90 months postdonation), and were treated with oral hypoglycemic agents. Graft survival in PTA recipients was poorer than in SPK due to poor compliance and bladder drainage–related problems. The surgical and metabolic complication rates of donors can be minimized by applying strict donor criteria. Therefore, LDPT with enteric drainage is an acceptable treatment for SPK.     

Enteric conversion after bladder‐drained pancreas transplantation is not associated with worse allograft survival

In the early experience of pancreas transplantation, bladder drainage was favored, but it often caused urologic, metabolic, and infectious complications that necessitated conversion to enteric drainage. Long‐term graft survival after enteric conversion and the impact of time interval from transplantation to enteric conversion on graft survival is poorly understood. We studied all bladder‐drained first‐time pancreas transplantations performed at the University of Wisconsin from 1985 to 2000. Time to conversion was estimated with the Kaplan‐Meier technique, whereas risk factors associated with conversion were estimated via a time‐varying Cox proportional hazards model. Of 386 bladder‐drained pancreata, 162 (41.9%) eventually required enteric conversion, 29 (17.9%) within the first year. Median time to conversion varied by indication: 0.68 years for surgical, 3.1 years for urologic, and 2.7 years for metabolic disorders. In a time‐varying Cox model adjusting for donor and recipient factors, enteric conversion did not affect the risk of pancreas graft loss (hazard ratio [HR] 0.86, P = .26). Kidney survival was not associated with enteric conversion. When necessary due to symptoms or complications, enteric conversion of bladder‐drained pancreata is safe and does not affect overall graft survival. This relationship appears to be true no matter when the conversion is performed.     

胰肾联合移植的外科并发症分析

目的：总结分析胰肾一期联合移植(SPK)外科并发症的发生情况、原因和处理方式。方法：12例Ⅰ型糖尿病合并尿毒症患者施行了SPK，最初2例应用胰液膀胱引流(BD)术式，另10例为改进的胰液空肠引流（ED）术式。术后早期采用他克莫司(FK506)／环孢素A(CsA)加霉酚酸酯(MMF)、皮质激素、抗淋巴细胞球蛋白(ALG)或抗CD25单抗四联诱导治疗，以后改为三联维持。抗凝治疗使用肝素和低分子右旋糖酐。结果：12例手术均获成功，术后移植胰、移植肾功能恢复良好，停用了外源性胰岛素。外科近期并发症；腹腔感染3例，切口感染2例，分别经引流、换药后二期愈合；肾周血肿2例，经手术探查、清理后好转，多与抗凝剂短期应用过量有关。远期并发症：2例BD术式患者长期存在化学性膀胱炎，其中1例发生2次反流性移植物胰腺炎，经保守治疗后好转。所有病例术后均未发生吻合口漏和移植物血管血栓形成等严重并发症。结论：外科并发症的综合防治是SPK成功的关键之一。     

Retroperitoneal pancreas transplantation with systemic-enteric drainage--case report

Enteric drainage and intraperitoneal graft position is the preferred technique for pancreas transplantation at most transplant centers. The technique of retroperitoneal pancreas transplantation was first described by Boggi et al. [Transplantation,79 (2005), 1137]. In this case report, a modified model of retroperitoneal pancreas transplantation with systemic-enteric drainage is presented. A 48-yr-old patient underwent combined retroperitoneal pancreas and kidney transplantation because of type-I-diabetes, and diabetic nephropathy. At the time of transplantation, the patient had a body mass index of 31 and severe atherosclerosis of the iliac vessels. After mobilization of the colon and mesocolon ascendens, the vessels of the pancreas graft were anastomosed end-to-side to the aorta and to the inferior caval vein of the recipient. For exocrinous drainage, a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the right colon mesentery. The graft was in a retroperitoneal position. The patient was insulin-independent after 48 h, the lipase and amylase levels were within the normal range. The first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed that the technique was safe and had technical advantages when compared with the classic method.     

Allograft pancreatectomy after pancreas transplantation with systemic-bladder versus portal-enteric drainage

From 1989 to 1997, we performed 159 pancreas transplantations (PTXs), including 117 simultaneous kidney PTX (SKPT), 25 PTXs alone (PTA), and 17 sequential PTXs after kidney transplantations (PAKT). A total of 73 PTXs were performed with systemic-bladder (S-B) and 86 with portal-enteric (P-E) drainage. The need for allograft pancreatectomy (PCTY) may be considered as an index of technical morbidity after PTX. A total of 37 PCTYs (23%) were performed at a mean of 4.7 months after PTX. Twenty-seven PCTYs were performed within 1 month, 30 (81%) within 3 months, and the remaining seven more than 6 months after PTX. The incidence of PCTY did not differ according to type of transplantation: simultaneous kidney PTX (SKPT) (23%), PTA (24%), and PAKT (23.5%). Indications for PCTY were thrombosis (23), rejection (9), infection (3), and pancreatitis (2). During the study, a total of 70 pancreas grafts were lost, with PCTY performed in 37 (53%). PCTY was directly related to the timing of graft loss; 77% of grafts lost within 3 months of PTX required PCTY, while 25% of grafts lost after 3 months resulted in PCTY (p < 0.01). The incidence of graft failure resulting in PCTY was similar according to type of transplantation: SKPT (55%), PTA (46%), and PAKT (50%). The incidence of PCTY was also similar according to technique of transplantation: 26% S-B versus 21% P-E, p = NS. However, the incidence of graft failure resulting in PCTY was higher in P-E (69%) versus S-B (43%) (p < 0.05) PTX recipients. Patient and kidney graft survival and pancreas retransplant graft survival rates were higher in PTX recipients with P-E drainage. CONCLUSIONS: PCTY is performed in over half of cases of pancreas allograft loss and is directly related to the timing and cause of graft loss. The incidence of PCTY is neither related to the type nor technique of PTX. The lower overall incidence of graft loss after PTX with P-E drainage is offset by a higher incidence of PCTY in these grafts that fail. These results suggest that whole-organ PTX with P-E drainage does not place the patient at an increased risk for PCTY and does not preclude successful pancreas retransplantation.