Logistics and technique for procurement of intestinal, pancreatic, and hepatic grafts from the same donor

OBJECTIVE: To assess a technique for simultaneous recovery of the intestine, pancreas, and liver from the same donor. SUMMARY BACKGROUND DATA: With the more frequent use of pancreatic and intestinal transplantation, a procurement procedure is needed that permits retrieval of both organs as well as the liver from the same cadaveric donor for transplantation to different recipients. It is believed by many procurement officers and surgeons, however, that this objective is not technically feasible. METHODS: A technique for simultaneous recovery of the intestine, pancreas, and liver was used in 13 multiorgan cadaver donors during a 26-month period, with transplantation of the organs to 33 recipients. The intestine was removed from 11 donors separately and in continuity with the pancreas in the other 2. Six additional pancreases were excised and transplanted separately. Thirteen livers were retrieved, one of which was discarded because of steatorrhea. Ten of the remaining 12 livers were transplanted intact; the other 2 were split in situ and used as reduced-size hepatic allografts in four recipients. RESULTS: None of the 11 intestinal, 6 pancreatic, 2 intestinal-pancreatic, or 14 whole or partial liver allografts sustained serious ischemic injury or were lost as a result of technical complications. One liver recipient died 25 months after surgery of recurrent C virus hepatitis. The other 32 recipients had adequate allograft function with a mean follow-up of 8 months. CONCLUSION: It was possible using the described technique to retrieve intestine, pancreas, and liver allografts safely from the same donor and to transplant these organs to different recipients.     

Evolution of synchronous renal and pancreatic transplantation

The utilization of pancreatic transplantation as a therapeutic option in type I diabetics is dependent on demonstrating its safety and efficacy. A protocol for synchronous renal and segmental pancreatic transplantation, utilizing pancreaticocystostomy, was initiated in February 1985, and through December 1988, 44 patients (mean age 34.8 years) received dual allografts. At last follow-up, 25 patients had functioning kidneys, and 17 patients were insulin independent 4 to 50 months after transplantation, with a mean fasting blood glucose level of 86 mg/100 ml. As our experience increased, three factors were identified as reducing pancreatic allograft and patient survival: vascular thrombosis, inadequate control of pancreatic secretions, and coronary artery disease. As a result, our protocol was modified to include postoperative heparin, external stenting of the pancreaticocystostomy, and dipyridamole thallium testing to screen for coronary artery disease. With these modifications, technical failures and postoperative morbidity were reduced with a resultant increase in 6-month graft and patient survival. These results provide impetus for considering synchronous renal and pancreatic transplantation as a therapeutic option for type I diabetics with end-stage renal disease.     

Comparison of growth, neovascularization, and enzymatic function of fetal intestinal grafts in the omentum and renal capsule.

Fetal tissues are less immunogenic and may be a useful donor source for organ transplantation. This report compares the fate of fetal small bowel segments transplanted in the omentum and renal capsule of recipient syngeneic rats. Two-centimeter segments of fetal jejunum and ileum were obtained from 26 donor 19-day gestational age rat fetuses and transplanted into the subrenal capsule (n = 35) and omentum (n = 40) in syngeneic Fisher rats (weight, 150 g) as free grafts. No immunosuppression was used. At 2 weeks posttransplantation, the recipient rats underwent laparotomy and the grafts were evaluated for viability, growth, enzymatic function, and revascularization. Viable grafts were identified in 27 of 35 renal capsule grafts and 34 of 40 omental grafts. The order of magnitude of fetal growth in the omentum for jejunum was 16 +/- 10 versus ileum 23 +/- 9 (NS). However, in the renal capsule, ileal growth (15 +/- 6) was significantly greater than jejunum (8 +/- 5; P less than .01). Growth for both jejunal and ileal segments was greater in the omentum (P less than .02). The lumen of all omental grafts remained patent; however, 26 of 27 renal grafts had cystic dilatations and areas of obstruction. Microfil casts of the specimens showed vascular connections (neovascularization) between the graft and omentum, a normal serosal vascular pattern, and many submucosal capillary-like vessels. Maltase activity was measured in fetal grafts and compared with control pups bred on the same date as the donor animals. The grafts had a higher maltase level 33.4 +/- 34.6 mumol/min/g than controls 8.3 +/- 2.0 (P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)     

Urinary diversions and intestinal grafts in renal transplantation in children. Report of 8 cases

In a series of 400 transplantations, 8 children presented a severe lesion of the lower urinary tract requiring an intestinal graft to divert the urine or to replace the useless bladder: 4 cases of posterior urethral valves and 4 cases of neurogenic bladder. Four permanent urinary diversions and 4 bladder enlargements, including 3 temporary diversions, were performed. The sigmoid colon was used in 5 cases and the ileum was used in 3 cases. The preparation of the intestinal graft was always performed prior to the transplantation. The uretero-intestinal anastomosis included an antireflux device in 3 of the 8 cases. There were no deaths in this series. Three occlusions and 2 lymphoceles occurred in the immediate post-transplantation period, but were corrected by re-operation. Two cases of calculi occurred in the long term, one of which required operation. Moderate stenosis of the renal artery in one case resulted in systemic hypertension which was well controlled by medical treatment. An episode of acute pyelonephritis resolved rapidly with antibiotic treatment. Two cases of acidosis were corrected by salt supplementation. There was one case of early graft rejection on the 15th day and a delayed rejection after 18 months, leading to removal of the transplant. At the present time, 6 renal grafts function normally (75%) with a follow-up of 1 to 8 years.     

Host-derived enterocytes in intestinal grafts

Replacement of donor lymphoid tissue by lymphocytes of recipient origin is an established phenomenon in small bowel transplants. However, replacement of donor epithelial cells of bowel grafts by host cells has not been demonstrated. The objective of our study was to determine whether donor enterocytes are replaced by host-derived enterocytes in the intestinal allograft. Graft biopsy specimens, obtained from five human male recipients of female intestine, were examined for the presence of male enterocytes. The biopsies dated from 90 to 770 days posttransplant. Formalin-fixed 3-microm specimen sections were stained for X and Y chromosomes by fluorescent in situ hybridization technique. Fluorescent microscopy of the stained sections identified male enterocytes in four patients, with a percentage of male cells ranging from 0.09% to 0.26% of the total enterocyte mass. Using the fluorescent in situ hybridization technique, we demonstrated the presence of host-derived male (XY) enterocytes in the female intestinal graft.     

Biliary, pancreatic, and hepatic imaging for the general surgeon

Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.     

Acute effects of different immunosuppressive drugs on pancreatic,islet, renal,and arterial hepatic blood flow in anesthetized rats

The effects of four different immunosuppressive drugs on organ blood flow were investigated. Sprague-Dawley rats were injected intravenously with 0.2 ml of either 15-deoxyspergualin (DSG; 5 mg/kg body weight), RS 61443 (80 mg/kg body weight), FK 506 (0.5 mg/kg body weight), cyclosporin A (9.5 mg/kg body weight), or the vehicles used. At 15 or 60 min after injection of the drugs, the blood perfusion of the whole pancreas, the pancreatic islets, and the kidneys, as well as the arterial blood flow to the liver, were measured in anesthetized animals using a microsphere technique. Fifteen minutes after administration, both FK506 and DSG decreased the fraction of whole pancreatic blood flow diverted through the islets. FK 506 and cyclosporin A reduced renal blood flow, but only 60 min after injection of the drug. None of the drugs influenced hepatic blood flow. RS 61443 did not affect the blood flow of the organ systems investigated. These differences in the effects of the drugs tested on blood flow might have some important implications on their efficacy and side effects. Thus, in view of its lack of influence on organ blood flow, RS 61443 seems to be preferable, at least when compared with cyclosporin A and FK 506 in the context of organ transplantation.     

Epidemiology,risk factors,and impact of bacterial infections on outcomes for pancreatic grafts

We aimed to determine the epidemiology, risk factors, and impact of bacterial infection on pancreatic function after pancreas transplantation. Data for pancreas transplant recipients were retrospectively reviewed between 2000 and 2014 for at least 1 year. We collected and analyzed post‐transplant data for bacterial infection, morbidity, and mortality. During the study period, 312 pancreas transplants were performed. In total, 509 episodes of bacterial infection were diagnosed in 191 patients (61%). Multidrug‐resistant (MDR) organisms were present in 173 of the 513 isolated microorganisms (33%). Risk factors independently associated with bacterial infection were acute allograft rejection (OR 1.7, 95%CI 1.1‐3), the need for post‐transplant hemodialysis, (OR 5.3, 95%CI 1.8‐15.7) and surgical re‐intervention (OR 2.8, 95%CI 1.5‐5.1), which was also considered a risk factor for infections caused by MDR bacteria. Graft survival was associated with the occurrence of one or more episodes of bacterial infection (log‐rank test = 0.009). Surgical re‐intervention was independently associated with graft loss (OR 2.5, 95%CI 1.3‐4.7). To conclude, pancreas recipients frequently experienced bacterial infections associated with the need for hemodialysis or surgical re‐intervention. Infection by MDR organisms is a growing concern in these patients and was related to graft survival. Graft loss was independently associated with surgical re‐intervention.     

Renal failure in ascites secondary to hepatic, renal, and pancreatic disease. Treatment with a LeVeen peritoneovenous shunt

Renal failure occurs in ascites of diverse causes. Functional renal failure (the hepatorenal syndrome) in cirrhotic patients is usually progressive and rapidly fatal. Insertion of a LeVeen shunt significantly reduces weight, as well as abdominal girth, and improves preoperative urine flow (488 vs 2,318 ml/24 hr; P less than .001) and natriuresis (12 +/- 15 vs 45 +/- 33 mEq/liter; P less than .003). The shunt should not be inserted in patients with alcoholic hepatitis (bilirubin level greater than 8 mg/100 ml). Ascitic fluid should be discarded at the time of surgery in patients with impaired cardiac function, a bleeding diathesis, and when liver function is more severely deranged.     

Use of polytetrafluoroethylene grafts for renal bypass

Fifty-six revascularizations of the renal arteries were performed in 52 patients with renovascular hypertension with the use of polytetrafluorethylene grafts between June 1979 and October 1984, with an average follow-up of 25.0 +/- 7.7 months. Ninety-two percent of the patients were considered to have good results (30% cured and 62% improved). Four patients were classified as unsuccessfully treated; one died postoperatively of myocardial infarction. All patients underwent late angiographic studies, with only one graft thrombosis being identified. No evidence of anastomotic stenosis, graft dilatation, or false aneurysm occurred during the follow-up period. From this experience, we believe polytetrafluoroethylene grafts are a valuable alternative to other graft materials for renal artery bypass and may be the preferred graft in the management of atheromatous lesions.     

Guidelines for adequate antibiotic prophylaxis after hepatic, biliary, and pancreatic surgery

The recent spectrum of bacteria isolated from patients with hepatic, biliary, and pancreatic infections mostly consists of Gram negative rods translocated from their intestinal flora. Cephem or carbapenem antibiotics should be selected based on the severity of surgical infection and risk to each patient to prevent postoperative infections. Once postoperative infection occurs, surgical procedures such as ultrasonography-guided percutaneous biliary drainage should be performed to reduce inflammation and to obtain samples for bacterial culture. The most commonly identified bacteria after hepatic, biliary, and pancreatic surgery are Pseudomonas species, MRSA, and Enterococcus species. Previously administered antimicrobial agents should be immediately interrupted and empiric antibiotic therapy with carbapenem started. Vancomycin or teicoplanin is selected when MRSA or Enterococcus faecium infection is suspected. Infection control systems should be in place for prevention of postoperative MRSA infections.     

Laparoscopic hand-assisted surgery for hepatic and pancreatic disease

Herein I describe my initial experience with the use of a novel device, the Omniport, in 15 patients undergoing hand-assisted laparoscopic surgery (HALS) on the liver and pancreas. The device, which essentially consists of a hand cuff with a spiral inflatable valve, enables withdrawal and reinsertion of the hand without loss of pneumoperitoneum during the operation. The cuff's effective sealing pressure is equal to the pneumoperitoneal pressure; hence, hand comfort is maintained during the intervention. The device was effective in maintaining pneumoperitoneum in all cases. All but one operation was completed with the HALS approach. The one conversion was due to bleeding from the superior mesenteric vein during a 90% pancreaticosplenectomy. Immediate effective control of the bleeding by compression between the thumb and index finger was achieved, and the cuff of the Omniport was deflated as the incision was enlarged. There were no postoperative complications. The HALS approach has distinct advantages in terms of exposure and safety over the total laparoscopic technique for major surgery on the liver and pancreas, and it is recommended for these interventions. Received: 4 August 2000/Accepted: 4 August 2000/Online publication: 20 October 2000