En bloc transplantation of the liver, pancreas, duodenum, spleen, and kidney in the rat.

Five organs consisting of the liver, pancreas, duodenum, spleen, and kidney from (Lewis X Brown Norway)F1 rats were transplanted simultaneously as an en bloc graft to Lewis recipients. No immunosuppression was given postoperatively. Serial laporatomies were performed for macroscopic examination and biopsies of the grafts. Macroscopically, the first evidence of rejection was splenic enlargement followed by fatty metamorphotic change of the liver, dilation and loss of peristalsis of the duodenum, and injection of the pancreas. The kidney maintained normal color and consistency until late in the rejection process. Histological examination suggested that the liver and the spleen may be more vulnerable to immune attack, since in these organs cellular infiltration started earlier and was more extensive in comparison to other organs. While the pancreas exhibited a typical, although somewhat delayed rejection pattern, the kidney seemed to maintain a well preserved structure. Interestingly, the duodenum showed no significant cellular infiltration throughout the postoperative period of examination despite severe mucosal destruction.     

Simultaneous transplantation of kidney and duct-ligated segmental pancreas in the rat. En bloc technique using two vascular anastomoses

A new surgical technique of simultaneous kidney and pancreas transplantation is described here. It was used to perform 28 isografts in inbred male Wistar ( RT1y ) rats: 3 animals died within 3 days from early complications and 4 had long-term complications (2 severe pancreatitis and 2 urinary tract complications); 1 animal was killed at 3 months, and its organs were examined histologically. At greater than 4 months after transplantation 2 animals died normoglycemic from undetermined causes. In 3 animals the isografted pancreas was removed at 6 months to assess the effectiveness of the transplant. Currently, 15 animals are alive and normoglycemic greater than 6 months after transplantation. Morphological aspects of simultaneously isografted organs are unchanged when compared with separately transplanted organs. In our opinion this technique provides a useful experimental model to study several technical and immunological problems still present in kidney and pancreas transplantation in diabetic patients.     

En bloc resection of the hip via a simultaneous double approach

The pelvis is not an uncommon localization for primary or secondary tumors. Progress in chemotherapy has reduced the risk of metastasis and advances in reconstruction surgery using prostheses or allografts has made it possible to preserve a functional limb. We describe our method for en bloc resection of the hip. We use a double simultaneous approach for en bloc resection of the hip. The posterior Kocher-Langenbeck approach is associated with a anterior iliocrural approach. Each approach is performed by a separate team. We analyzed the advantages and disadvantages of this method, describing three recent cases. The double-simultaneous approach allowed greater safety for en bloc carcinological resection of the hip for patients with malignant tumors or aggressive intra-articular extension. Reconstruction was achieved with a total hip arthroplasty, reducing the duration of the operation and in theory, blood loss and risk of secondary infection. This method would not be indicated for patients without pelvic involvement nor for patients with a small-sized tumor (<5 cm).     

大鼠全胰十二指肠肾脏整块联合移植

为适应胰肾联合移植（ＳＰＫ）发展的需要，在纯系Ｌｅｗｉｓ大鼠上建立ＳＰＫ模型，结果表明该术式切实可行，手术成功率在８２．６％，术后能长期存活，移植物血管通畅，从胰肾功能正常，胸腺外分泌引流入肠腔，尿路及代谢并发症发生率低，此模型可进一步用于ＳＰＫ有关的理论研究。     

Trends and perspectives in pancreas and simultaneous pancreas and kidney transplantation

Pancreas transplantation is still the best option to achieve normoglycaemia and insulin independence in patients with type I diabetes. As a result of improvements in surgical techniques, immunosuppression and patient selection, one year survival rates of 95, 83, and 88% for patient, pancreas, and kidney survival, respectively, are reported for patients with simultaneous pancreas and kidney transplantation. The main goals for the future are to reduce postoperative morbidity, to identify the relevant indications for single pancreas transplantation, to adopt the best surgical technique for individual patients' needs (bladder versus enteric drainage with or without portal venous delivery of insulin), and to develop immunosuppressive strategies with low nephrotoxic and diabetogenic potential.     

En bloc and dual kidney transplantation: two initial cases from a new kidney transplantation center

Aim

The aim of this study was to share our initial successful experiences with en bloc dual kidney transplantation.

Cases

En bloc kidney were obtained, for case 1 from a 3-year-old deceased pediatric donor who had undergone cadaveric liver transplantation due to fulminant hepatitis A virus infection 1 week prior. The donor length was 97 cm and weight 13 kg. According to the age and weight of the donor, we selected a 50-year-old respectively. For case 2, a kidney was retrieved from a 20-month-old pediatric donor after development of hypoxic brain injury secondary to status epilepticus. The donor lengh and weight were 75 cm and 13 kg respectively. A 30-year-old female patient was of 162 cm and 59 kg. The suprarenal aorta, suprarenal vena cava, and caval and aortic lumbar branches were closed with running sutures during the backtable procedures. After the classic Gibson incision, the donor aorta was anastomosed to the recipient right common iliac artery, and the donor inferior vena cava to the recipient right common iliac vein in end-to-side fashion. The ureters were implanted with mucosa-to-mucosa ureteroneocystostomies separately according to the Lich-Gregoir technique. After the vascular anastomoses the kidneys had immediate good perfusion in both cases. Postoperative recovery was rapid, the recipients were discharged uneventfullly.

Conclusion

En bloc dual kidney transplantation from young pediatric patients to adult recipients can be performed with low mortality and morbidity even by new centers.     

Proinsulinemia in simultaneous pancreas and kidney transplant recipients

It has been shown that lipid profiles do not differ between pancreas recipients with systemic and portal venous anastomosis. However, it is unclear whether venous drainage from the transplanted pancreas has an impact on recipient atherogenesis and if other factors should be considered. Increased concentration of proinsulin correlates with tachycardia and other risk factors for ischemic heart disease. The aim of this study was to compare proinsulin levels in different types of pancreatic graft venous drainage. Twenty-four simultaneous pancreas and kidney transplantation (SPK) recipients with systemic venous drainage (group S, n = 12) and portal venous drainage (group P, n = 12) under identical immunosuppressive treatment were prospectively observed during 24 months. Following transplantation, only recipients with normoglycemia, normal HbA1c, and normal serum creatine were evaluated. Proinsulin was assessed in fasting state; after glucagon stimulation (Delta-proinsulin), and during oral 75-g glucose tolerance test twice: between 3 and 6 months and 12 to 24 months posttransplantation. All SPK patients had higher proinsulin concentration in fasting state compared with age-matched healthy controls. After stimulation, proinsulin level did not significantly differ between groups; the type of the pancreas venous anastomosis did not change the release of proinsulin and should not have impact on cardiovascular risk factors.     

En bloc resection for locally advanced cancer of the pancreas: Is it worthwhile?

The benefit of radical surgical resection of contiguously involved structures for locally advanced pancreatic cancer is unclear. The aim of this study was to examine patient outcome after extended pancreatic resection for locally advanced tumors and to determine if any subset of extended resection affected outcome. We retrospectively reviewed the records of 116 patients with adenocarcinoma of the pancreas, who underwent extirpative pancreatic surgery between 1987 and 2000. Of the 116 patients, 37 (32%) required resection of surrounding structures (group I), and 79 patients (68%) underwent standard pancreatic resections (group II). In all cases, all macroscopic disease was excised. In group I a total of 46 contiguously involved structures were resected: vascular in 25 patients (54%), mesocolon in 16 (35%) (colic vessels in 3, colon in 13), adrenal in three (7%), liver in one (2%), stomach in one (2%) (for a tumor in the tail of the pancreas), and multiple structures in four. Excision of regional blood vessels included the superior mesenteric vein and/or portal vein in 16, hepatic artery in five, and celiac axis in four. No differences between groups I and II were detected for any of the following parameters: age, sex, history of previous operation, estimated blood loss, or hospital stay. For the entire cohort the morbidity and mortality were 38% and 1.7%, respectively, and these rates were similar in the two groups. Adjuvant therapy was administered to more than 90% of patients in both groups. However, patients in group I were more likely to have received neoadjuvant therapy (76% vs. 42%, P = 0.001). Total pancreatectomy and distal pancreatectomy were more often performed in group I (P = 0.005). Additionally, the median operative time was longer (8.5 hours compared to 6.9 hours (P = 0.0004)). Both groups had similar rates of microscopically positive margins and involved lymph nodes, as well as total number of lymph nodes removed. The median survival was 26 months for patients in group I and 16 months for patients in group II (P = 0.08). The median disease-free survival for groups I and II was 16 months and 14 months, respectively (P = 0.88). In comparing patients in group I, who underwent vascular resection vs. mesocolon (colon or middle colic vessels) resection, the median survival was 26 months and 19 months, respectively (P = 0.12). We were unable to detect a difference in outcome for patients with locally advanced cancers requiring extended pancreatic resections compared to patients with standard resections. En bloc resection of involved surrounding structures, to completely extirpate all macroscopic disease, may be of benefit in selected patients with locally advanced disease, particularly when combined with preoperative chemoradiation therapy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2002 (oral presentation).     

En bloc kidney and bladder transplantation from an anencephalic donor into an adult recipient

The visceral block, composed of both kidneys and their vascular pedicles, inferior vena cava, ureters and bladder, was removed from a 3-day-old male anencephalic donor and transplanted into a 32-year-old adult in chronic renal failure. The urinary tract was reconstructed by vesicovesicostomy for technical ease, and prevention of reflux and ureteral stenosis. Maximum urine output was 150 ml. per day and the kidney grafts were lost owing to rejection 5 months after transplantation.     

胰肾联合移植术后的免疫抑制治疗

目的探讨胰肾一期联合移植(SPK)术后免疫抑制药物的合理应用。方法 2005年1月至2009年6月我中心完成9例SPK,其中男5例,女4例,均采用空肠引流方式。术后采用IL-2单克隆抗体诱导的四联免疫抑制方案:IL-2单克隆抗体(舒莱或赛尼哌)+他克莫司(FK506)+霉酚酸酯(MMF)+激素,并逐渐过渡至单用FK506维持治疗。回顾性分析以上9例患者围术期及长期随访情况。结果 9例手术均获得成功。除1例早期死亡外,其余8例患者术后1周内肌酐降至正常水平,术后停用胰岛素时间为(11.5±3.5)d,空腹血糖恢复至正常时间为(15.4±6.3)d。8例患者随访4～50个月,共发生移植肾急性排斥4例,1例患者在接受床边血液透析过程中并发心脑血管意外后家属放弃治疗,其余3例患者经抗胸腺细胞球蛋白(ATG)或激素冲击治疗后移植肾功能均逆转恢复,随访过程中未发现移植胰腺排斥。结论胰肾联合移植是治疗糖尿病合并终末期糖尿病肾病的有效方法,术后早期采用IL-2单克隆抗体诱导的四联免疫抑制方案并逐渐过渡至单用FK506维持治疗是安全的。     

Macrovascular disease after simultaneous pancreas and kidney transplantation

The objective of this study was to evaluate the outcome of simultaneous pancreas and kidney transplantation (SPK) with focus on cardiovascular mortality and morbidity in relation to graft function. From January 1985 through 1999, 87 SPK were performed in the unit. Sixty recipients were males, median age at diabetes onset 13 yr (1-40) and age at transplantation 39 yr (29-54). No case was lost to follow-up. Morbidity and mortality during median 8 yr of follow-up (range 1-15 yr) were recorded. Major macrovascular disease (MVD) was defined as myocardial infarction or sudden death (AMI), stroke or peripheral gangrene requiring amputation of leg, foot or fingers. At the evaluation, 26 of 87 patients (30%) had died, 19 after loss of the pancreas graft and 20 after loss of the kidney. MVD was the dominant cause of death. Non-lethal MVD had previously been recorded in 62%. Of the 61 patients alive, 22 had lost their pancreas graft and 12 the concomitant kidney. MVD had occurred in 32%. Whereas 89% of the concomitant kidneys functioned when the pancreas graft did so, only 37% of the kidneys functioned if the pancreas had been lost, p < 0.0001. The mortality rate was significantly higher among patients who lost both grafts (16/26) than in those who lost only the pancreas graft (3/15), p = 0.01. Progressive MVD is a major clinical problem for SPK transplant patients, particularly if the kidney fails.     

Ipsilateral placement of simultaneous pancreas and kidney allografts

The current standard technique for simultaneous kidney pancreas transplantation usually involves transplanting the pancreas to the right and the kidney to the left iliac system. Here we describe a previously unreported technique where both organs are transplanted to the right iliac system through a single midline incision. Forty-nine patients underwent simultaneous ipsilateral pancreas and kidney transplantation. All pancreas grafts were drained enterically. Overall patient, pancreas, and kidney survival were 96% (47/49), 92% (45/49), and 94% (46/49) respectively. The 45 patients with functioning grafts are insulin free and off of dialysis. Mean serum creatinine at 1, 3, 6, and 12 months was 1.7+/-1.3, 1.2+/-0.3, 1.3+/-0.3, and 1.3+/-0.4 mg/dL, respectively. The placement of the pancreas and kidney transplants on the same side is safe and does not compromise patient or graft survival. This approach preserves the left iliac system for future retransplantation if necessary.     

Toxoplasmosis after a simultaneous pancreas and kidney transplantation

We report the case of a simultaneous kidney and pancreas transplant recipient who presented with vague neurologic symptoms 21 months following the surgery. Computed tomography, magnetic resonance imaging, and fundoscopy findings were normal. Serology titers for antitoxoplasmic antibodies were increased. This was an atypical presentation of toxoplasmosis in a simultaneous kidney and pancreas transplant patient.