PANCREAS TRANSPLANTATION WITH ISOLATED SPLENIC ARTERY SUPPLY

Abstract

Introduction: The critical deficiency of donor organs as a result of both strict criteria for potential donor selection and anatomic features of pancreas transplant blood supply limits the widespread application of pancreas transplantation. During the multiorgan grafts removal we have quite often to sacrifice the superior mesenteric artery (SMA) in favor of additional hepatic artery. In such cases the implied critical pancreas graft ischemia significantly limits its implementation. The evaluation of isolated splenic artery supply (ISAS) sufficiency of the pancreas graft had defined the purpose of this study. Materials and Methods: From January 2008 to February 2020, 61 patients had undergone pancreas transplantation: 34 women and 27 men. The median age was 34[30;39] years. In 53 (87%) cases we have performed standard Y-graft arterial reconstruction. In 9 (13%) cases we have performed pancreas transplantation with ISAS as a result of the SMA cutting off during organs’ explantation. We have used 640-slice dynamic volume perfused computed tomography (PCT) with measurement of the time of maximum PG’s tissue peak (TTP (sec.)), arterial blood flow (ABF) and arterial blood volume (ABV) in the PG’s head, body and tail areas to assess the PG’s condition. Results: 1 patient with ISAS PTx have died in early postoperative period due to infectious complications. In other 8 patients with pancreas graft’s ISAS we didn’t observe any pancreatic head necrosis and/or ischemic graft’s duodenum necrosis. Furthermore, there were no significant differences in the studied and controlled groups pancreas graft’s function: glycose – 4,4 vs 4,5 mmol/l (p=0,62), alpha amylase – 67 vs 84 U/l (p=0,7), pancreatic amylase – 39 vs 44 U/l (p=0,8), lipase – 42 vs 26 U/l (p=0,7), HbA1c 5,5 vs 5,4 % (p=0,9), intact insulin – 17 vs 10 mcIU/ml (p=0,4). We have found significant difference only in C-peptide level (2,5 vs 1,7 ng/ml (p=0,01)). The CT-perfusion results were: TTP–19[17;23] sec ABF –125[116;160], 125[117;139], 122[105;136] ml/min/100ml., ABV–40[32;58], 40[30;58], 42[36;62] ml/min. and statistically didn’t differ from perfusion parameters of PG with both functioning arteries. Conclusion: Pancreas transplantation with ISAS is reasonable due to well-developed arterial collaterals between splenic and superior mesenteric arteries systems. Preservation solution stream appearance through the SMA stump while flushing through the splenic artery during back-table procedure, in spite of risk of graft over flushing, can show the possibility of ISAS transplantation. The viability of the surgical technique with ISAS will allow to expand the criteria for pancreas harvesting and increase the number of transplantations.