SUCCESSFUL SOLITARY PANCREAS TRANSPLANTATION WITH PORTAL-ENTERIC DRAINAGE FOLLOWING UNSUCCESSFUL ISLET CELL TRANSPLANTATION

Abstract

P424 Aims: Islet transplantation (ITx) and solitary pancreas transplantation (SPT) basically share the same indications. Although the results of ITx do not match those of SPT yet, a growing number of patients is attracted by the opportunity of achieving insulin-independence by simple percutaneous β-cell injection without the added morbidity entailed by a major operation such as SPT. Considering that, at least ideally, each patient who meets the indications for either ITx or SPT, and who undergoes immunosuppression, should eventually achieve insulin independence, it seems relevant to investigate the consequences of multiple islet injections in the portal vein on the outcome of subsequent SPT with portal venous drainage. We herein report our experience with SPT drained in the portal vein after failed ITx. Methods: Between October 16th, 2002 and December 30th, 2003, 3 SPT with portal venous drainage, including 2 PTA and 1 PAK, were performed in recipients of unsuccessful ITx. All recipients had undergone ITx due to frequent, acute, and severe metabolic complications and/or rapidly progressive diabetic complications at two different Italian transplant centers. Despite multiple intraportal islet injections (mean: 2.3 ijs.; range 2-3 ijs.) no patient actually achieved permanent insulin independence and initial endocrine function, measurable in each recipient, gradually disappeared between 2 and 4 months after the last injection. The three patients were subsequently evaluated for possible SPT. There were 2 females and 1 male aged 60, 49, 26 and years, respectively, and with a body max index of 19.5, 21.4 and 23.0 kg/m2, respectively. Daily insulin requirements were 30, 35 and 38 units, respectively. Pannel reactive antibody titer was 0% in all recipients. Pancreata were procured from brain dead cadaveric donors and allocated to each recipient according to AB0 compatibility and negative cross-match, without any specific degree of HLA matching. Results: Immunosuppression was based on a quadruple regimen including tolerance induction with either basiliximab (n= 2) or ATG (n= 1) and maintenance therapy with steroids, mycophenolate mofetil and tacrolimus. The final decision to drain each graft into the portal vein was taken during surgical exploration after verifying the absence of portal ipertension and following direct mesurement of portal pressure (13, 14 and 16 cm H20, respectively). Pancreas grafts were reperfused after a period of cold ischemia time of 835, 695 and 638 minutes, respectively. All grafts showed immediate endocrine function and keep their recipients insulin free at the longest follow-up (18, 16, and 3 months, respectively). One patient developed nonocclusive venous thrombus which resolved with intravenous heparin infusion. Conclusions: Our experience shows how unsuccessful ITx with multiple intraportal injections does necessarily precludes the possibility of subsequent successful SPT with portal venous drainage. Further experience is needed to define contraindications and possible complications of SPT with portal drainage following ITx.