Vascular Choices in Pancreas Transplantation: Does it Matter?

Abstract

Introduction: Surgical techniques, particularly vascular anastomoses, for Pancreas Transplantation (PT) vary widely according to local expertise, surgeon preference and may also reflect implant experience. Enteric drainage has become the preferred method for exocrine drainage, due to improvements in organ assessment and quality allowing greater reliability in predicting outcomes, improving outcomes for recipients postoperatively. However, there is no clear consensus as to optimal positions for vascular anastomoses, with individual surgeon and unit preferences directing approach. We aimed to describe our 10 year experience with PT and identify impact of surgical vascular technique on graft outcomes. Methods: A retrospective analysis was made of a contemporaneously maintained database of all PT's (simultaneous pancreas kidney (SPK); pancreas after kidney (PAK) and pancreas transplant alone (PTA) performed in a single institution between the inception of the programme and the present (June 2001 to May 2011). Patients were divided according to surgical implantation position in an attempt to establish optimal anastomotic configurations. Primary endpoints used were patient and graft survival with post-operative complications (including haemorrhage, biopsy proven rejection and re-operation) secondary endpoints. Results: 230 PTs were performed over the study period (180 SPK's, 13 PTA's and 37 PAK's; 143 Males, 87 Females; median age 41 (range 15-67). Complete data were available for 177 recipients. Portal vein (PV) was anastomosed to Inferior Vena Cava (IVC, 58, 33%), Common Iliac Vein (CIV, 78, 44%), and External iliac vein (EIV, 41, 23%) with arterial anastomoses to the Common Iliac Artery (CIA, 150, 85%), External Iliac Artery (EIA, 25, 14%), internal iliac artery (IIA, 1, 0.5%) and Aorta (1, 0.5%). Arterial anastomosis choice had no impact on outcome but post-operative bleeding was significantly higher in IVC than CIV group (26% vs. 9%, p=0.01, Fisher's exact test) Rates of intra-abdominal sepsis (6.9% vs 21.9% p=0.05) and wound infections (10.3% vs 24.4% p=0.03) were lower in PT's with IVC than CIV anastomoses, but did not differ with EIV. Incidence of thrombosis (11.2%), rejection (23.5%) and transplant pancreatectomy (15.1%) did not vary according to choice of anastomosis (p=NS). 68% of PT's with EIV underwent re-operation compared with IVC and CIV configuration (45% & 49%; p=0.025 and p=0.05 respectively) Conclusion: The evolution of pancreatic implantation techniques has undoubtedly contributed positively towards improvement in graft outcomes. Together with more rigorous donor and recipient case selection, surgical technique has proven to have a significant positive impact on outcomes following PT. There is no optimum combination which improves graft survival, but it appears that anastomosis of PV to the IVC may have inferior outcomes in terms of haemorrhage risk. It appears that judicious anatomical decisions and important and coupled with meticulous technique may ensure improved outcomes.