Exocrine Drainage Research Articles

Experience from 100 consecutive pancreas transplants amidst low national transplant activity: a retrospective study at a single center in Korea.

Since 1992, over 800 pancreas transplants have been performed in Korea. However, this number is significantly lower compared to the number of kidney or liver transplants. Between 2015 and July 2023, Pusan National University Yangsan Hospital conducted 100 pancreas transplants, accounting for about 20% of all transplants performed in Korea during this period. The study comprised 27 simultaneous pancreas and kidney (SPK) transplants, 23 pancreas after kidney (PAK) transplants, and 50 pancreas transplant alone (PTA) cases. Duodenoduodenostomy was the primary surgical technique employed for exocrine drainage, along with various modifications of the venous outflow anastomosis. The availability of brain-dead donors for kidney transplants was lower compared to isolated pancreas transplants. Patients undergoing SPK transplants faced significantly longer waiting times than those receiving PTA or PAK transplants. The rate of surgical complications was acceptable, with a notably low thrombotic graft failure rate of 1.0%. In the PTA group, acute rejection of the graft pancreas occurred frequently (18.0%), though this was not statistically significant (P=0.328). The pancreas transplantation survival rates were 91.0%, 78.5%, and 75.4% at 1, 5, and 9 years, respectively. The PTA group exhibited a lower graft survival rate than the SPK and PAK groups, with marginal statistical significance (P=0.059). Graft survival rates have improved over time due to advancements in surgical techniques and immunosuppressant strategies. By sharing our experiences, we aim to enhance the activity and success of pancreas transplantation in Korea.

Endoscopic control after retroperitoneal pancreas transplantation with a Roux-en-Y duodenojejunostomy for exocrine drainage

Background. Simultaneous pancreas and kidney transplantation is a gold standard in the treatment of diabetes mellitus complicated by stage 5 chronic kidney disease as a result of diabetic nephropathy. One of the main problems of clinical pancreas transplantation is the pancreas graft exocrine drainage. In order to preserve the advantages of the retroperitoneal graft location and avoid the main disadvantage of duodenal drainage, namely, fatal complications potentially arising in case of necessary graft removal, we have proposed a modified method of retroperitoneal pancreatic transplantation with exocrine drainage via a modified Roux-en-Y duodenojejunostomy. It reduces the number of severe surgical complications and increases the recipient survival rate. When this method was used in previous years, it was not possible to assess the condition of donor duodenum mucosa and interintestinal anastomoses.Objective. To demonstrate the possibility of endoscopic assessment of interintestinal anastomoses when performing retroperitoneal pancreas transplantation with small intestine drainage of exocrine secretions.Results. The article presents the initial experience of endoscopic assessment of the interintestinal anastomoses and the mucous membrane of the donor duodenum after retroperitoneal pancreas transplantation with exocrine drainage via a Roux-en-Y duodenojejunostomy.Conclusion. The presented case demonstrates the feasibility of diagnostic endoscopic interventions when performing retroperitoneal pancreas transplantation with small intestine drainage of pancreatic secretions.

1058 Jejunal or Ileal Exocrine Drainage in Pancreas Transplantation?

Abstract Aim Pancreas transplantation (PT) is performed for restoration of endocrine function in type 1 diabetes mellitus with amelioration of diabetic complications. However, PT can have serious complications requiring salvage pancreatectomy and surgical approaches should be carefully considered. Anastomoses to jejunum or ileum are most often employed. We compare outcomes between these techniques. Method A retrospective analysis was performed on simultaneous pancreas and kidney transplants (SPK) at Manchester University Hospitals NHS Foundation Trust between 2013 and 2015. Follow up was completed until 2020. Results 86 SPK were performed. 59.2% were male with mean age of 41.5yo (SD±8.4). 72.4% (n = 55) were donors after brain death and 98.7% (n = 75) were receiving first PT. 43 SPK were performed with ileal anastomosis, 33 jejunal. There were no significant differences in demographics of recipients, donors, immunosuppression regimens, overall patient and graft survival and frequency of GI complications. Length of hospital stay was higher with ileal anastomosis (median 14 v 19 days, p<0.05), as was cold ischaemic time (median 8:48 v 9:31 hours, p<0.05). Three patients required salvage pancreatectomy and loop ileostomy formation with multi-organ support and prolonged ITU stay. Conclusions Long term outcomes between groups were comparable in this cohort. Catastrophic complications occur in the minority requiring salvage surgery. Here more occurred with ileal anastomosis, but this approach allows graft pancreatectomy and formation of loop ileostomy, avoiding a more proximal stoma in a clinically unstable patient. Further powered studies are required to rigorously examine the impact of enteric anastomosis site.

Jejunal or Ileal Exocrine Drainage in Pancreas Transplantation: Impact on Gastrointestinal Function.

Pancreas transplant can have serious complications requiring salvage pancreatectomy, and surgical approaches should be carefully considered, with jejunal or ileal anastomoses most often employed. The jejunum may reduce gastrointestinal disturbance, whereas the ileum is more immunogenic. Proximal gastrointestinal anastomoses pose challenges with salvage pancreatectomy and creation of high-output stoma, often in the context of end-stage renal failure. Here, we compared outcomes between these techniques. We retrospectively analyzed patient records of simultaneous pancreas and kidney transplants at a single center between 2013 and 2015, with follow-up to 2020. Our center performed 86 simultaneous pancreas and kidney transplants during the study period; 10 patients were excluded because of incomplete records of anastomosis type. Of included recipients, 59.2% were men (mean age 41.5 ± 8.4 y), 72.4% were donors after brain death, and 98.7% had received a first pancreas transplant. Forty-three simultaneous pancreas and kidney transplants were performed with ileal anastomosis and 33 with jejunal anastomosis. We found no significant differences in recipient or donor factors or immunosuppression regimen between anastomosis groups and no significant differences in overall patient, pancreas, or kidney graft survival or in gastrointestinal complications. Hospital length of stay was higher with ileal anastomosis (median 14 vs 19 days; P < .05), as was cold ischemic time (median 8:48 vs 9:31 hours; P < .05). Three patients required salvage pancre-atectomy and loop ileostomy formation with multiorgan support, prolonged intensive care unit stay, relaparotomy, and/or laparostomy. Long-term outcomes were comparable between our patient groups. Catastrophic complica-tions occur in a minority of cases, requiring salvage surgery. More complications occurred with ileal anastomosis, but this approach allows graft pancreatectomy and formation of loop ileostomy, avoiding a more proximal stoma in clinically unstable patients. Further studies are needed to examine the impact of enteric anastomosis site.

The first 10years of simultaneous pancreas-kidney transplantation in Finland.

Simultaneous pancreas-kidney transplantation (SPK) is an option for patients with type 1 diabetes (T1D) and kidney failure but can be associated with a high complication rate. Here we describe our 10-year experience since the launch of the SPK program. This retrospective study included consecutive patients with T1D receiving SPK from March 14, 2010 to March 14, 2020 at Helsinki University Hospital. Portocaval anastomosis (i.e., systemic venous drainage) and enteric exocrine drainage were used. A specific team was trained for both pancreas retrieval and transplantation, postoperative care was standardized to include somatostatin analogues, antimicrobial treatment, and preoperatively initiated chemothrombopropylaxis. During program maturation donor criteria were expanded and logistical processes improved to minimize cold ischemia time. Clinical data were collected from a nationwide transplantation registry and patient records. A total of 166 SPKs were performed (median 2 per year in the first 3years, 17.5 per year for the following 4years, and 23 per year for the past 3years). Seven patients (4.1%) died with a functioning graft with a median 43months follow-up. One-year pancreas graft survival was 97.0%, 3-year pancreas graft survival was 96.1% and 5-year was 96.1%. Mean HbA1c was 36mmol/mol (SD 5.57) and creatinine was 107μmol/L (SD 34.69) at 1-year after transplantation. All kidney grafts were functioning at the end of follow-up. Complications required re-laparotomy in 39 (23%) patients, mostly due to a pancreas graft related problem (N=28). No pancreas or kidney graft failure from thrombosis occurred. A planned, step-wise development of an SPK program offers a safe and effective treatment for patients with T1D and kidney failure.

Cytomegalovirus Graft Duodenitis Diagnosed by Transanal Double-Balloon Endoscopy Technique in an Enteric-Drained Pancreas Transplant Recipient: A Case Report

Duodenal graft complications are not uncommon after pancreas transplant (PTx). Although direct visualization and biopsy of the duodenal graft are important for accurate diagnosis and management, endoscopic access is often limited in cases of enteric-drained PTx. Herein, we present a case of cytomegalovirus (CMV) graft duodenitis that was successfully diagnosed by transanal endoscopy using the double-balloon technique. The patient was a 54-year-old woman who underwent simultaneous pancreas and kidney transplant for type 1 diabetes mellitus and end-stage kidney disease. Enteric drainage was established by anastomosing the graft duodenum to her ileum. One month after the transplant, she developed fever and complained of lower abdominal pain. Graft duodenitis was suspected by laboratory test and imaging study results. Transanal double-balloon endoscopy was performed, and the biopsy specimen of the mucosa of the graft duodenum revealed CMV duodenitis without histopathologic findings of acute rejection. The postendoscopy course was uneventful. Treatment with ganciclovir was promptly initiated, and the CMV duodenitis was resolved with good function of the pancreas graft. In patients who undergo PTx with establishment of exocrine drainage by enteroanastomosis to the recipient ileum, transanal double-balloon endoscopy might be a feasible and safe technique for the surveillance of duodenal graft complications, including CMV duodenitis.

Short- and Long-Term Intestinal Complications After Combined Pancreas-Kidney Transplantation

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice in patients with type 1 diabetes and end-stage renal disease, because it improves survival and quality of life. Currently, enteric exocrine drainage is the most commonly used method. Intestinal complications continue to be a major cause of posttransplant morbidity despite improvements in surgical technique. This study analyzed early and late intestinal complications related to SPK transplantation. We performed a retrospective analysis of 100 adult patients undergoing SPK transplantation between January 2009 and December 2019. We performed systemic venous drainage and exocrine enteric drainage with duodenojejunostomy. Statistical analysis was performed using SPSS v2. This study was performed in accordance with the Declaration of Istanbul and the 1964 Declaration of Helsinki. Informed consent was obtained from all participants involved in the study. Ten patients had the following early intestinal complications (10%): ileus (n=4), intestinal obstruction (n=2), graft volvulus (n=1), duodenal graft fistula (n=1), and jejunal fistula after pancreas transplantation (n=1). Two cases required relaparotomy: graft repositioning with Roux-en-Y conversion (n=1) and Y-roux conversion (n=1). Eight patients had repeated episodes of intestinal obstruction (8%), of whom 2 required surgery for resolution with 100% postoperative mortality. SPK transplantation with enteric drainage via duodenojejunostomy has a low rate of short- and long-term postoperative intestinal complications. Surgery in patients with recurrent intestinal obstruction has a high mortality risk and should be performed in reference transplant centers.

P.141: Hypoglycemia: A Rare Sign of Pancreas Graft Dysfunction

Introduction: Hypoglycemia is an unusual sign after pancreas transplantation and its cause remains unclear. Hyperinsulinemia and insulin antibodies have been proposed to play a role on its development. Methods: This is a retrospective review of a consecutive series of patients with documented symptomatic hypoglycemia after pancreas transplantation with a concurrent pancreas graft biopsy performed between June 2016 and June 2021. Results: 7 patients had symptomatic hypoglycemia after SPK (5) or PASPK (2) at a mean time of 33 months after transplant (3-86mo). All cases had systemic venous drainage with enteric (4) or bladder (3) exocrine drainage. Most had abnormal OGTT with hypoglycemia 2 hours after glucose administration. Two patients had a history of biopsy proven pancreas rejection. There were no other signs of graft dysfunction (serum amylase, lipase and creatinine at baseline) at the time of the hypoglycemia episode nor at the time of the biopsies.Biopsy results showed pancreas rejection in 2 cases (1 AMR, 1 ACTR), CNI toxicity in 4 cases (3 pancreas and 1 kidney and pancreas) and 1 case showed abnormal islet morphology (small size). Cases of rejection were treated according to Banff Classification type and grade. In the cases of CNI toxicity, tacrolimus was minimized (3) or discontinued and replaced with Belatacept (1). One patient lost the pancreas graft due to AMR. No patient developed rejection during follow-up after IS modification. Hypoglycemia episodes were resolved in 5 cases and became less frequent in the remaining patient.Discussion: Hypoglycemia is a rare sign after pancreas transplantation. Along with hyperglycemia and elevated enzymes, hypoglycemia could be a marker of pancreas graft dysfunction due to treatable causes such as CNI toxicity and rejection.

P.133: Systemic Venous Versus Portal Venous Drainage in Simultaneous Pancreas-Kidney Transplantation: A Matched-pair Analysis

Purpose: Portal venous drainage of pancreatic transplant appears more physiologic compared to systemic venous drainage. However, present data does not support the superiority of one technique over the other. The study purpose was to evaluate outcomes in vascularized pancreas transplantation (PTx) with enteric exocrine drainage based on technique of venous delivery. Methods: We retrospectively analyzed 231 simultaneous pancreas-kidney transplants (SPKTs) performed at our center between 7/2003 – 7/2019 and identified 27 that were performed with systemic venous (iliac vein) and enteric exocrine (systemic-enteric [S-E]) drainage. These 27 patients were compared to 27 case controls with portal venous and enteric exocrine drainage matched for recipient age, gender, race, and date of transplant. Results: The 2 groups were well-matched.Indications for S-E drainage were central obesity/thickened mesentery (10), unfavorable vascular anatomy (11), or surgeon preference (6). The S-E drainage group was characterized byslightly more patients ≥ 80 kg (44% S-E versus 26% P-E), with C-peptide positive diabetes (30% S-E versus 18% P-E), and with diabetes onset at >20 years of age (41% S-E versus 26% P-E, all p=NS), suggesting a Type 2 diabetes phenotype. Although the incidence of early pancreas thrombosis (3.7% S-E versus 0% P-E), early relaparotomy (30% S-E versus 22% P-E), and mean initial length of hospital stay (11 days S-E versus 8 days P-E) were numerically higher in S-E versus P-E SPKTs, none of these differences were significant. With a mean follow-up of 5 years in both groups, respective one and 3-year patient survival (100% and 96% S-E vs 100% and 100% P-E), kidney graft survival (100% and 96% S-E vs 100% and 89% P-E), and pancreas graft survival (96% and 96% S-E vs 100% and 100% P-E) rates were comparable. Conclusions: The method of venous delivery of insulin following PTx does not appear to influence medium-term outcomes in SPKT with enteric exocrine drainage. K. Gurung2, R. Stratta2, A. Farney2, G. Orlando2, C. Jay2, A. Reeves-Daniel3, A. Mena-Gutierrez3, N. Sakhovskaya3, W. Doares4, S. Kaczmorski4, M. Magid4, J. Rogers2 .

P.146: Enteric Conversion After Bladder Drained Kidney-Pancreas Transplantation

Background: In simultaneous kidney-pancreas transplantation (SPK), bladder (BD) and enteric (ED) are both options for pancreaticoduodenal exocrine drainage. While BD provides good early and long term SPK survival, it is associated with metabolic, urological and pancreatic complications leading to need for enteric conversion (EC). We report our single center experience in SPK patients (pts) who underwent EC after initial BD. Methods: Between 1990 and 2019, we performed 541 SPK, of which 474 were BD and 67 were ED. We retrospectively studied pts who underwent EC. Indications for EC, time from SPK to EC, resolution of symptoms, complications and pancreas graft survival were analyzed. Results: 56/474 pts underwent EC (11.8%). The mean time to EC was 4.5 years (yrs) (median 2.58 yrs) with intervals <1 yr = 19(33.9%), 1–5 yrs =20(35.7%), 5-10yrs=7(12.5%), 10–20 yrs =10 (17.8%). The main indication for EC was dehydration followed by recurrent urinary tract infections (UTI). 4/11 (36.4%) pts who had EC due to UTI had persistent UTI, 7/11 (63.6%) had resolution of UTI; the rest of the pts had complete resolution of the primary indication.6 (10.7%) pts had surgical complications post EC and 4 required re-exploration with ileoduodenostomy (bailout) operation for duodenal leak. Graft rejection was observed in 3 pts (5.3%) after EC and all were done 6–12 months post-transplant. The mean follow-up after EC was 5.7 yrs (median 4.25 yrs). Overall pancreas graft loss (GL) occurred in 7 pts (12.5%) after EC, including 2 pancreatectomies: 1 for duodenal fistula and 1 for gastrointestinal bleed. The mean interval between EC and GL was 4.1 yrs. Conclusion: In this single center review of SPK pts with initial BD, the rate of EC was low at 11.8%. Persistent UTI post EC may be due to diabetes-related bladder dysfunction and in isolation should not lead to EC. BD may still be considered as primary drainage in SPK if indicated with the caveat of possible reoperation for EC.

P.130: Achilles Heel No Longer: Marked Decline in Early Relaparotomy and Allograft Pancreatectomy Rates Following Simultaneous Kidney-Pancreas Transplantation in the Contemporary Era

Purpose: Technical complications requiring early relaparotomy (relap) and allograft pancreatectomy (AP) have long been the Achilles heel of simultaneous kidney-pancreas transplantation (SKPT). Methods: Single center retrospective review of all SKPTs from 11/1/01 – 8/12/20 managed with T-cell depleting antibody, tacrolimus, MMF, steroids, and enteric exocrine drainage. Early relap was defined as occurring within 3 months of SKPT. Patients (pts) were stratified into 2 sequential eras: Era 1 (E1): 11/1/01 – 5/30/13; Era 2 (E2) 6/1/13 – 8/12/20. Results: During the period of study, 255 SKPTs were performed (E1, n=165; E2, n=90) with an overall mean follow-up of 8.1±5 years. Recipient age and donor and recipient ethnicity, gender, and BMI were comparable between eras. E1 pts received organs from older donors (E1 27 vs. E2 23 years, P<0.001) with longer pancreas graft cold ischemic times (CIT) (E1 16 vs. E2 13 hours, P=0.04). E2 pts received more imported organs (E1 16% vs. E2 27%, P=0.04). E1 pts had a higher early relap rate (E1 43% vs. E2 14%, P<0.001) and were more likely to require AP (E1 10.3% vs E2 2.2%, P=0.019). E2 pts underwent systemic venous drainage more frequently (E1 8% vs. E2 29%, P<0.001). The most common indications for early relap in E1 were pancreas thrombosis (12%), abscess/infection (12%), bleeding (4%), and leak (4%) whereas in E2 were for abscess/infection (3%), small bowel obstruction (3%), and thrombosis (2%), P=0.001. Pancreas venous drainage technique did not affect either early relap or AP rates. Mean transplant volume was 14/year for E1 and 13/year for E2; mean transplant volume in the past 3 years of E2 was 18/year. Conclusions: Maximizing donor quality (younger donors) and minimizing CIT are paramount for reducing complications requiring either early relap or AP and for optimizing long-term pancreas graft survival following SKPT.

Simultaneous Pancreas and Kidney Composite Graft Transplant

Purpose: Limited vascular access could be encountered in an obese or re-transplant patient. We described modifications that facilitated an en bloc simultaneous pancreas and kidney (SPK) composite graft transplant in an obese type 2 diabetic patient with renal failure under hemodialysis. Methods: At the back-table, the superior mesenteric artery and splenic artery of the pancreas graft were reconstructed with a long "Y" iliac artery graft. The smaller left renal artery is anastomosed end-to-side to the larger and longer common limb of the arterial Y graft and the shorter portal vein is anastomosed end-to-side to the longer graft left renal vein. Thus, this en bloc composite graft allowed to facilitate “real” SPK transplant using single common graft artery and vein for anastomosis to one recipient arterial and venous site. The en bloc pancreas and kidney composite graft was implanted by suturing the graft left renal vein to IVC and graft common iliac artery the recipient distal aorta. Exocrine drainage was provided by anastomosis of the graft duodenum to a roux-en-y jejunum limb in an side-to-side fashion. Immunosuppressants included basiliximab, tacrolimus, mycophenolate mofetil, and methylprednisolone. Results: The operative time was 7 hours with cold ischemic time of 6 hours and 25 min. and warm ischemic time of 47 min. The patient was discharged on postoperative day 20, with a serum creatinine level of 1.4 ng/ml and a blood glucose level of 121 mg/dL. Conclusion: En bloc pancreas and kidney composite graft might be an option for patients with limited vascular access.

Exocrine drainage in pancreas transplantation: Complications and management.

The aim of this minireview is to compare various pancreas transplantation exocrine drainage techniques i.e., bladder vs enteric. Both techniques have different difficulties and complications. Numerous comparisons have been made in the literature between exocrine drainage techniques throughout the history of pancreas transplantation, detailing complications and their impact on graft and patient survival. Specific emphasis has been made on the early postoperative management of these complications and the related surgical infections and their consequences. In light of the results, a number of bladder-drained pancreas grafts required conversion to enteric drainage. As a result of technical improvements, outcomes of the varied enteric exocrine drainage techniques (duodenojejunostomy, duodenoduodenostomy or gastric drainage) have also been discussed i.e., assessing specific risks vs benefits. Pancreatic exocrine secretions can be drained to the urinary or intestinal tracts. Until the late 1990s the bladder drainage technique was used in the majority of transplant centers due to ease of monitoring urine amylase and lipase levels for evaluation of possible rejection. Moreover, bladder drainage was associated at that time with fewer surgical complications, which in contrast to enteric drainage, could be managed with conservative therapies. Nowadays, the most commonly used technique for proper driving of exocrine pancreatic secretions is enteric drainage due to the high rate of urological and metabolic complications associated with bladder drainage. Of note, 10% to 40% of bladder-drained pancreata eventually required enteric conversion at no detriment to overall graft survival. Various surgical techniques were originally described using the small bowel for enteric anastomosis with Roux-en-Y loop or a direct side-to-side anastomosis. Despite the improvements in surgery, enteric drainage complication rates ranging from 2%-20% have been reported. Treatment depends on the presence of any associated complications and the condition of the patient. Intra-abdominal infection represents a potentially very serious problem. Up to 30% of deep wound infections are associated with an anastomotic leak. They can lead not only to high rates of graft loss, but also to substantial mortality. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage. Duodenoduodenostomy is an interesting option, in which the pancreas is placed behind the right colon and is oriented cephalad. The main concern of this technique is the challenge of repairing the native duodenum when allograft pancreatectomy is necessary. Identification and prevention of technical failure remains the main objective for pancreas transplantation surgeons. In conclusion, despite numerous techniques to minimize exocrine pancreatic drainage complications e.g., leakage and infection, no universal technique has been standardized. A prospective study/registry analysis may resolve this.

HOW WE ACHIEVED 0% OF THROMBOTIC GRAFT LOSS -THE INITIAL 60 CASES OF PANCREAS TRANSPLANT

Background: One of the major surgical complications after pancreas transplant is early graft failure due to thrombosis. Unfor tunately, the early graft loss rate has not improved over the last 30 years. Even in recent reports, the technical failure rate due to thrombosis was 5%-10%. The low flow portal venous system must have the tendency of thrombosis, thus the graft pancreas in inherently thrombogenic. Therefore, wider and shorter anastomosis of the portal vein is better for maintaining blood flow. The size of the opening is more important than the length according to the equation above. Methods: We performed 60 cases of pancreas transplant (11 simultaneous pancreas-kidney, or simultaneous pancreas living-do nor kidney, 14 pancreas after kidney, 34 pancreas transplant alone, and one pancreas after liver transplant) in Pusan National University Yangsan Hospital, Korea, since 2015. There is no thrombotic graft loss in our cases. Results: Most of our cases were performed with venous drainage to vena cava and duodenal exocrine drainage. The venous anastomotic technique was evolved from the direct anastomosis (n=8). Then we did a diamond-shaped patch anastomosis (n=13). After that, the fence angioplasty with using vena cava graft was applied to 31 cases. And finally, we have been performing the ve nous anastomosis with aortic interpositional graft (n=8). The conventional or low molecular heparin was used for the prevention of thrombosis in the first 40 cases of transplant. However, we do not use any heparin anymore neither in the intraoperative nor postoperative periods. There was some partial thrombosis in graft splenic vein or superior mesenteric vein on computed tomog raphy scans. However, these partial thromboses did have any effect on graft loss. Conclusions: In conclusion, we need to understand the mechanism of thrombus in graft pancreas and should do the best effort to make the wide venous anastomosis and maintain the venous flow. We would like to share our know-how with members of transplant society.

Pseudocyst of Pancreas Transplant Allograft: A Case Report

BackgroundPancreatic pseudocysts are rarely reported complications of pancreas transplant. CaseWe present a case of a patient with simultaneous pancreas and kidney transplant with bladder exocrine drainage who developed reflux pancreatitis and symptomatic pancreatic pseudocyst as a result of neuropathic bladder, 15 years after the original transplant. He was initially managed with percutaneous aspiration and drainage along with Foley catheter placement to help with bladder emptying. But the pseudocyst recurred after drains and Foley were removed. Eventually, he underwent an enteric conversion of the pancreas allograft with resolution of his symptoms and the pseudocyst. ConclusionsEnteric conversion should be considered in cases of bladder-drained pancreas transplants with recurrent reflux pancreatitis and/or pseudocyst formation.

Surgical aspects of pancreas transplantation: exocrine drainage. Part 2

Exocrine drainage is an Achilles heel of pancreas transplantation. The author analyzed the outcomes of pancreas transplantations with different types of exocrine drainage in various centers (n=93). The article will ensure insight into evolution of techniques of exocrine drainage within the historical context and current state of this issue.

Surgical techniques of pancreas transplantation: exocrine drainage. Part 1

Exocrine drainage is an Achilles heel of pancreas transplantation. The author analyzed the outcomes of pancreas transplantations with different types of exocrine drainage in various centers (n=93). The manuscript ensures insight on the evolution and progress of exocrine drainage techniques in pancreas transplantation within the historical context and current state of the problem.

Surgical aspects of pancreas transplantation: exocrine drainage. Part 3

Exocrine drainage is an Achilles heel of pancreas transplantation. The author analyzed the outcomes of pancreas transplantations with different types of exocrine drainage in various centers (n=93). The article will ensure insight into evolution of techniques of exocrine drainage within the historical context and current state of this issue.

Risk Factors for Early Pancreatic Allograft Thrombosis Following Simultaneous Pancreas-Kidney Transplantation: A Systematic Review.

Simultaneous pancreas-kidney (SPK) transplantation remains the most effective treatment for providing consistent and long-term euglycemia in patients having type 1 diabetes with renal failure. Thrombosis of the pancreatic vasculature continues to contribute significantly to early graft failure and loss. We compared the rate of thrombosis to graft loss and systematically reviewed risk factors impacting early thrombosis of the pancreas allograft following SPK transplantation. We searched the MEDLINE, EMBASE, The Cochrane Library, and PREMEDLINE databases for studies reporting thrombosis following pancreas transplantation. Identified publications were screened for inclusion and synthesized into a data extraction sheet. Sixty-three studies satisfied eligibility criteria: 39 cohort studies, 22 conference abstracts, and 2 meta-analyses. Newcastle-Ottawa Scale appraisal of included studies demonstrated cohort studies of low bias risk; 1127 thrombi were identified in 15 936 deceased donor, whole pancreas transplants, conferring a 7.07% overall thrombosis rate. Thrombosis resulted in pancreatic allograft loss in 83.3% of reported cases. This review has established significant associations between donor and recipient characteristics, procurement and preservation methodology, transplantation technique, postoperative management, and increased risk of early thrombosis in the pancreas allograft. Further studies examining the type of organ preservation fluid, prophylactic heparin protocol, and exocrine drainage method and early thrombosis should also be performed.

Pancreas transplantation following total pancreatectomy for chronic pancreatitis.

Total pancreatectomy for chronic pancreatitis leads to brittle diabetes and challenging glycemic control with half of all patients experiencing severe hypoglycemia, many requiring medical intervention or hospitalization. Pancreas transplantation has the potential to manage both the endocrine and the exocrine insufficiency in this patient population. Between June 1, 2005, and July 1, 2016, 8 patients with brittle diabetes following total pancreatectomy underwent pancreas transplantation. All grafts had systemic venous and enteric exocrine drainage. Data included demographics, graft and patient survival, pre- and post-transplant supplementation with pancreatic enzymes, and narcotic usage. Patient survival rate at 1 and 3years was 88%. Pancreas graft survival rate of those alive at 1year was 100% and 86%, respectively. About 75% of these patients remained insulin-free until their time of death, loss of follow-up, or present day. Of the patients with maintained graft function at 3years, none required further hospitalization for glycemic control. About 75% of these patients have also maintained exocrine function without pancreatic enzyme supplementation. Pancreas transplant can treat both exocrine and endocrine insufficiency and give long-term insulin-free survival and should be considered as a viable treatment option for patients who have undergone total pancreatectomy for chronic pancreatitis.