Portal Venous Drainage Research Articles

SIGNIFICANCE OF PORTAL VENOUS DRAINAGE AFTER WHOLE-ORGAN PANCREAS TRANSPLANTATION FOR ENDOCRINE GRAFT FUNCTION AND PREVENTION OF DIABETIC NEPHROPATHY

The significance of portal venous drainage after whole-pancreas transplantation both for metabolic control and development of diabetic nephropathy was investigated. Streptozotocin-diabetic inbred LEW rats received a duct-ligated pancreas graft with either systemic or portal venous drainage and were followed for up to one year. Normal and untreated diabetic rats (n=18 in each group) served as controls. Irrespective of the route of venous drainage pancreas transplants normalized the diabetic polyuria, polyphagia, and polydipsia. Growth rates and general health did not differ from normal rats. Pancreas transplantation with portal venous drainage furthermore normalized nonfasting blood glucose and peripheral insulin levels, and intravenous glucose tolerance. Pancreas transplantation with systemic venous drainage, however, was associated with peripheral hyperinsulinemia, slightly elevated nonfasting blood glucose levels, and supranormal K-values in intravenous glucose tolerance tests. Though portal venous drainage was associated with better metabolic control than systemic venous drainage, both techniques of pancreas transplantation proved equally effective to prevent the development of diabetic glomerular membrane thickening determined 6 and 12 months posttransplant.

Systemic Venous Drainage of Pancreas Allografts as Independent Cause of Hyperinsulinemia in Type I Diabetic Recipients

To evaluate the metabolic consequences of pancreas transplantation with systemic venous drainage on beta-cell function, we examined insulin and C-peptide responses to glucose and arginine in type I (insulin-dependent) diabetic pancreas recipients (n = 30), nondiabetic kidney recipients (n = 8), and nondiabetic control subjects (n = 28). Basal insulin levels were 66 +/- 5 pM in control subjects, 204 +/- 18 pM in pancreas recipients (P less than 0.0001 vs. control), and 77 +/- 17 pM in kidney recipients. Acute insulin responses to glucose were 416 +/- 44 pM in control subjects, 763 +/- 91 pM in pancreas recipients (P less than 0.01 vs. control), and 589 +/- 113 pM in kidney recipients (NS vs. control). Basal and stimulated insulin levels in two pancreas recipients with portal venous drainage were normal. Integrated acute C-peptide responses were not statistically different (25.3 +/- 4.3 nM/min in pancreas recipients, 34.2 +/- 5.5 nM/min in kidney recipients, and 23.7 +/- 2.1 nM/min in control subjects). Similar insulin and C-peptide results were obtained with arginine stimulation, and both basal and glucose-stimulated insulin-C-peptide ratios in pancreas recipients were significantly greater than in control subjects. We conclude that recipients of pancreas allografts with systemic venous drainage have elevated basal and stimulated insulin levels and that these alterations are primarily due to alterations of first-pass hepatic insulin clearance, although insulin resistance secondary to immunosuppressive therapy (including prednisone) probably plays a contributing role. To avoid hyperinsulinemia and its possible long-term adverse consequences, transplantation of pancreas allografts into sites with portal rather than systemic venous drainage should be considered.

Portal venous collateral drainage in IVC obstruction

Collateral venous drainage via the portal venous system has been demonstrated in three patients with testicular teratoma and IVC obstruction using contrast venography and enhanced computed tomography (CT). The use of CT in assessing the extent of the collateral circulation in IVC obstruction together with implications for surgical management are discussed.

Studies of the Entero‐insular Axis Following Pancreas Transplantation in Man: Neural or Hormonal Control?

To study the role of hormonal and neural factors in the control of the entero-insular axis the insulin, C-peptide, and glucose-dependent insulinotropic peptide (GIP) responses to oral and intravenous glucose were investigated in 5 patients who had received a combined kidney and paratopic pancreas transplant, with physiological portal venous drainage. The incremental areas under the insulin and C-peptide responses to oral glucose were significantly greater than the responses to intravenous glucose (insulin: patients 7983 +/- 1937 (+/- SE) vs 3513 +/- 2188 mU l-1 min, p less than 0.002, control subjects 5505 +/- 1035 vs 1066 +/- 484 mU l-1 min, p less than 0.004; C peptide: patients 440 +/- 80 vs 144 +/- 61 nmol l-1 min, p less than 0.01, control subjects 200 +/- 38 vs 63 +/- 16 nmol l-1 min, P less than 0.01). The incretin effects for insulin (patients 4.4 +/- 1.4, control subjects 7.7 +/- 1.8) and C-peptide (patients 4.4 +/- 0.9, control subjects 3.7 +/- 0.9) and the GIP responses to oral and intravenous glucose were not significantly different between transplant patients and control subjects. As the incretin effect was preserved, despite a denervated pancreas, hormonal rather than neural factors may be more important in mediating increased insulin secretion after oral carbohydrate. The normal GIP response is compatible with its proposed role as an insulinotropic hormone.

Orthotopic nonauxiliary total bowel transplantation using rats: technical procedure.

A procedure for nonauxiliary orthotopic total bowel transplantation is described, in which the graft from jejunum to distal colon is transplanted with portal venous drainage in end-to-end fashion in a one-stage procedure. The early postoperative mortality (within 4 days) was 23.8% in this study and presently is approximately 20% in our laboratory. It is noteworthy that the incidence of venous thrombosis is very low in this model. Continuous venous infusion, vascular perfusion, and luminal irrigation with Euro-Collins solution were employed in this preparation. The technique described is expected to prove useful for orthotopic nonauxiliary bowel transplant investigation because of its technical simplicity, low early postoperative mortality, and low incidence of vascular complications.

Pancreatic endocrine responses to nutrients and bombesin after segmental pancreas autotransplantation in dogs.

The capacity of autotransplanted (ATP) distal pancreas segments with systemic venous and peritoneal exocrine drainage to support physiologic control of plasma glucose levels was tested, and compared with the functions of "simulated autotransplants" (SATP) prepared with similar dissection and peritoneal exocrine drainage, but with hepatic portal venous drainage, in dogs. In ATP in the postabsorptive state, plasma levels of glucose, immunoreactive insulin (IRI) and immunoreactive glucagon (IRG1) were normal. Autotransplants resulted in impaired glucose tolerance after meals with impaired early insulin responses, and the normal brisk rise of IRG1 in the plasma was delayed and reduced through the first 30 min of feeding. In ATP, also, the response to bombesin was abnormal; the normal stimulation of release of both IRI and IRG1 was delayed in both cases. In studies of responses to oral and intravenous glucose in ATP and SATP dogs, similar mild degrees of glucose intolerance were found with both routes of administration; however, whereas in ATP dogs increases of IRI were highly exaggerated with both routes of administration of glucose, in SATP dogs plasma IRI rose from subnormal levels in the postabsorptive state through subnormal increments with both routes of administration. Further studies are necessary to determine the relative importance of denervation and reduction of the mass of the pancreas in these effects, and to assess the significance of the differences in blood insulin levels in the two preparations.

Small bowel allografts: Sequence of histologic changes in acute and chronic rejection

Using a rat model of accessory small bowel transplantation, the histologic sequence of both acute and chronic rejection in intestinal allograft rejection has been defined. Histologically, all allografts were normal for the first 5 postoperative days. Allografts with caval venous drainage were subject to acute rejection. By 6 to 7 days postoperatively, plasma cells and lymphocytes infiltrated the lamina propria of these grafts (phase I). By 8 to 9 days postoperatively, the cellular infiltration intensified and was associated with villous blunting and scattered epithelial sloughing (phase II). By the 10th day, complete mucosal destruction developed, with heavy transmural infiltration by lymphocytes, plasma cells, and polymorphonuclear leukocytes (phase III). This histologic end point of acute graft rejection was accompanied by death of the host. Grafts with portal venous drainage underwent a similar, although less rapid, sequence of histologic changes (phase 16 to 9 days, phase II 10 to 13 days, phase III 13 or more days) resulting in graft fibrosis and encapsulation. Some variability was seen among different areas of a given circumferential cross section taken from grafts in phases I and II. Studying circumferential cross sections allowed correct classification into the appropriate phases.

The effects of duct obliteration and of autotransplantation on the endocrine function of canine pancreatic segments.

This study in dogs addresses itself to the endocrine function of the duct-obliterated left pancreatic lobe (body and tail), which is the portion of the pancreas used for segmental transplantation. The endocrine function was determined with intravenous (i.v.) glucose tolerance tests and expressed in K-values and insulin-response curves. Duct obliteration of the nontransplanted left lobe was associated with normal K-values in the presence of the unmodified right lobe, but with reduced K-values in its absence. Removal of the left lobe while leaving the right lobe untouched was not associated with reduced K-values, but duct obliteration of the whole pancreas was. When the duct-obliterated left lobe was transplanted onto the iliac vessels (segmental autografts), K-values were reduced when compared with the unmodified situation, but were significantly higher than with nontransplanted, duct-obliterated left lobes. Insulin-response curves of nontransplanted, duct-obliterated segments differed both qualitatively and quantitatively from the unmodified situation, but insulin-response curves of duct-obliterated segmental autografts showed only qualitative differences with the unmodified situation. It is concluded that duct obliteration rather than the absence of the right lobe is the predominant cause of reduced glucose tolerance with duct-obliterated left pancreatic lobes. It is suggested that duct obliteration affects the endocrine pancreas both in a qualitative and quantitative fashion. The qualitative effect is similarly demonstrable with segmental autografts and nontransplanted segments, but the quantitative effect is largely dissolved with autografting by virtue of caval as opposed to portal venous drainage.

Maltose absorption as an indicator of small-intestinal allograft rejection

Maltose and lactose absorption, which require an intact brush border for breakdown and absorption as glucose, was evaluated as a function test to monitor the integrity of the small-bowel graft. Using the rat model of accessory small-bowel transplantation, absorption tests (in the form of an oral glucose tolerance test) were performed on iso- and allografts with either portal (PP-A) or caval venous drainage (PC-A). In isografts the absorption of maltose was found to be reproducible and not influenced by the type of venous drainage. This was not the case with the use of lactose which thus was not studied further. Allografts with PC-A demonstrated a reduction in their capacity for maltose absorption on the fifth postoperative day, as the glucose peak at 30 min (T30) was significantly blunted in comparison to that for isografts with PC-A (167 mg% ± 12 vs 204 mg% ± 8). Functional impairment preceded histologic changes which did not arise before the sixth-to-seventh postoperative day in rats with PC-A. Allografts with PP-A absorbed maltose on the fifth postoperative day nearly as effectively as did isografts (T30 min: 185 mg% ± 14 vs 213 mg% ± 8). By the ninth postoperative day, the serum glucose curve after maltose administration was flattened for grafts with PC-A (T30 min: 137 mg% ± 11) which were rejected acutely (host's death) after 11.8 days ± 0.45. A similar impairment of maltose absorption was not seen in the PP-A group (chronic graft rejection after 22.8 days ± 1.8) until the 15th postoperative day. These results suggest that maltose absorption becomes impaired before the clinical appearance of rejection and its histologic alterations. The maltose absorption test effectively predicts rejection and monitors the function of the intestinal graft in this animal model.

A modified sugiura operation for bleeding varices in children

Objections to portal systemic shunting in children with life-threatening hemorrhage from esophageal varices include the high incidence of postshunt encephalopathy with neurologic and psychiatric sequelae and the inability to provide an adequate shunt in very young children. We have operated on eight children in the past 4 years for bleeding varices. The causes were: portal vein thrombosis (3), congenital hepatic fibrosis (2), chronic active hepatitis (2), and cystic fibrosis (1). The ages at operation were between 2 and 17 years. These children underwent various modifications of an operation described by Sugiura. The operation we have developed is done through a single thoracoabdominal incision, dividing and anastomosing the esophagus with a stapler, preserving the vagal innervation to the pylorus and antrum, and wrapping the fundus around the distal esophagus at the site of the anastomosis. The venous drainage of the lower esophagus and of the upper stomach is divided. The operation is therefore shorter and simpler, but adheres to the principles enunciated by Sugiura. Complications include one significant postoperative anastomotic leak and one symptomatic esophageal stricture. Longterm results have been gratifying with no evidence of rebleeding from esophageal varices. We believe that our modification of the original Sugiura operation is the preferred therapy of bleeding esophageal varices when surgical intervention is indicated because it preserves the normal structure and function of the upper gastrointestinal tract as well as the portal venous drainage to the liver.

Graft-versus-host reaction induced by spleen grafting in inbred strains of rats. Influence of portal venous drainage.

Acute graft-versus-host (GvH) reaction was induced by spleen grafting in inbred rats. A comparison of the influence of portal or caval drainage of the spleen graft on the survival time was made. This comparison revealed a prolongation of survival time in case of a portal drainage when the graft was an auxiliary half-spleen graft. This result suggests that the liver may have, in some conditions, protective capacities against an acute GvH reaction.

The Dominican Republic conjoined twins: ischiopagus, tetrapus, omphalophagus

Alta and Clara, the Dominican Republic conjoined twins (ischiopagus, omphalopagus, tetrapus) were evaluated prior to separation with plain films, vaginograms, arteriograms, intravenous pyelogram, barium enema, and upper gastrointestinal series with small bowel follow-through. The clear demonstration of their internal anatomy allowed the surgeons to plan the operative approach and to make a reasonable judgment regarding viability of each baby. Each twin had a semicircular pelvis which joined the other to form a complete ring. There were a few hepatic arterial twigs from Alta which crossed the midline, proving at surgery to be a small bridge of tissue connecting the two livers. Clara's superior mesenteric arteries supplied the majority of the small bowel. Portal venous drainage was separate for each twin. Each baby had two kidneys in normal position with the bladders laterally placed. Each bladder received one ureter from each twin. Two separate small bowels joined proximal to the single colon which terminated in an anus related to Clara's pelvic structures. Following separation, each baby did well. Their postoperative anatomy is described.

Long term studies of pancreas transplantation in experimental diabetes mellitus.

Alloxan diabetes was induced in inbred rats that then were divided into four groups consisting of unoperated diabetic controls, sham-operated diabetic controls, rats given pancreaticoduodenal isografts, and rats given duct-ligated pancreas isografts. The animals were studied for from 18 months (controls) to two years (transplants) and the following important results were obtained: 1) In striking contrast to the diabetic controls, pancreas transplants of both types produced immediate and permanent relief of hyperglycemia, immediate and lasting elevation of serum insulin levels, a normal weight and growth curve, and good health for two years. Removal of the graft was followed by recurrence of severe diabetes. 2) Pancreas transplants of both types prevented the widespread and severe renal, ophthalmic and neural lesions of diabetes that were found in the diabetic controls. 3) The duct-ligated pancreas graft and pancreaticoduodenal transplant were equally effective in controlling diabetes. Ligation of the pancreatic duct was not followed by significant morphologic or clinical evidence of pancreatitis or by loss of endocrine function. 4) Portal venous drainage of the pancreas transplant was unnecessary for good endocrine function.

Simultaneous allografts of both kidneys in pigs with different portal and caval venous drainage

Simultaneous allografts of both kidneys were performed in pigs. The experiments were carried out in three groups of animals. In group I both kidneys were grafted with portal venous drainage. In group II both kidneys were grafted with caval venous drainage. In group III the renal vein of one kidney was anastomosed to the portal vein whereas the renal vein of the other kidney was anastomosed to the caval vein. Although in group I the animals showed longterm survival (two of them over one year), in groups II and III all animals died within a few days with typical signs of rejection. These results indicate that the portally anastomosed kidney does not produce immunologic paralysis of the host to avoid the rejection reaction of the other cavally anastomosed kidney.

Organs transplantation in pig with different portal and caval venous drainage.

Liver, heart, kidney allografts in pig with different venous caval and portal drainage have been performed by the authors. Immunological response was different in relation to the transplanted organ and to the venous drainage. Organ allografts with portal venous drainage showed a more prolonged tolerance in comparison with controls. They suggested that the particular behavior of organs transplants in pig may be referred to the unusual lymphatic system quite different from any other animal.

Ligation of the Inferior Vena Cava Above the Renal Veins

No AccessJournal of Urology1 Sep 1961Ligation of the Inferior Vena Cava Above the Renal Veins John B. Wear John B. WearJohn B. Wear Present address: Department of Urology, University Hospital, Madison, Wis. More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)65162-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1961 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByRosenthal J and Loo R (2018) Portal Venous Drainage for Cadaveric Renal TransplantationJournal of Urology, VOL. 144, NO. 4, (969-971), Online publication date: 1-Oct-1990.Caplan B, Halasz N and Bloomer W (2018) Resection and Ligation of the Suprarenal Inferior Vena CavaJournal of Urology, VOL. 92, NO. 1, (25-29), Online publication date: 1-Jul-1964. Volume 86Issue 3September 1961Page: 301-303 Advertisement Copyright & Permissions© 1961 by The American Urological Association Education and Research, Inc.MetricsAuthor Information John B. Wear Present address: Department of Urology, University Hospital, Madison, Wis. More articles by this author Expand All Advertisement Loading ...