Systemic-enteric Drainage Research Articles

A Single Center 11 Year Experience with 202Pancreas Transplants: Evolving Trends

A single center experience with pancreas transplantation (PTx) over an 11+ year period is reviewed. Methods: We retrospectively studied outcomes in 202 consecutive PTxs in 192 patients at our center. All patients received either rATG or alemtuzumab (Alem) induction with tacrolimus/MMF and tapered steroids or early withdrawal. 179 PTxs (89%) were performed with portal-enteric and 23 with systemic-enteric drainage. Results: From 11/01 to 3/13, we performed 162 simultaneous kidney-PTxs (SKPT), 35 sequential PTxs after kidney (PAK), and 5 PTx alone (PTA; 40 solitary PTxs [SPT]). 186 PTxs (92%) were primary and 16 pancreas retransplants. With a mean follow-up of 5.5 years, overall patient (87% SKPT versus 87.5% SPT), kidney (74% SKPT versus 82.5% SPT) and pancreas graft survival (both 65%) rates were comparable. Causes of PTx loss were also similar between SKPT and SPT; the rates of early thrombosis were 8.6% and 5%, respectively. Acute rejection rates were similar between groups (SKPT 29% versus SPT 26%, p=NS). A randomized trial of Alem versus rATG induction in SKPT demonstrated lower rates of acute rejection and infection in the Alemgroup; consequently, Alem induction has been used exclusively in all PTxs since 2009. Early steroid elimination has been feasible in most patients. Surveillance PTx biopsy-directed immunosuppression has contributed to equivalent long-term outcomes in SKPT and SPT. Good results have been achieved in African-American patients and in patients with a type 2 diabetes phenotype. Conclusions: Excellent 5 year outcomes following PTx can be achieved as >86% of patients are alive, >87% of surviving patients are dialysisfree, 80% of surviving patients remain insulin-free, and 88% of surviving patients have detectable C-peptide levels.

Case Report: Pancreas Graft With a Duodenal Complication Rescued Using Total Duodenectomy

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for type 1 diabetics with end-stage renal disease. Recently patients with type 2 diabetes have been considered for transplantation. Despite that the patient and graft survival rates have improved over the past years, it continues to be a procedure with high surgical complication rates. We herein report a case of a pancreatic graft with a duodenal complication rescued using a total duodenectomy, a procedure that is seldom used. A 57-year-old type 2 diabetic underwent a SPK transplantation with systemic-enteric drainage. He was converted to a Roux en Y at day 7 for a small duodenal fistula without peritonitis. At day 13, with good graft function, he presented with gastrointestinal and abdominal bleeding. At laparotomy he had a congestive duodenum with intraluminal bleeding and an anastomotic fistula. We performed a total duodenectomy with enteric drainage. The patient was discharged home on day 39 with a pancreatic fistula on intramuscular Octretotide that lasted for 3 months. He was never readmitted and has good pancreas and kidney function at 16 months of follow-up. We think this is an option to rescue a pancreas graft with duodenal complications in selected cases.

Pancreas Transplantation in African American Compared to Non African American Patients: Does Recipient Ethnicity Influence Outcomes?

The influence of African American (AA) recipient ethnicity on outcomes following pancreas transplantation (PT) is uncertain. Methods: We retrospectively studied 202 consecutive PTs in 192 patients at our center. All patients received either rATG or alemtuzumab induction with tacrolimus, MMF, and tapered steroids. Results: From 11/01 to 3/13, 39 PTs (36 simultaneous pancreas-kidney) were performed in AA recipients and 163 in non AA recipients (161 Caucasian). The AA group had fewer solitary PTs (8% AA versus 23% non AA), more PTs performed with systemic-enteric drainage (23% AA versus 9% non AA), more sensitized patients (28% AA versus 10% non AA), more 5-6 HLA mismatches (64% AA versus 42% non AA), more patients ≥80 kg (51% AA versus 24% non AA), more patients with detectable pretransplant C-peptide levels (36% AA versus 14% non AA), and more patients with a shorter duration (≤18years) of pretransplant diabetes (38% AA versus 17% non AA, all p<0.05). The latter 3 differences suggested that a type 2 diabetes phenotype was more prevalent in the AA group. With a mean follow-up of 5.5 years, overall patient (90% AA versus 86.5% non AA), kidney (67% AA versus 77% non AA) and pancreas graft survival (59% AA versus 67 % non AA) rates were comparable. The rates of early thrombosis were 10% versus 7%, while cumulative clinical acute rejection rates were 33% versus 27% in the AA and non AA groups, respectively. However, the incidences of death-censored kidney graft loss (30% AA versus 13% non AA) and dual graft loss (22% AA versus 6% non AA, both p<0.05) were much higher in AA patients. Conclusions: PT in AA recipients is characterized by fewer solitary PTs and more PTs with systemic-enteric drainage, more sensitized patients and HLA-mismatching, and more patients with a type 2 diabetes phenotype. Although survival rates and the incidences of early thrombosis and acute rejection are similar, AA patients are at a greater risk for both isolated kidney and dual graft loss in the absence of mortality.

Experience with 53 portal–duodenal drained solitary pancreas transplants

Systemic-enteric drainage is currently the most common technique for pancreas transplantation (PT). A novel alternative technique, portal-duodenal drainage (PDD), has potential physiological benefits and provides improved monitoring of the pancreatic graft. The current study describes 53 solitary PT procedures (43 pancreas after kidney and 10 pancreas transplant alone) using the PDD technique over the last three yr. This method resulted in one-yr patient survival at 96% and 83% graft survival. There were five cases (9.4%) of thrombosis, in which transplantectomy and two-layer closure of the native duodenum were performed. No fistulas were observed. Here, we demonstrate that the PDD technique in PT was as safe and effective as current techniques in clinical use.

Pancreas Transplantation with Systemic-Enteric Drainage when Portal-Enteric Drainage is Contraindicated

Although most Pancreas Transplants (PTs) are currently performed with exocrine enteric drainage, <20% also incorporate portal venous delivery of insulin (portal-enteric drainage). The purpose of this study was to analyze outcomes according to surgical technique.

Ten Years of Simultaneous Pancreas-Kidney Transplantation: A Retrospective Single-Center Analysis of Prospectively Obtained Data

Introduction Simultaneous pancreas-kidney transplantation (SPK) is a standardized and life-saving procedure for a patient suffering from both insulin-dependent diabetes mellitus type 1 (IDDM 1) and end-stage diabetic nephropathy. To expand the donor pool and to determine the influence of the preprocurement pancreas suitability scoring system (P-PASS) on pancreas graft survival we retrospectively analyzed our data on SPK. Patients and Methods From 1999 to 2010 we performed 55 SPKs, using systemic-enteric drainage as surgical approach. The immunosuppressive therapy was induced with basiliximab; maintenance therapy was based on tacrolimus, mycophenolate mofetil, and steroids. Data were prospectively obtained, analyzed, and correlated to the P-PASS. Results The overall 10-year patient survival rate was 78% with a 10-year pancreas survival rate of 53%. Three patients needed retransplantation of SPK and 6 patients needed singular pancreas retransplantation. Seventeen patients showed acute rejection episodes and 14 patients suffered from cytomegalovirus (CMV) infections. We compared 43 patients receiving organs from an “ideal” donor (P-PASS <17) with 12 patients receiving grafts from “marginal” donors (P-PASS ≥17). Neither P-PASS nor donor age demonstrated significant influence on pancreas graft survival. However, the body mass index (BMI) of the donor showed a negative tendency ( P = .059). Conclusion The P-PASS showed no significant prediction of pancreas graft survival. In view of our data, expansion of the German donor pool is possible. A multicenter study of SPK using “marginal” pancreas grafts is mandatory to define a realistic “cut-off” value for P-PASS.

Expression and significance of local Th1 and Th2 cytokines in the grafts of pig simultaneous pancreas-kidney with portal versus systemic venous drainage

Objective To investigate the expression and significance of local Th1 and Th2 cytokines in the grafts of pig simultaneous pancreas-kidney with portal versus systemic venous drainage. Methods Fifty-eight non-related and first hybrid landraces were divided into Sham (n = 10), PE (portal-enteric drainage) (n =24) and SE ( systemic-enteric drainage) (n =24) groups. Type 1 diabetic mellitus was induced by whole pancreatectomy ,and right-side nephrectomy was also performed in the recipients. The pigs in sham group were only subjected to laparotomy. The portal vein was anastomosed to superior mesenteric vein of the recipient in PE group or to the inferior hepatic cava of the recipients in SE group. The tissues of the graft pancreas and kidney were obtained by surgery for detecting the expression of mRNA and protein of IFN-γand IL4 by RT-PCR and ELISA on the day 3,and 7 after transplantation. Results Compared with sham group,the local expression of mRNA and protein of IFN in the graft pancreas and kidney of both SE and PE groups was significantly up-regulated ( P < 0. 05 ) ( On the day 7, protein expression in sham, SE, and PE groups :in the graft pancreas, [ (3.36±0.25 ), (7.72±0.67 ), and ( 6.52±0.34 ) pg/mg protein ];in the graft kidney, [ ( 3.66±0.28 ), ( 10.83±1.48 ), and (7.79±0.60) pg/mg protein ]. The local expression of mRNA and protein of IL-4 was significantly up-regulated in PE group (P < 0.05 ), but down-regulated or no expression was detected in group SE (on the day 7, protein expression in sham, SE, and PE groups:in the graft pancreas, [ (7.18±0.16), (6.10±0.16) ,and (20.66±1.47) pg/mg protein];in the graft kidney, [ (5.74±0.48) ,(10.38±0.92) ,and ( 19.66±1.57) pg/mg protein]. Conclusion That the blood flow of graft pancreas passes by liver in SPK with PVD can induce a Th1 to Th2 inmaune shift. This may be one of mechanisms of immunologic benefits of PVD. Key words: Simultaneous pancreas-kidney transplantation; Cytokines; Portal venous drain-age; Systemic venous drainage; Pig

Retroperitoneal pancreas transplantation with systemic-enteric drainage - case report

Enteric drainage and intraperitoneal graft position is the preferred technique for pancreas transplantation at most transplant centers. The technique of retroperitoneal pancreas transplantation was first described by Boggi et al. [Transplantation,79 (2005), 1137]. In this case report, a modified model of retroperitoneal pancreas transplantation with systemic-enteric drainage is presented. A 48-yr-old patient underwent combined retroperitoneal pancreas and kidney transplantation because of type-I-diabetes, and diabetic nephropathy. At the time of transplantation, the patient had a body mass index of 31 and severe atherosclerosis of the iliac vessels. After mobilization of the colon and mesocolon ascendens, the vessels of the pancreas graft were anastomosed end-to-side to the aorta and to the inferior caval vein of the recipient. For exocrinous drainage, a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the right colon mesentery. The graft was in a retroperitoneal position. The patient was insulin-independent after 48 h, the lipase and amylase levels were within the normal range. The first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed that the technique was safe and had technical advantages when compared with the classic method.

Impact of Portal Versus Systemic Venous Drainage on Acute Rejection of Simultaneous Pancreas−Kidney Transplantation in Pig

The immunological benefits of portal venous drainage (PVD) in pancreas transplantation remain debated clinically. We established simultaneous pancreas-kidney transplantation (SPK) models with portal venous drainage and systemic venous drainage to compare the impact of venous drainage site on acute rejection in pig. Forty-eight nonrelated, first hybrid landrace pigs were divided into PE (portal-enteric drainage) and SE (systemic-enteric drainage) groups. Type I diabetes mellitus was induced by whole pancreatectomy, and right-side nephrectomy was also performed in the recipients. The donor portal vein was anastomosed to superior mesenteric vein of the recipients in PE group or to the inferior hepatic cava vena of the recipients in SE group. Graft tissue specimens were obtained with laparotomy on Day 3 and 7 after transplant, and the severity of acute rejection was scored according to Nakhleh and Banff criteria. The cold ischemia time, fasting plasma glucose and urine creatinine of the 2 groups had no statistic difference between 2 groups at Day 1, 3, 5, and 7 after transplant (P>0.05). The occurrence of both pancreas and kidney acute rejections in PE group was significant later and slighter than SE group (P<0.05). PVD, compared with SVD, could ameliorate and delay acute rejection in pig SPK. It might become a tolerance inducing method of pancreas transplantation, decrease the cost and improve the quality of SPK, if further confirmed by clinical trials.

Effects of Portal Versus Systemic Venous Drainage in Pancreas and Kidney-Pancreas Transplantation

We performed a retrospective analysis to compare pancreas transplantation with systemic-enteric drainage (SE) or portal-enteric drainage (PE). Methods We reviewed 38 consecutive pancreas transplants including 31 simultaneous kidney-pancreas (SKP) and 7 pancreas after kidney (PAK), using either systemic ( n = 18) or portal ( n = 20) venous drainage. Demographic, clinical, and immunologic variables were similar for both groups. Results There were no significant differences in patient, kidney, or pancreas allograft survival rates after a mean follow-up of 23 months (range 1–60). The mean length of hospital stay within 3 months was 34 days among the SE group versus 20 days in the PE group ( P = ns). The incidences of intraabdominal infection, early relaparotomy, and acute rejection episodes were not different between groups. The blood pressure levels were similar among the SE and PE groups. There was no significant difference in creatinine, or fasting glucose, C-peptide, cholesterol, or triglyceride levels or homeostatic model assessment (HOMA) beta cell, HOMA-S, and HOMA-IR index. HbA1c was lower at 6 and 12 months in the PE group ( P < .05). Mean prednisone and mycophenolate mofetil doses as well as tacrolimus levels were identical for both groups. Conclusion The results suggested sustained long-term endocrine function in both groups, showing that in the short term, portal venous drainage did not offer major metabolic or immunologic advantages compared with systemic delivery of insulin.