Generalities of Pancreas Transplantation Indications
Pancreas and pancreas-kidney transplantation are considered now an acceptable
alternative for the treatment of Type I diabetic patients particularly if there
is already significant diabetic nephropathy. Pancreas transplantation is also
performed with less frequency to treat Type II diabetes (less than 4% of recipients).
Diabetes mellitus is the major cause of end-stage renal disease and the secondary
complications of diabetes (neuropathy, diabetic gastroparesis and retinopathy)
have significant impact in the patients' quality of life. The objectives of
pancreas transplantation are: a)normalize insulin production and glucose metabolism,
and b) prevent and in some cases correct systemic and vascular complications
of chronic hyperglycemia. A much more unusual indication for pancreas transplant
is pancreas failure secondary to chronic pancreatitis.
Generalities of Pancreas Transplantation
As of October 2000, more than 15,000 pancreas transplants have been reported
to the International Pancreas Transplantation Registry (>11,000 in the US, >4,000
outside the US). Simultaneous kidney-pancreas (SPK) transplantation is the treatment
of choice in uremic type I diabetics. Both organs may originate from a cadaveric
donor. Simultaneous cadaver pancreas living-donor kidney transplantation (SPLK)
offers the potential benefits of living kidney donation (e.i. shorter waiting
time, improved short term and long term renal graft outcome). Patients who have
previously undergo a successful kidney transplant may receive a pancreas after
kidney (PAK) transplantation. In patients in whom pancreas transplantation is
indicated (e.g. brittle diabetes) but that have not yet developed advanced kidney
disease the transplantation of a pancreas alone (PA) is considered the treatment
Overview of Surgical Approach
The most widely used surgical technique at the present time is whole-organ
pancreas transplantation. The exocrine secretions are managed in different ways.
Initially, polymer duct obliteration was widely practiced, however, this technique
was associated with a high incidence of vascular thrombosis, pancreatitis and
formation of fistulas. At this time intestinal and bladder drainage are mostly
Bladder drained pancreas transplants attained general acceptance in the 1990's
(>80-90% in 1995,1996) however, complications such as hematuria, urine leaks,
recurrent urinary tract infections, urethritis, and reflux pancreatitis have
been described in about 25% of patients. After the first year more than 10%
of patients require conversion to enteric drainage. With the bladder drainage
technique (pancreaticoduodenocystostomy) the quantitative evaluation of exocrine
secretions in urine was used for the diagnosis of rejection (decrease of urinary
amylases and lipases). Insulin is systemically drained (iliac veins) in bladder
drained pancreas and this may lead to hyperinsulinemia. In enteric drained grafts
drainage of insulin can be done into the portal vein and this appears to be
more physiologic. Enteric drainage consists of the anastomosis of the pancreas
and attached duodenal segment into the small bowel. Currently the majority of
pancreas transplants are enteric-portally drained. Recent comparative studies
have shown that fewer readmissions occurred with this surgical technique and
that there is overall decreased recipient morbidity with improvement of rehabilitation
and quality of life. One study has shown decrease in the incidence and severity
of rejection episodes with portal-enteric drainage. Incidence of infectious
complications also have been reported to be lower with enteric versus bladder
The first pancreas transplant was performed in 1966. Very poor graft survival
was observed during the first two decades of pancreas transplantation. Progressive
improvement in outcome have been seen for pancreas transplantation since the
late 1980's. The best results are still obtained with simultaneous kidney-pancreas
transplants (SPK) with a one year graft survival of 82%; however, good one year
graft survivals are also obtained with PAK (74%) and PTA (76%). In all groups
graft survival improvements have resulted from decrease in technical failures
and decrease in immunological failures.
Overall one year patient survival is excellent being more than 94%.
It has been demonstrated that a better quality of life is obtained by patients
with SPK when compared to patients with kidney transplants alone. Pancreas transplantation
does not affect adversely the survival of the renal graft (overall one year
kidney survival in SPK is more than >90%).
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