- May be performed in diabetic patients with end-stage renal disease either as simultaneous pancreas-kidney (SPK) transplantation, or as pancreas-after-kidney (PAK) transplantation.
- Pancreas transplantation has minimal impact on immunosuppression.
- Nonuremic patients with type 1 diabetes usually receive pancreas transplantation alone (PTA).
- Risk of immunosuppression is added to the surgical risk.
- Untreated or recent malignancy.
- Active or chronic infection.
- Inability to comply with postoperative immunosuppression and follow-up.
- Advanced extrarenal complications of diabetes (coronary artery disease).
- Evidence of insulin resistance (type 2 diabetes, insulin requirements > 1 unit/kg, BMI > 30).
- Improved quality of life.
- Provides optimum glucose control.
- Improves or minimizes complications of diabetes.
- Reverses early diabetic nephropathy in both native and graft kidneys.
- Results in euglycemia without hypoglycemia.
- Conveys a survival benefit for type 1 diabetic patients with end-stage renal disease.
- 5-year graft survival is 57–71%.
- Inherent risks of postoperative immunosuppression.
- Venous thrombosis (affects 3–5% of grafts in the first 24–48 hours).
- Complications of exocrine drainage:
- Cystitis and balanitis in bladder-drained grafts.
- Abscess or leak in enteric drainage.
- Sterile ice for back-table preparation and surface cooling of the graft.
- Fixed retractor for optimal exposure.
- Freedom from malignancy and infectious disease.
- Donor age, mechanism of death, medical history, and perimortem hyperglycemia or hyperamylasemia affect suitability of the pancreatic graft.
- Inspection at the time of donation.
- Eligibility is based on utility of a pancreatic graft as well as individual fitness for operation, with emphasis given to preoperative weight loss as necessary.
- Preoperative evaluation is directed toward identification and treatment of diabetic complications, most importantly coronary artery disease, and includes:
- Stratified cardiac evaluation (all recipients).
- Assessment for coexistent pulmonary vascular obstructive disease in the absence of a femoral pulse.
- Investigation of aortoiliac occlusive disease with noninvasive flow studies, MR angiogram, CT angiogram, or standard angiography.
- Preoperative preparation includes placement of arterial and central venous lines, nasogastric tube, and Foley catheter, as well as sequential compression devices. Patients should also receive preoperative antibiotic prophylaxis.
- For both donor and recipient procedures:
- The patient should be supine.
- The abdomen is entered through a midline incision.
- Figure 31–1: The lesser sac is entered by dividing the gastrocolic ligament.
- The stomach is retracted superiorly and the transverse colon inferiorly to expose the pancreatic body and tail.
- Careful palpation of the pancreas to detect masses or abnormalities is followed by careful dissection of the gastrohepatic and hepatoduodenal ligaments.
- The common bile duct, gastroduodenal artery, right gastric artery, and coronary vein are sequentially divided.
- The celiac axis is exposed, the left gastric artery ligated, and the supraceliac aorta controlled.
- The posterior aspect of the pancreas is inspected using a Kocher maneuver, with ...
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