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  • 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.

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Absolute

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  • Untreated or recent malignancy.
  • Active or chronic infection.
  • Inability to comply with postoperative immunosuppression and follow-up.

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Relative

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  • Advanced extrarenal complications of diabetes (coronary artery disease).
  • Evidence of insulin resistance (type 2 diabetes, insulin requirements > 1 unit/kg, BMI > 30).

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Expected Benefits

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  • 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%.

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Potential Risks

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  • 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.
  • Bleeding.
  • Pancreatitis.

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  • Sterile ice for back-table preparation and surface cooling of the graft.
  • Fixed retractor for optimal exposure.

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Donor

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  • 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.

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Recipient

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  • 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.

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  • For both donor and recipient procedures:
    • The patient should be supine.
    • The abdomen is entered through a midline incision.

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Donor Pancreatectomy

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  • 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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