CHAPTER 101: Overview—Pancreas Transplantation

INTRODUCTION

The main goals of pancreas transplantation are

• Insulin independence and normoglycemia with normal hemoglobin A1c levels

• Prolonged survival

• Improved quality of life

Over 50% of pancreas recipients have systemic dysfunctions at the time of transplantation.

Dysfunctions can be of varied nature, and include but are not limited to:

• gastrointestinal

• neurologic

• ocular

• renal

• vascular

Pancreas transplantation:

• Is the only system able to achieve a continuous euglycemic environment (with normal glycosylated hemoglobin levels) in the absence of exogenous insulin.

• Insulin independence is frequently achieved immediately after transplantation.

• On a long term basis, may prevent the progression (or development) of diabetic complications such as:

  • Retinopathy

  • Nephropathy

  • Lipid derangements

  • Carotid artery disease

  • Coronary artery disease

  • Cardiac dysfunction

  • Motor, sensory, and autonomic neuropathy

INDICATIONS

Candidates for pancreatic transplantation include:

• Type 1 diabetics (main indication)

  • ~75% of cases

• Selected Type 2 diabetics

  • ~20% of cases

• Failed previous pancreas transplant recipients

• Diabetics due to total pancreatectomy, e.g., due to chronic pancreatitis

• Diabetics due to cystic fibrosis (very rare)

PATIENT SELECTION

• Thorough preoperative workup is essential in order to optimize patient and graft outcomes.

• Cardiovascular complications (e.g., myocardial infarction or stroke) constitute the major source of morbidity and mortality.

• Low threshold for cardiac catheterization (some authors suggest routine cardiac catherization)

• Imaging studies (such as CT scan) to assess patency and calcification of vessels involved in anastomoses

• Increasing age and elevated BMI correlate with inferior outcomes

PANCREATIC TRANSPLANT CATEGORIES:

1. SIMULTANEOUS PANCREAS KIDNEY (SPK) TRANSPLANTATION (85% of cases)

   • Most frequent type of pancreas transplant, indicated for Type 1 diabetics with renal failure

   • Simultaneous implantation of both organs

   • Immunosuppression similar for both organs

   • Approximately 85% of all cases of pancreas transplantation

2. PANCREAS ALONE (PTA) TRANSPLANTATION (10% of cases)

   • Indicated primarily in labile (“brittle”) Type 1 diabetics with hypoglycemic unawareness

     • Also a consideration in Type 1 diabetics who wish to eliminate (or diminish) the risk or progression of diabetic complications in exchange for immunosuppression.

   • Approximately 10% of all cases of pancreas transplantation

3. PANCREAS AFTER KIDNEY (PAK) TRANSPLANTATION (5% of cases)

   Most frequently indicated for Type 1 diabetics who

   • Received a previous kidney transplant (such as from a live donor)

   • Received a previous SPK or PAK in which only the pancreas graft has failed

   • Approximately 5% of all cases of pancreas transplantation

DONOR SELECTION AND PROCUREMENT

• When considering potential deceased donors, the accepting surgeon should determine the likelihood of function after implantation based on donor quality

• A history of diabetes in the donor should always be excluded

• Hyperglycemia in a brain dead donor does not constitute by itself a contraindication to pancreatic procurement

• At the time of procurement (and during the back table preparation) the organ should be inspected for the presence of detrimental factors such as inflammation, tumor, ...