CHAPTER 103: Pancreas Implantation

PRE-OPERATIVE CONSIDERATIONS:

• We meet with the patient immediately prior to the procedure to address any pending questions

• In instances of a combined kidney pancreas, we usually perform the pancreatic implantation prior to the renal one to minimize the pancreas cold ischemic time.

• In cases of systemic venous drainage (anastomosis to the external iliac vessels),

  • the pancreas is preferably placed on the right lower quadrant

    • allows drainage of exocrine contents into the small bowel or bladder

    • placing the pancreas on the right lower quadrant provides alignment of the iliac vessels and prevents topographic impediments (to the small bowel and bladder) associated with the left/sigmoid colon.

  • The kidney is routinely placed on the left lower quadrant.

  • This sidedness may be altered depending on

    • Surgeon preference

    • Vascular disease involving the iliac vessels and aorta

    • Previous surgeries (transplants, ostomies, scars)

    • Other factors

• Verify that the correct allograft is available or will be available at the time of implantation

• The recipient should have adequate venous access – at least two large bore peripheral IV

• Placement of central venous lines depends on the potential for intra-operative decompensation as well as surgeon preference

• Placement of arterial lines depends on the potential for intra-operative decompensation as well as surgeon preference

• Urinary catheter ALWAYS placed

• We routinely administer oral aspirin prior to and after the procedure.

• It is also our practice (if possible) NOT to discontinue medications that recipients may have been taking on a routine basis

  • Clopidrogel, oral anticoagulants, and other medications that predispose to hemorrhage can be either continued at the time of surgery or discontinued/reversed prior to the transplant

    • The risk of cardiovascular/thrombotic complications should be balanced with the possibility of bleeding when making this decision.

  • If discontinued, they should be restarted postoperatively as soon as it is considered safe.

• IV fluids:

  • Combined kidney pancreas transplant

    • We routinely administer 2-4 liters of isotonic crystalloids during the entire procedure.

    • However, such volume can be modified based on physiologic parameters obtained during the surgery

    • Adding potassium to IV fluids is discouraged

  • Isolated pancreas transplant

    • The volume of IV fluids administered is based on the physiologic needs of each individual patient.

• We routinely maintain sequential compression devices on both lower extremities during the entire case to diminish the incidence of deep venous thromboses.

Timeout

• Performed immediately prior to incision after the abdomen has been painted and draped

• Review all medications given preoperatively.

• Intravenous antibiotics administered (assuring that they are received within minutes of incision).

• Other medications administered

  • induction agents,

    • If combined kidney pancreas

      • 500 milligrams solumedrol (or other desired dosage)

      • 25 g mannitol,

      • 100 mg of furosemide

      • (alternatively, diuretics can be infused prior to reperfusion).

PORTAL VENOUS OUTPUT WITH ENTERIC DRAINAGE OF EXOCRINE SECRETIONS - Figure 103-1

• This is our preferred technique.