Chapter 31. Pancreas Transplantation

• 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.

Absolute

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

Relative

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

Expected Benefits

• 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%.

Potential Risks

• 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.

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

Donor

• 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.

Recipient

• 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.

Donor Pancreatectomy

• 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 ...