A Prospective Comparison of Simultaneous Kidney–Pancreas Transplantation With Systemic-Enteric Versus Portal-Enteric Drainage

Stratta, Robert J.; Shokouh-Amiri, Hosein; Egidi, Maria Francesca; Grewal, Hani P.; Kizilisik, A.T; Nezakatgoo, Nosratollah; Gaber, Lillian W.; Gaber, A.

doi:10.1097/00000658-200106000-00003

Cited by 86 publications

(71 citation statements)

References 28 publications

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“…The incidence of surgical complications is also similar by type of transplant (SPK compared to solitary pancreas transplantation) [1][2][3] . Leaks from the allograft duodenum have been reported to occur in 5%-20% of bladder-drained and 5%-8% of bowel-drained pancreas transplants [9,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][67][68][69][70][71][72][73]80,[91][92][93][94][95] . Increasing experience with enteric exocrine drainage is likewise associated with a decreased rate of technical complications [9,38,80,[96][97][98][99][100][101][102][103] .…”

Section: El-hennawy H Et Al Exocrine Drainage In Pancreas Transplantsmentioning

confidence: 99%

“…However, in most cases, "portal venous" drainage usually infers that the allograft has a vertical orientation with the body and tail directed towards the pelvis, the head and duodenum directed cephalad, and the recipient SMV as the site for the venous anastomosis [18][19][20][21][22] (Figure 4). The bowel anastomosis is most commonly performed to a bowel loop that is not excluded from the transit of intestinal contents [4,16,17,33,[39][40][41][42][44][45][46][49][50][51][52][53][112][113][114][115][116][117][118][119][120][121] . Alternatively, the allograft duodenum can be connected directly into the native stomach or duodenum, to a diverting Roux limb without or with a venting jejunostomy, or to an omega loop [23][24][25][26][27][28][29][30][31][32]122] (Table 7).…”

Section: Bowel Drainage Of the Pancreatic Ductal Secretions (Portal-ementioning

confidence: 99%

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Exocrine drainage in vascularized pancreas transplantation in the new millennium

El‐Hennawy¹,

Stratta²,

Smith³

2016

WJT

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The history of vascularized pancreas transplantation largely parallels developments in immunosuppression and technical refinements in transplant surgery. From the late-1980s to 1995, most pancreas transplants were whole organ pancreatic grafts with insulin delivery to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). The advent of bladder drainage revolutionized the safety and improved the success of pancreas transplantation. However, starting in 1995, a seismic change occurred from bladder to bowel exocrine drainage coincident with improvements in immunosuppression, preservation techniques, diagnostic monitoring, general medical care, and the success and frequency of enteric conversion. In the new millennium, pancreas transplants are performed predominantly as pancreatico-duodenal grafts with enteric diversion of the pancreatic ductal secretions coupled with iliac vein provision of insulin (systemic-enteric technique) although the systemic-bladder technique endures as a preferred alternative in selected cases. In the early 1990s, a novel technique of venous drainage into the superior mesenteric vein combined with bowel exocrine diversion (portal-enteric technique) was designed and subsequently refined over the next ≥ 20 years to recreate the natural physiology of the pancreas with firstpass hepatic processing of insulin. Enteric drainage usually refers to jejunal or ileal diversion of the exocrine secretions either with a primary enteric anastomosis or with an additional Roux limb. The portal-enteric technique has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion. Reports in the literature suggest no differences in pancreas transplant outcomes irrespective of type of either venous or exocrine diversion. The purpose of this review is to examine the FIELD OF VISION

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Section: El-hennawy H Et Al Exocrine Drainage In Pancreas Transplantsmentioning

confidence: 99%

Section: Bowel Drainage Of the Pancreatic Ductal Secretions (Portal-ementioning

confidence: 99%

Exocrine drainage in vascularized pancreas transplantation in the new millennium

El‐Hennawy¹,

Stratta²,

Smith³

2016

WJT

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“…Being familiar with multiple surgical techniques of PT is helpful because the optimal technique may need to be individualized based on anatomic issues. Purported benefits of PT with portal venous outflow include technical, metabolic, and immunologic "advantages" [2][3][4][5][6][7][8][9]12]. However, these benefits have not been confirmed by either prospective cohort studies, randomized controlled trials, or large analyses based on registry databases [1,[4][5][6][7][8]12].…”

Section: Discussionmentioning

confidence: 99%

“…However, the potential of portal-enteric drainage has never been fully realized as it currently accounts for only 18% of SKPT and PAK and 10% of PTA transplants [1]. A number of studies have demonstrated no major or consistent differences in outcomes for bladder-drained or enteric-drained PTs with either portal or systemic venous drainage [4][5][6][7][8]. Although nearly all PTs are currently performed with one of the three above techniques, current philosophy dictates that the most appropriate technique to be performed is the one with which the surgical team has the most experience.…”

Section: Introductionmentioning

confidence: 99%

Pancreas Transplantation with Systemic-Enteric Drainage when Portal-Enteric Drainage is Contraindicated

Ac²,

Orl³

et al. 2014

Pancreat Disord Ther

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Although most Pancreas Transplants (PTs) are currently performed with exocrine enteric drainage, <20% also incorporate portal venous delivery of insulin (portal-enteric drainage). The purpose of this study was to analyze outcomes according to surgical technique. Methods:We retrospectively reviewed outcomes in 202 consecutive PTs in 192 patients at our center. All patients received either r-ATG or alemtuzumab induction with tacrolimus/mycophenolate ± steroids. Results:From 11/01 to 3/13, we performed 162 simultaneous kidney-PTs (SKPT), 35 sequential PTs after kidney, and 5 PTs alone (40 solitary PTs). A total of 179 (89%) were performed with portal-enteric and 23 with systemic-enteric drainage; all PTs were initially approached as intent-to-treat with portal-enteric drainage. Indications for systemic-enteric drainage were pancreas retransplantation following primary PT with portal-enteric drainage (N=9), central obesity (N=7), and unfavorable vascular anatomy (n=7). The systemic-enteric drainage group was characterized by more pancreas retransplants (39% versus 4%, p<0.0001), more solitary PTs (35% versus 18%, p=0.09), more African-Americans (39% versus 17%, p=0.02) and more patients with C-peptide positive diabetes (30% versus 13%, p=0.054) compared to the portal-enteric drainage group. Although the proportions of male recipients (70% versus 56%), recipients ≥ 80 kg (30% versus 24%), and early relaparotomy rates (48% versus 36%) were all numerically higher in systemic-enteric versus portal-enteric PTs, respectively, none of these differences were significant. The incidence of early PT thrombosis was 4% in systemic-enteric compared to 8% in portal-enteric PTs (p=NS). With a mean follow-up of 5 years in systemic-enteric compared to 6 years in portal-enteric PT recipients, respective patient survival (70% versus 84%) and pancreas graft survival (61% versus 60%) rates were comparable; respective death-censored kidney graft survival (81% versus 82%) rates were similar. Conclusion:In patients with disqualifying technical features for PT with portal-enteric drainage, comparable overall results can be achieved with systemic-enteric PT as a secondary technique.

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“…Recipients of portally drained pancreas allografts usually have lower circulating insulin levels than those with the systemic drainage 27 but no clear difference in metabolic or clinical outcome. 28 Correction of metabolic deficits-Successful pancreas transplantation results in independence from exogenous insulin, normal blood glucose concentration, normal or nearnormal HbAlc, and prompt correction of ketoacidosis. The response to oral and intravenous glucose challenge and to secretagogues such as arginine are re-established.…”

Section: Metabolic Considerationsmentioning

confidence: 99%

Pancreas and islet cell transplantation

Bottino

Trucco

Balamurugan

et al. 2002

Best Practice & Research Clinical Gastroenterology

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Currently, for the patient with type 1 diabetes, a definitive treatment without resorting to the use of exogenous insulin can be achieved only with pancreas or islet cell transplantation. These means of restoring β-cell mass can completely maintain essentially normal long-term glucose homeostasis, although the need for powerful immunosuppressive regimens limits their application to only a subgroup of adult patients. Apart from the shortage of donors that has limited all kinds of transplantation, however, the widespread use of β-cell replacement has been precluded until recently by the drawbacks associated with both organ and islet cell transplantation. Although the study of recurrence of diabetes has generated attention, the fundamental obstacle to pancreas and islet transplantation has been, and remains, the alloimmune response. With a better elucidation of the mechanisms of alloengraftment achieved during the last 3 years, the stage has been set for further advances. Keywords type 1 diabetes; autoimmunity; allorejection; immunosuppression; toleranceThe different aetiological types of diabetes mellitus are designated type 1, type 2 and other specific types. 1 Type 1 diabetes is characterized by β-cell destruction and the requirement of insulin treatment for survival. Type 2 diabetes is a metabolic disorder due to an interplay between dysfunctional insulin production and impaired periphor response. The other forms of impaired glucose homeostasis can be due to different genetic defects, destruction of the exocrine pancreas or malfunction of other endocrine organs. 1

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A Prospective Comparison of Simultaneous Kidney–Pancreas Transplantation With Systemic-Enteric Versus Portal-Enteric Drainage

Abstract: These results suggest that simultaneous kidney and pancreas transplantation with SE or PE drainage can be performed with comparable short-term outcomes.

Cited by 86 publications

References 28 publications

Exocrine drainage in vascularized pancreas transplantation in the new millennium

Exocrine drainage in vascularized pancreas transplantation in the new millennium

Pancreas Transplantation with Systemic-Enteric Drainage when Portal-Enteric Drainage is Contraindicated

Pancreas and islet cell transplantation

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