Improved surgical outcomes following simultaneous pancreas‐kidney transplantation in the contemporary era

Abstract

Background: Complications leading to early technical failure have been the Achilles' heel of simultaneous pancreas-kidney transplantation (SPKT). The study purpose was to analyze longitudinally our experience with early surgical complications following SPKT with an emphasis on changes in practice that improved outcomes in the most recent era.Study design: Single center retrospective review of all SPKTs from 11/1/01 to 8/12/20 with enteric drainage. Early relaparotomy was defined as occurring within 3 months of SPKT. Patients were stratified into two sequential eras: Era 1 (E1): 11/1/01-5/30/13; Era 2 (E2) 6/1/13-8/12/20 based on changes in practice that occurred pursuant to donor age and pancreas cold ischemia time (CIT).Results: 255 consecutive SPKTs were analyzed (E1, n = 165; E2, n = 90). E1 patients received organs from older donors (mean E1 27.3 vs. E2 23.1 years) with longer pancreas cold CITs) (mean E1 16.1 vs. E2 13.3 h, both p < .05). E1 patients had a higher early relaparotomy rate (E1 43.0% vs. E2 14.4%) and were more likely to require allograft pancreatectomy (E1 9.1% vs. E2 2.2%, both p < .05). E2 patients underwent systemic venous drainage more frequently (E1 8% vs. E2 29%) but pancreas venous drainage did not influence either relaparotomy or allograft pancreatectomy rates.The most common indications for early relaparotomy in E1 were allograft thrombosis (11.5%) and peri-pancreatic phlegmon/abscess (8.5%) whereas in E2 were thrombosis, pancreatitis/infection, and bowel obstruction (each 3%). Conclusion:Maximizing donor quality (younger donors) and minimizing pancreas CIT are paramount for reducing early surgical complications following SPKT.

Effect of donor pancreas extraction time on pancreas transplantation—a Swiss tertiary center experience

“…This is consistent with our cohort, in which all pancreas graft losses were caused by thrombotic complications, however, ET did neither affect the incidence of graft thrombosis nor major complications. The rate of relaparotomy was high, however in line with previously published data 40,43–47 . However, complications in general and even loss of the pancreas graft did not negatively affect patient survival.…”

“…The rate of relaparotomy was high, however in line with previously published data. 40,[43][44][45][46][47] However, complications in general and even loss of the pancreas graft did not negatively affect Regarding graft pancreatitis in our cohort, ET and CIT did not affect post-transplant amylase levels and incidence of graft pancreatitis. This is consistent with the finding of Humar et al that prolonged CIT had no negative effect on the incidence of pancreatitis after PT, 7 although with different definitions of graft pancreatitis.…”

Critical Care Length of Stay and Support Requirements for Patients Postpancreas Transplant

“…Observational studies had highlighted that up to 40% of pancreas recipients would require relaparotomy to address early surgical complications within the first 3 months of transplant, which included bleeding, graft thrombosis, and enzyme or anastomotic leaks. 2–4 The low return-to-theatre rate from this service evaluation could be attributed to the better recipient and donor selections, organ preservation, back-table preparation, graft placement, and exocrine drainage techniques. 5 The gradual fall in critical care LOS of patients was likely a reflection of the application of the enhanced recovery principles and iCOUGH (incentive spirometry, coughing, oral hygiene, understanding, getting out of bed, head-of-bed elevation) to patients following major surgery.…”

Does dialysis modality or duration influence outcomes in simultaneous pancreas‐kidney transplant recipients? Single center experience and review of the literature

“…Prior to May 2013 ( n = 165), 15% of donors were ≥40 years of age and 27% were >35 years of age. Since this time ( n = 90), no donors were ≥40 years and only 7% were >35 years 47 . In addition, at this time we changed our practice to minimize pancreas cold ischemia times, targeting a threshold of ≤16 h (preferably ≤12 h) 47,48 .…”

“…46 years. 47 In addition, at this time we changed our practice to minimize pancreas cold ischemia times, targeting a threshold of ≤16 h (preferably ≤12 h). 47,48 Prior to May 2013, 46% of SPKTs were performed with a pancreas cold ischemia time >16 h and 21% had a cold ischemia time of ≥20 h. Since this time, 23% of cases had a pancreas cold ischemia time >16 h and only one (1%) had a cold time in excess of 20 h. Both of these changes in policy were initiated because of an unacceptably high incidence (>40%) of early relaparotomy in our initial cohort.…”