Journal of the Louisiana State Medical Society
with donor’s common, internal, and external iliac artery (y-graft) to either directly-to-right common iliac artery or to an already placed arterial conduit from right common iliac artery to facilitate this anastomosis (Figure 1). At this time, the allograft is reperfused, hemostasis is achieved, and allograft splenectomy is performed by endovascular stapler. The end of duodeno-jejunal segment of allograft is then anastomosed either end-to-side or side-to-side in an antecolic fashion to the anterior aspect of the greater curvature of the stomach (Figure 1). In the case of simultaneous kidney pancreas (SKP) trans- plantation, the kidney can be transplanted either before or after pancreas transplantation. Because the kidney table benchwork is much faster than the pancreas; we transplant the kidney first, while the pancreas allograft is prepared. Transplanting the kidney first also decreases the pressure on the pan- creas allograft during implantation of the kidney. Per our center’s protocol, all pancreas transplant recipients received anti-thymocyte globulin (1mg/ kg/day for four to five days) for induction therapy. Tacrolimus, mycophenolate mofetil, and steroids were used for maintenance immunosuppression. All patients also received prophylactic therapy for Pneumocystis jiroveci, cytomegalovirus (CMV), and fungi for three months after transplantation. Upper endoscopy was performed for every patient with possible pancreatic dysfunction to study the transplanted duodenum (Figure 2). Pancreatic dysfunction was defined as elevated serum levels of
Figure 1: Schematic drawing of the portal-endocrine and gastric-exocrine technique of pancreatic transplantation.
of pancreas transplantation.
pancreatic enzymes or signs of possible pancreatic rejection, such as unexplained fever or abdominal pain. Episodes of rejection or CMVduodenitis were confirmed by biopsy from the transplanted duodenum obtained during upper endos- copy (Figure 3). Pancreas transplant failure was defined as c-peptide levels <0.8 ng/mL, pancreatectomy, or death. Pancreas allograft rejection was treated by anti-thymo- cyte globulin, pulse steroid therapy, and increasing the dose of maintenance immunosuppressive medications. CMV duodenitis was treated by valganciclovir and decreasing the dose of maintenance immunosuppression. RESULTS From October 2007 to November 2013, 40 pancreas transplants were done at our center. Among them, 38 pa- tients (mean age = 40.8±9.1 years; male = 19 [50%]; Cauca- sian = 25 [66%]) underwent pancreas transplantation with the portal-endocrine and gastric-exocrine technique; 31were SKP and seven were pancreas transplant alone (PTA). Only two patients (5%) were transplanted with other techniques; one recipient had inadequate SMV and was transplanted with systemic enteric technique. In the other case, the small bowel was procured for transplantation; therefore, the do- nor’s duodenumwould not reach to stomach. This case was transplanted with portal enteric technique. In 38 enrolled
METHODS This study was approved by the institutional review board of our center and was done in accordance with Dec- laration of Helsinki and Good Clinical Practice guidelines. All patients who had pancreas transplantation with the technique of portal-endocrine and gastric-exocrine drainage at our center from October 2007 to November 2013 were included in this retrospective study. Demographics, clini- cal characteristics, and the post-transplant course of these patients were analyzed. All transplant recipient candidates were informed on this new technique of pancreas transplantation and signed the consent form to undergo transplantation with this technique. We have already described the portal-endocrine and gastric-exocrine drainage technique of pancreas trans- plantation in detail. 4 In brief, after evaluating the recipi- ent’s superior mesenteric vein (SMV) to make sure that it is patent and adequate in size, the allograft, which has been procured in a standard fashion with only a 4-5 inch extra duodenojejunal segment, is implanted. First, anastomosis is fashioned with an end-to-side portal to SMV anasto- mosis to be subsequently followed by anastomosis of the reconstructed arterial supply of pancreas, which was done
208 J La State Med Soc VOL 166 September/October 2014
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