our study, 75% of our patients who lost their organ due to rejection were non-compliant. Moreover, 71% of deaths in our study were due to cardiovascular causes. Therefore, other factors like noncompliance and death due to comorbid disorders were among the main contributing factors to our inferior results as compared with the national average. The SKP and PTA patients in our center were transplanted by the same surgeons and both had good quality donors. Conse- quently, one of the major contributing factors to the lower graft survival in PTA versus SKP patients was development of pancreatic vascular thrombosis in three PTA patients. Post-transplantation studies showed that all these three patients had hypercoagulable disorders. Moreover, due to the absence of uremia-induced platelet dysfunction in PTA patients, they aremore predisposed to develop pancreatic vascular thrombosis as compared with SKP patients. Additionally, underlying hypercoagulable disorders are more likely to
Figure 4: Allograft survival in simultaneous kidney pancreas (SKP), pancreas transplant alone (PTA), and all patients.
the technique of transplantation. Therefore, portal-endocrine and gastric-exocrine technique of pancreatic transplantation appears not to be associated with higher risk of any major complication. The limitations of this study are its retrospective design, lack of control group, and small sample size. Since October 2007, all pancreas transplants at our center were performed using the portal-endocrine and gastric-exocrine drainage technique of pancreas transplantation, except for two cases. Because of the changes in the guidelines for management of pancreas transplantation over time, the patients who had pancreas transplantation at our center with a different tech- nique before October 2007 were not considered as optimal controls for comparison with patients who had pancreas transplantation with portal-endocrine and gastric-exocrine drainage technique, thereafter. However, the best study design to compare the advantages and disadvantages of different techniques of pancreas transplantation would be a randomized controlled trial with large sample size. Our study shows that portal-endocrine and gastric- exocrine technique of pancreatic transplantation provides an easy access to the transplanted duodenum for evaluation of pancreatic dysfunction. This technique should be com- pared with other techniques of pancreas transplantation in randomized controlled trials. REFERENCES 1. Boggi U, Amorese G, Marchetti P. Surgical techniques for pancreas transplantation. Curr Opin Organ Transplant 2010;15:102-11. 2. Stratta RJ. Surgical nuances in pancreas transplantation. Transplant Proc 2005;37:1291-3. 3. Shokouh-Amiri MH, Gaber AO, Gaber LW, et al. Pancreas transplantation with portal venous drainage and enteric exocrine diversion: a new technique. Transplant Proc 1992;24:776-7.
be diagnosed in SKP patients before transplantation because these patients will most probably present with repeated vas- cular access thrombosis before transplantation. Therefore, after these three cases of pancreatic vascular thrombosis, all PTA candidates at our center undergo evaluation for hypercoagulable disorders before transplantation. Choosing the optimal type of venous drainage remains one of the controversial issues in pancreas transplantation. 1,24 In the systemic venous drainage technique, the portal vein is connected to the recipient’s iliac vein or inferior vena cava. 24 In the portal venous drainage technique, the technique that was used in this study, the end of donor portal vein is anas- tomosed to the side of recipient’s superior mesenteric vein, resulting in direct delivery of the pancreas allograft venous outflow to the liver. 3,24 The portal technique is more physi- ologic and results in less hyperinsulinemia because nearly half of the insulin produced by the pancreas is metabolized by the liver before entering the systemic circulation. 24,25 It has been suggested that hyperinsulinemia could have a potential adverse effect on the lipid profile and accelerate atherosclerosis. 26,27 Moreover, initial studies suggested that the portal technique could provide immunologic advan- tages and result in less acute rejection and graft loss. 28-30 In contrast, a recent long-term study has shown that these two techniques of venous drainage have similar graft and patient survival rates and cardiovascular outcomes. 24 In our study, two patients developed donor duodenal perforation, and two developed peptic ulcer at the site of the duodenogastric anastomosis. However, these are known complications of enteric techniques of pancreas transplantation, and their incidence is not higher with our technique. Moreover, as mentioned before, pancreatic vas- cular thrombosis in three patients was due to undetected underlying hypercoagulable disorders and probably not to
J La State Med Soc VOL 166 September/October 2014 211
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