Impact of pancreatic venous drainage site on long‐term patient and graft outcome in simultaneous pancreas‐kidney transplantation

Abstract

The impact of portal or systemic venous pancreas graft drainage on patient and graft outcome remains controversial. In the present study, the impact of venous drainage type on long-term patient and graft survival is assessed. From July 1996 to December 2002 80 simultaneous pancreas-kidney transplants were enrolled into a prospective study: 44 received a pancreas allograft with portal (P-SPK group) and 36 with systemic venous drainage (S-SPK group). Enteric exocrine drainage was performed in all recipients receiving the same immunosuppressive treatment. At one yr, the patient survival rates were 91.7% and 95.5% both for S-SPK and P-SPK groups, respectively; no significant difference in survival was shown at any time point of the follow-up. The one-, three-, five-, and eight-yr pancreas survival rates were 75%, 60.6%, 56.7%, and 44%, respectively in the S-SPK group compared to 88.6%, 84.1%, 78.4%, and 31.3% in the P-SPK group. The one-, three-, five-, and eight-yr kidney survival rates were 91.7%, 78.15%, 74.1%, and 57.9%, respectively in the S-SPK group compared to 93.2%, 88.6%, 78.4%, and 38.9% in the P-SPK group. Comparing the two groups, no significant difference was shown in the total number of surgical complications as well as in the number of each complication. No significant difference in long-term outcomes between the two groups was shown, even if in S-SPK group a higher incidence of pancreas graft loss has been reported and it was in part correlated to a higher number of graft thromboses.

Exocrine drainage in vascularized pancreas transplantation in the new millennium

“…However, neither large registry analyses nor prospective cohort studies have been able to corroborate these purported benefits (Table 9) [1,33,[39][40][41][42][44][45][46][49][50][51][52][53][112][113][114][115][116][117][118][119][120][121][122][123] . Conversely, when comparing the three major techniques of pancreas transplantation, there are likewise no well controlled studies to suggest any major drawbacks of portal-enteric vs either systemic-bladder or systemic-enteric drainage.…”

“…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] .…”

“…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).…”

Hypoglycemia following pancreas transplantation

“…Conversely, portal venous drainage directs secreted insulin to the liver in a more physiologic manner. Despite this theoretic advantage, several studies have failed to show differences in graft survival [26][27][28][29], fasting glucose [ 26 , 28 , 29 ], or lipid metabolism [ 28 , 29 ], and systemic drainage has remained the more commonly performed procedure [ 30 ]. This issue is particularly important because the heterotopic allograft pancreas is denervated and thus devoid of autonomic nervous system control while still under the modulatory infl uences of humoral factors, such as incretins.…”

Role of simultaneous pancreas-kidney transplantation in the treatment of diabetes mellitus

“…Az eljárás azonban nem váltotta be a hozzá fűzött reményeket és nem terjedt el [29]. Jelenleg a hasnyálmirigy-transzplantációk mintegy 20%-a történik portalis endokrin drenázs alkalmazásával, csökkenő tendencia mellett [30,31]. A pécsi transzplantációs program korábban alkalmazta a portalis vénás drenázst, de a módszer nem bizonyult egyér-telműen előnyösnek, és a továbbiakban már nem alkalmazzák.…”