Simultaneous pancreas‐kidney transplantation: portal versus systemic venous drainage of the pancreas allografts

Abstract

Simultaneous pancreas-kidney (SPK) transplantation is considered a valid therapeutic option for patient with type I diabetes mellitus and end-stage diabetic nephropathy. This study was performed to determine whether the technique of pancreas venous drainage affects patient survival as well as graft survival and function. From October 1996 to April 1999 34 uremic patients with type I diabetes mellitus were randomly assigned to two groups: the first group (SV group = 17) received SPK transplantation with systemic venous drainage, and the second group (PV group = 17) received pancreas allograft with portal drainage. A Roux-en-Y loop was performed in all the patients. Patient follow-up included clinical course and metabolic studies. At 1 yr, patient survival rates were 88.2% in the SV group and 94.1% in the PV group while graft survival rate was 76.4% in both groups. Several surgical complications were attributed to the enteric drainage without any graft failure in both groups. One venous thrombosis occurred in each group. No significant differences have been evidenced in kidney and pancreas function. The preliminary results of this randomized trial did not evidence any significant differences between portal and systemic venous drainage of pancreas allograft.

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).…”

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

“…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].…”

“…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.…”