A new technique for kidney-pancreas transplantation

Reduction of hepatorenal and pancreatic damage by Ferula elaeochytris extract in STZ induced diabetic rats

The therapeutic potential and antioxidant capacity of Ferula elaeochytris extract (FE) in the liver, kidney and pancreas of rats with diabetes induced by streptozotocin (STZ) was assessed using biochemistry, histopathology and immunohistochemistry. Forty adult Wistar albino male rats were divided randomly into five groups of eight rats each. The normal control (NC) group was untreated. The diabetes control (DC) group was treated with STZ to induce diabetes. The diabetes + acarbose group (DAC) was treated with STZ, then with acarbose daily for 28 days. The diabetes + FE (DFE) group was treated with STZ, then FE daily for 28 days. DC rats had inflammatory cell infiltration, hydropic degeneration and necrosis, whereas the DFE rats exhibited nearly normal histology. Insulin immunostaining in the pancreatic beta cells was decreased in the DC group compared to the NC group, whereas the DFE group was similar to the NC group. Many serum biomarkers of damage to liver, kidneys or pancreas were elevated in the DC group compared to the NC group; these biomarkers were decreased in the DFE group. The DC group exhibited increased malondialdehyde levels and decreased levels of the antioxidant defense system constituents compared to the NC group. The level of biomarkers the DFE group was close to the NC group. FE exhibited a protective effect against tissue damage owing to its antioxidant activities and to its ability to effect regeneration of β-cells in STZ induced diabetic rats.

A novel technique of portal-endocrine and gastric-exocrine drainage in pancreatic transplantation

BACKGROUND

Pancreas transplant (PT) is an established treatment for patients with diabetes mellitus. Diagnosis of rejection has continued to be problematic. In 2007, a new technique of PT with gastric exocrine (P-G) drainage was first performed at our institution. This technique facilitates access to pancreas allograft. The purpose of this study was to compare our experience with PT using P-G technique and the technique of portal enteric (P-E) with venting jejunostomy.

STUDY DESIGN

Thirty patients who underwent PT between 2007 and 2009 (G-I) and 30 consecutive patients before this time (G-II) were studied. In both groups arterial and venous anastomosis was similar to standard P-E technique. In G-I, the end of allograft jejunum was anastomosed to the anterior aspect of the stomach. In the G-II, allograft duodenum was anastomosed to the Roux-en-Y and end of Roux-en-Y was brought out as venting jejunostomy.

RESULTS

Donor and recipient demographic data, number of antigen matches, and immunosuppressant were similar in both groups. All patients achieved euglycemia. In G-I, 3 patients underwent pancreatectomy, 2 owing to vessel thrombosis and 1 owing to chronic rejection. Two patients died with functioning pancreatic allografts. In G-II, 1 pancreas was removed owing to vessel thrombosis. Seven patients with cytomegalovirus and 4 patients with rejection in G-I were diagnosed with endoscopy of allograft duodenum. One-year patient and graft survivals were similar.

CONCLUSIONS

This technique has proven to be safe with good patient and allograft survival. Access to donor duodenum and pancreas allograft via endoscopy is unique to this technique and provides the added advantage of life-long easy access to allograft.

Surgical techniques for pancreas transplantation

PURPOSE OF REVIEW

Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function.

RECENT FINDINGS

Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion.

SUMMARY

Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.

Surgical nuances in pancreas transplantation

The modern surgical era of vascularized pancreas transplantation (PTX) began with the systemic-bladder drainage technique. According to International Pancreas Transplant Registry (IPTR) data, most PTX procedures are performed with systemic venous delivery of insulin and either bladder (systemic bladder) or enteric (systemic-enteric) drainage of the exocrine secretions. Since 1995 the number of PTX procedures performed with primary enteric drainage has increased dramatically, accounting for more than 70% of cases since 2001. Despite an evolution in exocrine drainage, the proportion of enteric drained PTXs with portal venous delivery of insulin (portal enteric drainage) has remained low, representing about 20% of cases. In recent IPTR analyses no differences were reported in short-term outcomes according to surgical technique. Coincident with more physiologic implantation techniques, the surgical complication rate has decreased to 10% to 20%. Experience with donor and recipient selection can reduce morbidity, inasmuch as risk factors for surgical complications include prolonged pre-transplantation peritoneal dialysis, donor or recipient BMI body mass index >28 kg/m2, donor or recipient age older than 45 years, cerebrovascular cause of donor brain death, prolonged preservation, and prior abdominal surgery in the recipient. New techniques include simultaneous living donor kidney and deceased donor PTX, gastroduodenal artery revascularization, laparoscopic living donor nephrectomy and distal pancreatectomy, en bloc kidney and pancreas transplantation, P-E drainage with venting jejunostomy, retroperitoneal PTX with P-E drainage, and unusual vascular grafts. In the future the emphasis will shift from short-term surgical to long-term medical outcomes as the ultimate measure of success.