Retrieval of the pancreas allograft for whole-organ transplantation

Impact of Gastroparesis on Outcomes After Pancreas Transplantation

Background

Gastroparesis (GP) is a chronic disorder of the stomach characterized by delayed gastric emptying and frequently associated with longstanding diabetes. This is a single-center retrospective analysis designed to establish the prevalence and assess the impact on posttransplant outcomes of GP among pancreas transplant recipients.

Methods

Medical records for all recipients of pancreas transplants performed between January 2003 and December 2023 were reviewed. GP was defined by abnormal gastric-emptying scintigraphy or other motility study or a history of symptoms. Primary outcomes included graft loss and patient death. Clinical outcomes included length of stay after transplant and readmissions, including specifically for GP symptoms.

Results

Of 731 recipients, 156 (21%) were diagnosed with GP before transplant. Patients with GP were younger and more likely to be female individuals. Posttransplant, there was no difference in length of stay, graft survival, or patient survival. Patients with GP were more likely to be readmitted and to be specifically admitted for GP symptoms. Requirement for interventions was more common in patients with GP.

Conclusions

GP is identified with increased frequency among the specific patient population referred for pancreas transplant, and although it does not seem to affect allograft or patient survival, it does seem to have an impact on readmissions and the need for interventions.

Validation of the Back-table Graft Arterial Anastomosis Between the Splenic Artery and Superior Mesenteric Artery: Arterial Complications After a 21-year Single-center Experience of Pancreas Transplantation

OBJECTIVE

To determine the role of the arterial splenomesenteric anastomosis (ASMA) vascular reconstruction technique in terms of arterial vascular complications in pancreas transplantation (PT) recipients.

BACKGROUND

The ASMA technique was first described in 1992 by the Hospital Clínic Barcelona group. Regardless that the iliac Y-graft technique is the most frequently used worldwide, evidence of arterial complications and implications of using a different back-table reconstruction is conspicuously absent in the literature.

METHODS

Descriptive review of 407 PTs performed at a single center (1999-2019) by analyzing the type of arterial reconstruction technique, focusing on ASMA. The end points were the management of arterial complications and long-term patient and graft survival.

RESULTS

ASMA was performed in 376 cases (92.4%) and a Y-graft in 31 cases (7.6%). A total of 34 arterial complications (8.3%) were diagnosed. In the ASMA group (n=30, 7.9%), they comprised 15 acute thrombosis, 4 stenosis, 1 pseudoaneurysm, and 10 diverse chronic arterial complications, whereas in the Y-graft group (n=4, 12.9%), 3 acute thrombosis and 1 chronic artery-duodenal fistula occurred. Graft salvage was achieved in 16 patients (53.3%) from the ASMA group and in 2 (50%) from the Y-graft. After a median follow-up of 129.2 (IQR 25-75%, 77.2-182) months, the overall graft and patient survival for the whole cohort at 1, 5, and 10 years were 86.7%, 79.5%, and 70.5%, and 98.5%, 95.3%, and 92.5%, respectively.

CONCLUSIONS

The ASMA proves to be a safe and more easily reproducible technique and could therefore be considered a safe alternative vascular reconstruction procedure to the Y-graft in the PT population.

The Use of Long-Term Monthly Basiliximab Infusions as Rescue Maintenance Immunosuppression in Pancreas Transplant Recipients

This single-center retrospective study was designed to evaluate the use of basiliximab as an alternative rescue maintenance immunosuppression in situations where standard maintenance immunosuppression is not tolerated after a pancreas transplant. All pancreas transplants performed between January 11, 2006, and January 6, 2022, were reviewed. All recipients received rabbit antithymocyte globulin (rATG) induction with tacrolimus + sirolimus maintenance for simultaneous pancreas and kidney (SPK) and additional low-dose mycophenolic acid for pancreas transplant alone (PTA). Basiliximab 40mg IV q 4 weeks was either added to or in replacement of adjunct immunosuppression in cases of medication intolerance. All recipients who received ≥3 months of basiliximab with ≥1 year follow-up were included. 29/557 (5.2%) recipients (5 SPK and 24 PTA) were identified. Median time to switch was 13 months. When compared 1:2 to matched controls on standard immunosuppression, there was no difference in pancreas rejection, allograft loss, or mortality. Eleven recipients had 13 episodes of pancreas rejection at a median of 28 months post conversion. Eight pancreas allografts failed at a median of 28 months post conversion, and there were five deaths-all occurring in PTA, 4/5 occurring ≥1 year after discontinuation of basiliximab. Renal allograft rejection occurred in one SPK and there was one renal allograft loss. Five PTA developed renal failure. Ten remain on basiliximab (2/5 SPK, 8/24 PTA) at a median of 44 months with good pancreas and kidney function; 4 pts > 4 years. Basiliximab can be considered an alternative rescue maintenance strategy in pancreas transplant recipients who failed other conventional agents.

Epidemiology and Risk Factors for Invasive Fungal Infections in Pancreas Transplant in the Absence of Postoperative Antifungal Prophylaxis

Background

Invasive fungal infections (IFIs) remain a rare yet dreaded complication following pancreas transplantation. Current guidelines recommend antifungal prophylaxis in patients with 1 or more risk factors. At our center, single-dose antifungal prophylaxis is administered in the operating room but none subsequently, regardless of risk factors. Here we evaluate the 1-year incidence, outcome, and risk factors associated with IFI following pancreas transplantation.

Methods

A retrospective, single-center cohort study was conducted in patients who underwent pancreas transplantation between 1 January 2009 and 31 December 2019. Records were manually reviewed, and cases were adjudicated using consensus definitions. The 1-year cumulative incidence, mortality, and risk factors were analyzed by Kaplan-Meier method and differences between populations were assessed with Fisher test and Mann-Whitney U test.

Results

Three hundred sixty-nine recipients were included. Twelve IFIs were identified: candidiasis (8), aspergillosis (2), histoplasmosis (1), and cryptococcosis (1). Intra-abdominal infections were the most common presentation (5), followed by bloodstream infections (3), disseminated disease (2), pulmonary disease (1), and invasive fungal sinusitis (1). Median time to IFI was 64 days (interquartile range, 30-234 days). One-year cumulative incidence was 3.25% (95% confidence interval, 1.86%-5.65%). There were no significant differences between patients with or without IFI regarding type of transplant (P = .17), posttransplant dialysis (P = .3), rejection (P = .5), cytomegalovirus serostatus (P = .45), or reoperation (P = .19). For patients with IFI, the 1-year graft and patient survival rates were 58% versus 95% (P < .0001) and 75% versus 98.6% (P < .001), respectively.

Conclusions

Our study suggests that the use of a single-dose antifungal prophylaxis administered in the operating room but none subsequently does not result in an increased incidence of IFI following pancreas transplantation.

Effect of donor pancreas extraction time on pancreas transplantation-a Swiss tertiary center experience

We aimed to assess the effect of donor pancreas extraction time (ET) on postoperative complications and graft function after pancreas transplantation (PT). We analyzed all consecutive donor pancreas procurements for the simultaneous pancreas and kidney transplantation (SPK) and the associated PT in a Swiss transplant center over a 20-year period. Pancreas ET was defined as the time from cold flush to static storage of the pancreas on ice. The primary endpoint was the effect of extraction time on surgical complications. Secondary endpoints comprised the effect of ET on graft function (insulin-free survival) and graft pancreatitis. Of 115 procured pancreas grafts the median donor pancreas ET was 65 min (IQR: 48-78 min). In multivariable analysis, ET did not negatively affect major complications (OR 1.41 [95% CI: .59-3.36]; p = .438) and insulin-free survival (HR 1.42 [95% CI: .55-3.63]; p = .459). The median CIT was 522 (441-608) min. CIT was associated with major complications (OR 2.51 [95% CI: 1.11-5.68]; p = .027), but without impact on insulin-free survival (HR 1.94 [95% CI: .84-4.48]; p = .119). Patients with and without graft pancreatitis had no statistically significant differences in ET and CIT (p = .164 and p = .47, respectively). In multivariable analysis, Amylase levels > 270 U/L on postoperative day 1 were significantly associated with major complications (OR 3.61 [95% CI: 1.06-12.32]; p = .040). Our results suggest that although no effect of ET on complications and graft function after PT was found, shorter CIT and less graft pancreatitis can have a positive impact on surgical complications. Results could possibly be influenced by the exceptional quality of the pancreas donors, with short travel distances and preservation times in Switzerland.

Endoscopic visualization of graft status in patients with pancreas transplantation

BACKGROUND

Enteric drainage into the recipient duodenum in pancreas transplantation (PT) can identify the graft duodenum by endoscopy. This study aimed to identify the characteristic endoscopic findings associated with graft failure or acute rejection in patients with PT.

METHODS

We reviewed the medical records of patients who underwent PT with duodenoduodenostomy (DD) between January 2015 and August 2019. During this period, there were 44 PTs with DD in 42 patients; 122 endoscopies were performed and analyzed.

RESULTS

Overall, pancreatic graft survival was 82% at a mean follow-up of 27 months (range 6-55 months). There were 8 graft failures and 10 acute rejections. In all 8 graft failures, a deep ulcer covered with fibrinous exudates of the graft duodenum was confirmed on endoscopy. Diffuse erythema inside the graft duodenum was observed in 8 of 10 acute rejections. The factors associated with acute rejection were elevated serum lipase level (OR 8.5, p = 0.02) and diffuse erythema inside the graft duodenum on endoscopy (OR 20.5, p < 0.01) in multivariate analysis.

CONCLUSIONS

In PT with DD patients, graft failure can be visualized by endoscopy, and diffuse erythema inside the graft duodenum may be a finding of acute rejection.

Pancreas Transplantation in a Single Center: Risk Factors Associated With Pancreatic Allograft Thrombosis

BACKGROUND

Pancreas transplantation remains a challenging procedure for small and medium-sized transplants teams, despite improvements in graft survival. Data regarding the impact of the procurement team's experience on the outcomes of pancreas transplant are lacking. The objective of this study was to evaluate risk factors that lead to pancreatic allograft thrombosis, especially the experience of the pancreas procurement team.

METHODS

A retrospective study of 137 patients who underwent pancreas transplantation between March 2005 and May 2017 was conducted. Donor's and recipient characteristics were evaluated as well as their relationship to pancreatic allograft thrombosis. Cases were divided according to the number of pancreas procurements previously done by the procurement surgeon: group 1 (30 to 40 retrievals) and group 2 (≥40 retrievals).

RESULTS

Simultaneous pancreas-kidney transplants accounted for 89.8% of cases (n = 123). Surgeons from group 2 performed 62.8% (n = 86) of the procurements. The graft was removed in 19 cases (13.8%) due to thrombosis. In univariate analysis, lower experience of the retrieval team was associated with allograft loss (P = .04). In multivariate analysis, donor intensive care unit time ≥5 days (P = .03) and lower experience of the procurement team were associated with increased risk of pancreatic allograft thrombosis (P = .02), whereas recipient's age from 30 to 40 years (P = .018) or ≥40 years (P = .02) was found as a protective factor.

CONCLUSIONS

Pancreatic allograft thrombosis remains an important cause of graft loss in pancreas transplantation. Recipient's age, prolonged donor intensive care unit time, and lower experience of the procurement team directly influence pancreatic allograft thrombosis.

Technical factors that minimize the occurrence of early graft failure in pancreas transplantation

Pancreatic transplantation is the only treatment for insulin-dependent diabetes resulting in long-term euglycemia without exogenous insulin. However, pancreatic transplantation has become debatable following the improvements in the results of islet transplantation and artificial pancreas. Therefore, surgeons who perform pancreas transplants require the best surgical technique that can minimize technical failure. We aimed to report our experiences with pancreatic transplantations. We transplanted 65 pancreatic grafts between 2015 and 2020. Except for one death due to hypoxic brain damage after surgery, no postoperative technical failure was observed. We usually perform duodeno-duodenal anastomosis using the transperitoneal approach, with retrocolic placement of the graft pancreas. There was no leakage from the duodenum even after immunologic graft failure. To prevent venous thrombosis, which is the most common cause of technical failure, we used the inferior vena cava for anastomosis and added graft venoplasty with a patch of donor vena cava or aortic interposition graft to the bench procedure; subsequently, there were no cases of technical failure due to thrombosis post-transplantation. Therefore, the 1-year graft survival (insulin-free) rate was more than 95%. The improving the surgical technique will maintain pancreatic transplantation as the best treatment for insulin-dependent diabetes. This article is protected by copyright. All rights reserved.

Complications during multiorgan retrieval and pancreas preservation

In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.

Contrast-Enhanced Ultrasound Versus Doppler Ultrasound for Detection of Early Vascular Complications of Pancreas Grafts

OBJECTIVE. The purpose of this study is to compare conventional duplex ultrasound and contrast-enhanced ultrasound (CEUS) for identifying vascular abnormalities in pancreas allografts in the immediate posttransplant setting. Identification of pancreas allografts at risk of failure may impact patient care because early intervention for vascular insufficiency can lead to graft salvage. MATERIALS AND METHODS. Two radiologists who were blinded to patient outcomes performed a retrospective analysis of the postoperative Doppler ultrasound and CEUS images of 34 pancreas grafts from transplants performed between 2017 and 2019. A total of 28 patients who did not require surgical reexploration were considered the control group. Six patients had surgically proven arterial or venous abnormalities on surgical reexploration. Each radiologist scored grafts as having normal or abnormal vascularity on the basis of image sets obtained using Doppler ultrasound only and CEUS only. Comparisons of both the diagnostic performance of each modality and interobserver agreement were performed. RESULTS. Both readers showed that CEUS had increased sensitivity for detecting vascular abnormalities (83.3% for both readers) compared with Doppler ultrasound (66.7% and 50.0%). For both readers, the specificity of CEUS was similar to that of Doppler imaging (81.6% and 78.9% for reader 1 and reader 2 versus 76.3% and 84.2% for reader 1 and reader 2). For both readers, the negative predictive value of CEUS was higher than that of Doppler ultrasound (96.9% and 96.8% for reader 1 and reader 2 versus 93.5% and 91.4% for reader 1 and reader 2). Interobserver agreement was higher for CEUS than for Doppler ultrasound (κ = 0.54 vs κ = 0.28). CONCLUSION. CEUS may provide radiologists and surgeons with a means of timely and effective evaluation of pancreas graft perfusion after surgery, and it may help identify grafts that could benefit from surgical salvage.

Pancreas transplantation following total pancreatectomy for chronic pancreatitis

BACKGROUND

Total pancreatectomy for chronic pancreatitis leads to brittle diabetes and challenging glycemic control with half of all patients experiencing severe hypoglycemia, many requiring medical intervention or hospitalization. Pancreas transplantation has the potential to manage both the endocrine and the exocrine insufficiency in this patient population.

METHODS

Between June 1, 2005, and July 1, 2016, 8 patients with brittle diabetes following total pancreatectomy underwent pancreas transplantation. All grafts had systemic venous and enteric exocrine drainage. Data included demographics, graft and patient survival, pre- and post-transplant supplementation with pancreatic enzymes, and narcotic usage.

RESULTS

Patient survival rate at 1 and 3 years was 88%. Pancreas graft survival rate of those alive at 1 year was 100% and 86%, respectively. About 75% of these patients remained insulin-free until their time of death, loss of follow-up, or present day. Of the patients with maintained graft function at 3 years, none required further hospitalization for glycemic control. About 75% of these patients have also maintained exocrine function without pancreatic enzyme supplementation.

CONCLUSIONS

Pancreas transplant can treat both exocrine and endocrine insufficiency and give long-term insulin-free survival and should be considered as a viable treatment option for patients who have undergone total pancreatectomy for chronic pancreatitis.

Pre-hepatic and pre-pancreatic transplant donor evaluation

Innovations in surgical techniques coupled with advances in medical and pharmacological management in the past few decades have enabled organ transplantation to become integral to the management of end stage organ failure. In this review article, we will review the role of the radiologist in the work up of liver and pancreas donors during evaluation of their donor candidacy. The critical role of imaging in assessing the parenchymal, biliary and vascular anatomy in liver donor candidates will be reviewed, as well as highlighting the anatomical findings that may pose a contraindication to transplantation. The limited role of imaging in pancreas donor evaluation is also covered, as well as a brief overview of the surgical techniques available and how the radiologist's findings influence operative technique selection.

Steroid-free three-drug maintenance regimen for pancreas transplant alone: Comparison of induction with rabbit antithymocyte globulin +/- rituximab

Graft survival following pancreas transplant alone (PTA) is inferior to other pancreas transplants. Steroid elimination is appealing, but a two-drug maintenance strategy may be inadequate. Additionally, recipients tend to have diabetic nephropathy and do not tolerate nephrotoxic medications. A three-drug maintenance strategy permits immunosuppression through different mechanisms as well as an opportunity to use lower doses of the individual medications. Induction consisted of five doses of rabbit antithymocyte globulin (1 mg/kg/dose). As of October 2007, a single dose of rituximab (150 mg/m² ) was added. Maintenance consisted of tacrolimus, sirolimus and mycophenolate mofetil. From 2004 to 2017, 166 PTA were performed. Graft loss at 7 and 90 days were 4% and 5%, and 1-year patient and graft survival were 97% and 91%. Comparing induction without and with rituximab, there was no significant difference in 7- or 90-day graft loss, 1-year patient or graft survival, or in the rate of rejection or infection. Rabbit antithymocyte globulin induction and steroid withdrawal followed by a three-drug immunosuppression regimen is an excellent strategy for PTA recipients.

Fence Angioplasty Prevents Narrowing of Venous Anastomosis in Solitary Pancreas Transplant

Background

Graft thrombosis is the leading cause of early graft failure in pancreas transplants. Direct anastomosis grafting of the portal vein to the iliac vein or vena cava generally appears narrowed on postoperative computed tomography (CT) scans. However, modification of surgical techniques may prevent venous narrowing, which also prevents thrombosis-related graft failure.

Material/Methods

We performed 31 solitary pancreas transplants since 2015. Retrospective analysis of these patients was performed.

Results

Fence angioplasty was applied in the final 12 cases, and no technical failures or early graft losses occurred in these cases. Three graft losses, including 2 immunologic losses and 1 patient death with functioning graft, occurred after at least postoperative 4 months. The venous anastomoses were evaluated via intraoperative Doppler ultrasound and postoperative CT scans. Intraoperative Doppler ultrasound revealed improved spectral waves of venous anastomoses in the fence group (monophasic spectral wave, 42.9% vs. 0%, p=0.017). The fence-graft applied group had no cases of narrowing, whereas the non-fence group had high narrowing rates on CT scans (84.2% vs. 0%, p<0.001). Furthermore, with less use of postoperative heparin, postoperative bleeding rates were lower in the fence group (36% vs. 0%, p=0.026).

Conclusions

Fence angioplasty is a definitive method for avoiding venous anastomotic stenosis and preventing graft failure due to thrombosis.

Impact of Deceased Donor Cardiac Arrest Time on Postpancreas Transplant Graft Function and Survival

Introduction

Transplantation of pancreas allografts from donors that have experienced preprocurement cardiopulmonary arrest (PPCA) is not common, though use of PPCA grafts is routine in liver and kidney transplantation. This article reviews a large number of PPCA pancreas grafts at a single center and reports posttransplant outcomes including early graft dysfunction, length of hospital stay, rejection, and early and late graft survival.

Methods

Preprocurement cardiopulmonary arrest, arrest time, and donor and recipient pancreatic enzyme levels were collected from electronic and written medical records. The PPCA donors were stratified into 4 groups: none, less than 20 minutes, 20-39 minutes, and 40 minutes or greater. Graft survival was assessed at 7 and 90 days and at 1 year. Long-term graft survival was assessed by Cox regression analysis.

Results

The records of 606 pancreas transplants were reviewed, including 328 (54%) simultaneous pancreas and kidney transplants. Preprocurement cardiopulmonary arrest occurred in 176 donors (29%; median time, 20 minutes). Median peak donor lipase was higher in PPCA donors (40 μ/L vs 29 μ/L, P = 0.02). Posttransplant, peak recipient amylase, and lipase levels were similar (P = 0.63). Prolonged arrest time (>40 minutes) was associated with higher donor peak lipase and lower recipient peak amylase (P = 0.05 for both). Stratified by donor arrest time, there was no difference in 7-day, 90-day, or 1-year graft survival. Cox regression comparing the 4 groups demonstrated no statistical difference in 10-year survival.

Conclusions

These results support transplantation of pancreas allografts from PPCA donors. Prolonged asystole was associated with higher peak donor serum lipase but lower peak recipient serum amylase. There were no differences in allograft survival.

Pancreas transplantation using compatible but non-identical ABO blood group donors

BACKGROUND

There are limited data on the outcomes of pancreas transplants using ABO non-identical but compatible (NIC) donors.

METHODS

A review of all pancreas transplants from a single institution from 01/2003 to 07/2016 (n = 606) revealed 41 recipients of a NIC donor pancreas which were matched for age, race, gender, year, and type of transplant with 41 ABO identical cases. Groups were compared for allograft survival, incidence of acute cellular rejection (ACR), length of hospital stay, 3-month readmissions and transfusion requirements. Serum haptoglobin and lactate dehydrogenase were used to identify hemolysis in patients requiring repeated transfusions without overt blood loss.

RESULTS

The 1-year graft survival was 100% and 88% in the study and control groups. In the study group, 6/41(14%) developed hemolysis, all of which were ABO O into A. All responded to donor blood type specific transfusions.

DISCUSSION

There are limited data on outcomes of solid organ transplant using NIC donors with almost none specifically addressing pancreas transplantation. In this study, graft survival was similar but 14% developed hemolysis, which was transient and treated with transfusion of donor blood type specific blood.

CONCLUSION

Non-identical but compatible pancreas transplants have similar graft survival compared to ABO identical. Hemolysis may occur so some caution is required.

The Pancreas Can Take the Cold: Lower Waitlist Times Through Importation

BACKGROUND

Our center has used a strategy of pancreas importation owing to long regional waitlist times. Here we assess the clinical outcomes and financial considerations of this strategy.

METHODS

This was a retrospective observational cohort study of patients who received a pancreas transplant at Montefiore Medical Center (MMC) from 2014 to 2017 (n = 28). Clinical parameters, including hemoglobin A_1c and complications, were analyzed. The cohort was compared with United Network for Organ Sharing (UNOS) Region 9 with the use of the UNOS/Organ Procurement and Transplantation Network database. Cost analysis of length of stay (LOS), standard acquisition (SAC) fees, and transportation was performed with the use of internal financial data.

RESULTS

Pancreas importation resulted in significantly shorter simultaneous pancreas kidney transplant waitlist times compared with Region 9: 518 days vs 1001 days (P = .038). In addition, postoperative complications and 1-year HbA_1c did not differ between groups: local 6.30% vs import 6.17% (P = .87). Patients receiving local pancreata stayed an average of 9.2 days compared with 11 days for the import group (P = .36). As such, pancreas importation was associated with higher mean charges ($445,968) compared with local pancreas recipients ($325,470).

CONCLUSIONS

Long waitlist times in Region 9 have encouraged our center's adoption of pancreas importation to address the needs of our patient population. This practice has resulted in a reduction of waitlist times by an average of 483 days. Understandably, centers have long been wary of importation owing to perceived risk in clinical outcomes. In our single-center experience, we have demonstrated equivalent postoperative glucose control and graft survival. Importantly, there does appear to be increased costs associated with importation, which are mainly driven by LOS. Curiously, importation from regions with lower SAC fees has the potential to offset costs related to transportation expenses. Notwithstanding these findings, pancreas importation does have the potential to lessen the financial societal burden through reduction in waitlist times.

Techniques of pancreas graft salvage/indications for allograft pancreatectomy

PURPOSE OF REVIEW

Despite improvements in pancreas allograft outcome, graft complications remain a significant cause of morbidity and mortality. This review analyses the issues involved in the management of conditions that may require graft pancreatectomy, including the indications and techniques for graft salvage.

RECENT FINDINGS

With early recognition of graft complications, liberal use of radiological interventions, improved infection control, access to critical care and innovative surgical techniques, graft salvage is now feasible in many circumstances where graft pancreatectomy would previously have been necessary.

SUMMARY

The outcome of pancreas transplantation continues to improve with advances in the management of graft-threatening complications.

Pancreas Transplantation: An Alarming Crisis in Confidence

In the past decade, the annual number of pancreas transplantations performed in the United States has steadily declined. From 2004 to 2011, the overall number of simultaneous pancreas-kidney (SPK) transplantations in the United States declined by 10%, whereas the decreases in pancreas after kidney (PAK) and pancreas transplant alone (PTA) procedures were 55% and 34%, respectively. Paradoxically, this has occurred in the setting of improvements in graft and patient survival outcomes and transplanting higher-risk patients. Only 11 centers in the United States currently perform ≥20 pancreas transplantations per year, and most centers perform <5 pancreas transplantations annually; many do not perform PAKs or PTAs. This national trend in decreasing numbers of pancreas transplantations is related to a number of factors including lack of a primary referral source, improvements in diabetes care and management, changing donor and recipient considerations, inadequate training opportunities, and increasing risk aversion because of regulatory scrutiny. A national initiative is needed to "reinvigorate" SPK and PAK procedures as preferred transplantation options for appropriately selected uremic patients taking insulin regardless of C-peptide levels or "type" of diabetes. Moreover, many patients may benefit from PTAs because all categories of pancreas transplantation are not only life enhancing but also life extending procedures.

A registry analysis of damage to the deceased donor pancreas during procurement

Surgical injury to the pancreas is thought to occur commonly during procurement. The UK Transplant Registry was analyzed to determine the frequency of pancreatic injuries, identify factors associated with damage, and assess the impact of injuries on graft survival. Twelve hundred ninety-six pancreata were procured from donation after brain death donors, with 314 (19.5%) from donation after circulatory death donors. More than 50% of recovered pancreata had at least one injury, most commonly a short portal vein (21.5%). Liver donation, procurement team origin, hepatic artery (HA) arising from the superior mesenteric artery (SMA), and increasing donor BMI were associated with increased rates of pancreas damage on univariate analyses; on multivariate analysis only the presence of an HA from the SMA remained significant (p = 0.02). Six hundred forty solid organ pancreas transplants were performed; 238 had some form of damage. Overall, there was no difference in graft survival between damaged and undamaged organs (p = 0.28); however, graft loss was significantly more frequent in pancreata with arterial damage (p = 0.04) and in those with parenchymal damage (p = 0.05). Damage to the pancreas during organ recovery is more common than other organs, and meticulous surgical technique and awareness of damage risk factors are essential to reduce rates of procurement-related injuries.

Islet-after-failed-pancreas and pancreas-after-failed islet transplantation: Two complementary rescue strategies to control diabetes

For selected patients with type 1 diabetes, β-cell replacement is the treatment of choice, either by islet transplantation (ITX) or whole pancreas transplantation (PTX). When either modality fails, current practice is to consider retransplantation, or return to exogenous insulin. We investigate outcomes with PTX after failed ITX (PAI), and ITX after failed PTX (IAP). All patients receiving PAI or IAP at a single institution were identified. Donor and recipient variables were documented, including transplant outcomes analyzed for insulin requirement and metabolic control. Five subjects were listed for PAI, and 2 received transplants. Of the 4 listed for IAP, 3 have received transplants. The mean waitlist time was 4.5 ± 4.1 y for PAI and 0.35 ±0 .4 y for IAP (p = 0.08). Metabolic control was excellent after PAI, with 2/2 insulin-independent. After IAP, 1/2 achieved insulin independence and good metabolic control after 2 islet infusions. The third could not receive 2(nd) infusion and presented c-peptide levels < 0.1 nmol/L. Both strategies are feasible. The outcomes after PAI in our center must be offset by much longer waitlist time due to the sensitization status of these patients. Data from multicentre experience will allow more robust comparative outcomes to be made, the current observations being restricted to a limited patient set.