Pancreatic Transplant: Indications, Procedure, and Complications

Pancreatic Transplant

Pancreatic transplantation has been accepted as a therapeutic alternative to continued insulin therapy in diabetic patients with imminent or established end-stage renal disease who have had a plan to have a kidney transplant. Successful additions of a pancreas:

• It does not jeopardize the survival of the patient.
• It may improve the survival of the kidney.
• It will restore normal glycemia.

Successful pancreatic transplantation improves the quality of life by:

• Reducing the need for frequent glucose monitoring, and
• Reducing episodes of hypoglycemia.

Types of Pancreatic Transplantation

The most common type of transplantation is the simultaneous pancreas and kidney transplantation (80%). 15% of pancreatic transplantation involves the transplantation of the pancreas after the transplantation of the kidneys. In about 8% of cases, the pancreas is transplanted alone.

Indications of Pancreatic Transplantation

Type I diabetes with clear C-peptide deficiency is the main indication of simultaneous pancreas and kidney transplantation. When the patient is on insulin therapy with C-peptide levels below 2 ng/ml. When the patient is on insulin therapy with C-peptide levels above 2 ng/ml, but BMI is below 28.

Also read: Basics of Transplantation: Explore Types, Methods, and History

Donor Selection 

Organs from younger, leaner, hemodynamically stable and deceased donors is preferred.

Pancreas for significant steatosis is avoided. If the pancreas from a donor with steatosis is taken, then there is an increased risk of:

• Post-operative complications.
• Perioperative fat necrosis.
• Infection and pancreatitis.

Procurement Principle, Preparation and Transplantation

Minimal handling of the pancreas should be assured during procurement. To ensure this, en bloc removal of the pancreas and liver is done to reduce the warm ischemia time.

Bench Table Preparation

The en bloc is then taken to the bench resection, where the spleen is removed, at least 1 cm of portal vein is maintained, and the excess distal or proximal duodenum is trimmed

The Iliac artery is used as a Y graft and an end-to-end anastomosis is done between the internal iliac artery and splenic artery, and the external iliac artery is anastomosed with the superior mesenteric artery. Graft is placed on the right side to prevent undue stretching of venous anastomosis. Systemic venous drainage is preferred over portal venous drainage in pancreas transplantation. Systemic venous drainage can be attained by:

Anastomosis of portal vein to external iliac vein. Common iliac vein. Distal part of IVC.

The iliac artery graft is anastomosed to the common iliac artery of the recipient. To establish portal drainage, the donor portal vein is anastomosed to the recipient proximal superior mesenteric vein. However, this is not preferred.

Also read: Pediatric Rhabdomyosarcoma (RMS) of The Genitourinary Tract

Exocrine secretions from the pancreas after transplantation

The small portion of the duodenum stump can be anastomosed to the intestine in a side-to-side fashion with the recipient's mid-jejunum to facilitate the enteric drainage. The orientation of the duodenum can be superior or inferior to the jejunum. The small portion of the duodenum can be anastomosed to the bladder in order to facilitate bladder drainage. A 4-5 cm cystostomy is done on the anterior dome of the bladder. The orientation of the duodenum is always inferior to the bladder.

Bladder drainage is advantageous because it allows the monitoring of urinary amylase, which is an early indicator of graft function. The disadvantage of bladder drainage is the occurrence of hematuria due to recurrent drainage. Enteric drainage is usually preferred over bladder drainage.

Complications of Pancreatic Transplantation

Pancreatic graft thrombosis is the most common complication faced after pancreatic transplantation because of low blood flow through the organ. Venous thrombosis is more common than arterial thrombosis since the flow of blood is slower in the veins. It usually occurs within the first week of transplantation.

Vascular or venous thrombosis is the most common cause of non-immunologic graft failure, in patients who underwent pancreatic transplantation. Early pancreatitis can occur if the pancreas was handled during the procurement and developed ischemia. If anastomosis is not good there are chances of a leak. In case of bladder drainage, a small leak can be managed by a Foley's catheter. In case of enteric drainage, operative intervention is required. Bleeding can also occur in patients with transplanted pancreases. Bleeding can be of 2 types:

• Immediate post-transplant bleeding occurs from pancreatic parenchyma.
• Delayed gastrointestinal bleeding occurs in case of enteric anastomosis on postoperative days 6 to 10 → self-limiting.

Also read: Important MCQ's For Head & Neck in NEET SS Surgery

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