Pancreatic Transplantation (Hardcover)

The most comprehensive source on pancreatic transplantation available, this guide describes short- and long-term
outcomes, issues in patient evaluation, donor management, and recipient care, surgical procedures, and strategies for
complication avoidance. With expert contributions from specialists at leading US and international centers, this will
stand alone as the foremost guide to the subject.
Preface v
Acknowledgments vii
Contributors xvii
Outcomes After Pancreatic Transplantation Ron Shapiro Robert J. Corry Ngoc Thai 1
Introduction 1
SPK Transplantation 1
PAK Transplantation 3
Pancreatic Transplantation Alone 4
Impact of Immunosuppression 5
Causes of Graft Loss 6
Exocrine Drainage 7
Debate 7
Conclusion 8
References 8
The Effect of Pancreatic Transplantation on Secondary Complications of Diabetes Gunnar E. Tyden Goran Solders Jan
Bolinder 11
Introduction 11
Nephropathy 11
Neuropathy 12
Retinopathy 14
Peripheral Microcirculation 14
Quality of Life 34
Patient Survival 15
References 16
The History of Pancreas Transplantation Thomas E. Starzl Ngoc Thai Ron Shapiro 19
The Dominant Role of Drug Immunosuppression 19
Pancreas Transplant Proceduresvs. Immunosuppression Era 21
References 27
Evaluation of the Pancreas Transplant Recipient Jerry McCauley 31
Introduction 31
Genetics and Pathogenesis of Type 1 Diabetes 31
The Evaluation Process 34
Recipient Risk Factors for Pancreas Transplantation 38
Contraindications to Pancreas Transplantation 42
Organ Allocation System 43
References 43
Technical Aspects of Pancreatic Recovery David A. Geller Robert J. Corry S. Forrest Dodson 47
Evolution of Pancreas Procurement 47
Rapid En Bloc Technique for Combined Pancreas/Liver Recovery 48
Ex Vivo Separation of the Liver and Pancreas 50
Replaced Right Hepatic Artery 50
Pancreas/Kidney Procurement Alone 51
Intestine/Pancreas/Liver Procurement 51
Benchwork Reconstruction (Pancreas Back-Table) 51
References 52
Live Donor Pancreas Transplantation Miguel Tan Raja Kandaswamy David E. R. Sutherland Rainer W. G.
Gruessner 55
Introduction 55
Preoperative Donor Evaluation 55
Operative Technique 56
Donor Outcomes 60
Recipient Outcomes 61
Summary 62
References 62
Anesthetic Management in Kidney-Pancreas and Isolated Pancreatic Transplantation Raymond M. Planinsic Ramona
Nicolau-Raducu 65
Evaluation of the Patient 65
Intraoperative and Immediate Postoperative Management 66
Conclusion 68
References 68
Technical Aspects of Pancreas Transplantation Ron Shapiro Robert J. Corry Ngoc Thai 71
Back-Table Preparation 71
Implantation 74
References 80
Medical Management After Pancreas Transplantation M. Francesca Egidi 83
Introduction 83
Immediate Postoperative Period: General Aspects 83
Anticoagulation 83
Fluid and Electrolyte Balance 84
Blood Sugars and Endocrine Function 84
Exocrine Function 85
Renal Function 86
Medications 86
Conclusions 88
References 88
Immunobiology of Allograft Rejection Jennifer E. Woodward Abdul S. Rao 93
Introduction 93
T-Cell-Mediated Allograft Rejection 93
Initiation of Allograft Rejection 98
Mechanisms of Graft Destruction 98
Chronic Rejection 100
Conclusions 101
References 101
Immunosuppressive Agents in Pancreatic Transplantation Seamus J. Teahan Angus W. Thomson 103
Adrenal Corticosteroids 103
Antiproliferative Agents 104
T-Cell-Directed Immunosuppressive Agents 105
Lymphocyte-Depleting Agents 106
Deoxyspergualin 107
Novel Experimental Immunosuppressive Agents 109
References 110
Immunosuppression for Pancreas Transplantation Amit Basu Cynthia A. Smetanka Henkie P. Tan Akhtar S. Khan Ron
Shapiro 113
Introduction 113
SPK Transplantation 113
PAK Transplantation 120
Solitary Pancreas Transplants 122
Pancreas Transplantation Alone 123
Steroid Withdrawal/Steroid Avoidance 125
Sirolimus in Pancreas Transplantation 126
Conclusions 126
References 127
Pancreas Transplant Rejection Liise K. Kayler Henkie P. Tan 131
Immunosuppression 131
Acute Rejection 132
Chronic Rejection 133
Conclusion 134
References 134
Pathology of the Allograft Pancreas Parmjeet S. Randhawa Anthony J. Demetris 137
Introduction 137
Nonspecific Biopsy Changes 138
Donor Disease 138
Ischemic/Preservation Injury 138
Vascular Thrombosis 138
Acute Antibody-Mediated Rejection 139
Acute Cellular Rejection 139
Chronic Rejection 143
Graft versus Host Disease 144
Acute Pancreatitis 144
Chronic Pancreatitis 145
Bacterial Infections 145
CMV Infection 146
Posttransplant Lymphoproliferative Disorders 146
Urologic Complications 147
Recurrent Insulin-Dependent Diabetes Mellitus 147
Summary 148
References 148
Fine Needle Aspiration Biopsy in Kidney and Pancreas Transplantation M. Francesca Egidi 153
Introduction 153
FNAB Technique and Specimen Evaluation 154
The Role of FNAB in Research 157
References 157
Surgical Complications After Pancreatic Transplantation Cynthia A. Smetanka Ron Shapiro Amit Basu Akhtar S.
Khan Amadeo Marcos Henkie P. Tan 159
Vascular Complications 159
Intra-abdominal Complications 161
Urological Complications 162
Comparison Between Surgical Techniques 163
Relaparotomy 164
Pancreas Retransplantation 167
Current Trends: The Decreasing Rate of Surgical Complications 168
Conclusions 169
References 169
Medical Complications Following Pancreas Transplantation Joao Seda Neto Jerry McCauley Henkie P. Tan Ron
Shapiro 171
Introduction 171
Bone Disease 171
Hypoglycemia 172
Macrovascular Disease 173
Recurrent Autoimmune Pancreatitis 174
Fluid and Acid-Base Disturbances 175
Conclusion 176
References 176
Infectious Complications in Pancreas Transplant Recipients Eun Jeong Kwak Shimon Kusne 179
Introduction 179
General Principles 179
Bacterial Infections 179
Viral Infections 181
Cytomegalovirus 181
EBV and PTLD 183
Herpes Simplex Virus 184
Varicella-Zoster Virus 184
Fungal Infections 185
Candidiasis 185
Aspergillosis 185
Cryptococcosis 186
Preventive Strategies 186
Miscellaneous Infections 186
Conclusions 186
References 187
Malignancy After Pancreas Transplantation Michael J. Hanaway Joseph F. Buell Jennifer Trofe Thomas M. Beebe
M. Roy First V. Ram Peddi Thomas M. Gross Rita Alloway E. Steve Woodle 191
Materials and Methods 191
Results 192
Discussion 195
References 200
Neurologic Complications of Pancreas Transplantation Benjamin H. Eidelman 203
Pretransplantation Conditions 203
Posttransplant Conditions 204
The Early Posttransplantation Phase 204
The Late Posttransplant Phase 207
References 209
Radiology Aspects Michael P. Federle Keyanoosh Hosseinzadeh James V. Ferris Albert Zajko Manuel Brown 211
Introduction 211
Imaging Techniques 211
Complications 218
Summary 225
References 226
Islet Cell Transplantation Cynthia A. Smetanka Rita Bottino Massimo Trucco 229
Introduction 229
History of Islet Cell Transplantation 229
Islet Cell Biology and Physiology 230
Human Islet Isolation-Donor Selection, Procedures, and Assessment 232
Indications and Patient Selection 234
The Day of the Transplant: Immediate Pretransplant Evaluation and Methods of Implantation 237
Peritransplant Management and Medications 239
Complications Related to Islet Transplantation 241
Current Outcomes 243
Future Prospects 244
References 251
New Approaches to Pig-to-Man Islet Transplantation W. Bennet C. G. Groth 257
Islets Exposed to Xenogeneic Blood Undergo Instant Injury 257
The Role of Platelets in IBMIR 258
The Role of Coagulation in IBMIR 260
The Role of Complement in IBMIR 261
Complement Inhibition and Heparin Administration Abrogate IBMIR 262
IBMIR is an Innate Inflammatory Reaction 261
Future Prospects 262
References 262
Pregnancy After Pancreas Transplantation Velma P. Scantlebury 265
Introduction 265
Background 265
Immunosuppressive Drugs 266
Maternal Outcome 268
Kidney and Pancreas Outcome (Function) 269
Fetal Outcome 270
Recommendations 270
References 271
The Role of the Transplant Coordinator Deborah S. Good Holly Woods 275
Introduction 275
Referral 275
The Evaluation 275
Further Studies 276
Inpatient Follow-Up 277
Outpatient Follow-Up 277
Posttransplant On-Call Responsibility 278
Additional Responsibilities 278
Summary 278
Pancreas Transplantation at the University of Minnesota: 1966-2005 David E. R. Sutherland Rainer W. G. Gruessner
David L. Dunn Arthur J. Matas Abhinav Humar Raja Kandaswamy Angelika C. Gruessner John S. Najarian S.
Michael Mauer William R. Kennedy Frederick C. Goetz R. Paul Robertson 279
Introduction 279
Era 0 273
Era 1 281
Era 2 283
Era 3 284
Era 4 284
Era 5 286
Summary of Procedures 286
Statistical Analyses 287
Recipient Categories and Duct Management Overall and by Era 287
Outcome Analysis 292
General Discussion 315
References 319
Pancreas Transplantation: The University of Wisconsin Experience Jon S. Odorico Stuart J. Knechtle Hans W.
Sollinger 333
Introduction 333
Rationale 333
Indications for Transplantation 334
Risk Factors 336
Pancreas Donor Operation 336
Pancreas Transplant Operation 337
Immunosuppression and Postoperative Monitoring 341
Diagnosis and Treatment of Rejection 342
Results 344
References 350
Experience with Portal-Enteric Pancreas Transplantation at the University of Tennessee Memphis Robert J. Stratta M.
Hosein Shokouh-Amiri M. Francesca Egidi Hani P. Grewal A. Tarik Kizilisik Donna K. Hathaway Lillian W.
Gaber A. Osama Gaber 359
Introduction 359
Historical Background 360
Program Overview 362
Recipient Selection and Pretransplant Evaluation 365
Operative Procedure 369
Perioperative Management 370
Immunosuppression 370
Postoperative Monitoring 371
Long-Term Follow-Up and Statistical Analysis 372
Results 372
Metabolic, Physiologic, Quality of Life, and Long-Term Outcomes 383
Summary 387
References 387
Simultaneous Pancreas-Kidney Transplantation at the Ohio State University Elmahdi A. Elkhammas Alp Demirag Ginny
L. Bumgardner Ronald P. Pelletier Ronald M. Ferguson Mitchell L. Henry 391
Introduction 391
Recipient Selection Criteria 392
Donor Selection and Recipient Operation 392
Immunosuppression 392
Patient and Graft Survival 392
Acute Rejection 394
Enteric Conversion 395
Urological Complications 395
Technical Failure 356
Infections 397
Summary 397
References 398
Pancreatic Transplantation at the University of Maryland Benjamin Philosophe Venkatesh Krishnamurthi Stephen T.
Bartlett 399
The Evolution of Laparoscopic Living Donor Nephrectomy and Its Influence on Pancreas Transplantation 399
Simultaneous Cadaver Pancreas-Living Donor Kidney Transplantation 401
Patient Selection 401
Patient Evaluation 402
Technical Aspects 402
Results: The Impact of Portal Venous Drainage on Graft Survival and Rejection 405
Summary 410
References 410
The Northwestern University Experience in Pancreas Transplantation Dixon B. Kaufman 413
Advances in Immunosuppression 413
CMV Disease in Simultaneous Pancreas-Kidney Transplantation 417
Summary 418
References 420
Pancreas Transplantation at Indiana University: A Brief Overview of Recent Progress Jonathan A. Fridell Avinash
Agarwal John A. Powelson 421
Introduction 421
Preservation 421
Technical Aspects 421
Posttransplant Management and Immunosuppression 421
Results 423
New Indications 423
References 425
Pancreas Transplantation: The Stockholm Experience Gunnar E. Tyden 427
Donors 427
Technique for Pancreatic Transplantation with Pancreaticoenterostomy 427
Immunosuppression and Anticoagulation 429
Monitoring for Rejection 429
Patients 429
Results 430
Conclusion 430
References 431
Pancreas Transplantation at the University of Louvain Saint Luc Hospital in Brussels (Belgium) and the EUROSPK Trial
Jean-Paul Squifflet 433
Introduction 433
Population 433
Surgical Technique 433
IS Therapy 435
Results 436
Islet Research 437
The EUROSPK Protocol 437
Conclusions 439
References 440
Retroperitoneal Pancreas Transplantation with Portal-Enteric Drainage Ugo Boggi Fabio Vistoli Marco Del Chiaro
Stefano Signori Franco Mosca 441
Pancreas Recovery and Preparation 442
Transplant Procedure 443
Postoperative Management/Graft Surveillance 445
Results 446
Conclusions 449
References 449
Index 453