Pancreatic Transplantation Book

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