[Frontiers in Bioscience 2, e34-40, August 1, 1997]|
PANCREAS TRANSPLANTATION: INDICATIONS, CLINICAL MANAGEMENT, AND OUTCOMES
John P. Leone, MD, PhD1, Abhinav Humar1 , Rainer W. G. Gruessner, MD, PhD2, and David E.R. Sutherland, MD3
1Transplant Fellow, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, 2Professor & Chief, Section of Pancreatic Transplantation, Department of Surgery University of Minnesota, Minneapolis, Minnesota, 3Professor & Chief, Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
Received 6/15/97; Accepted 6/23/97; On-line 7/25/97
The decision to undergo a pancreas transplant requires a major commitment from both the surgeon and patient. The procedure is at risk for complications due to its technical difficulty combined with the inherent nature of the gland itself. Due to the conditions of the vascular anastomoses and the low-flow state of the pancreas, we recommend the use of low-dose anticoagulation (heparin or dextran) post-operatively (37). While the risk of post-operative bleeding is less than 5%, the risk for graft thrombosis is virtually eliminated. Post-operative hematuria is common but usually stops spontaneously. However, cystoscopic cauterization may be required for persistent bleeding. The most serious problems encountered post-operatively are leaks from the lateral duodenal suture (staple) lines or the duodenal/bladder anastomosis (38). Breakdowns at these sites occur secondary to technical problems (early) or chronic ulceration (late). Conservative management (urethral catheter drainage) usually controls small leaks and allows for sponteous healing and closure. However, larger leaks usually require abdominal exploration and anastomotic repair. Dependent on the situation which is encountered surgically, some patients may require either conversion to enteric drainage or graft pancreatectomy (39). Small bowel obstruction, incisional hernia, lymphocele, enterocutaneous fistula, and graft thrombosis are other problems included in the list of complications which occur with far less frequency.
A high rate of early infection in pancreas transplant recipients has been reported by Sollinger, et. al. (40). Their study showed that approximately 82% of SPK patients have at least one episode of infection (91% immunological and 9% surgical) while on quadruple immunosuppression (ALG, AZA, CSA, and prednisone). These early infections are surgically related and can present as intra-abdominal abscesses, wound infections, anastomotic leaks, and urinary tract infections (most common). Most urinary tract infections will respond to prompt initiation of antibiotic therapy. However, cystoscopic evaluation is required for a persistent or recurrent urinary infection. In such cases, a nidus for infection is usually identified and removal of an anastomotic staple or suture eliminates the cause. Conversion to enteric drainage may be warranted for patients with persistent UTI and no identifiable source (39). Late infections by a variety of opportunistic microbes are usually related to immunosuppression. The most common organisms involved in superficial and deep wound infections are staphylococcus species (56%) and candida species (33%) (41). In a report from our center, intra-abdominal fungal infections were as high as 9% and associated with significant morbidity and mortality (42). Furthermore, patients on dialysis (either hemo- or peritoneal-) prior to transplant were at significantly higher risk for developing an intra-abdominal infection (43). Thus, the risk of a higher infection rate further emphasizes the need to transplant this patient population when they first demonstrate evidence of renal failure and to not wait until they are debilitated by uremia and dialysis dependent.
Male patients are prone to urethritis and urethral strictures when the pancreas is bladder drained (40). The cause being chronic urethral irritation by pancreatic secretions (enzyme related). Temporary placement of a uretheral catheter usually relieves the pain and discomfort a patient experiences. However, enteric conversion may be required for severe cases (39). Acid/base disturbances are another problem associated with pancreatic secretions and bladder drainage. Urinary bicarbonate losses can be corrected by an oral sodium bicarbonate regimen in most cases. However, severe imbalances may need enteric conversion to stabilize the base deficit (39).