IHPBA 2020 - Session Planner

Poster Transplant
PT04 Transplantation: Pancreas (ePoster)
Selection of ePoster Presentations from Abstract Submissions
PT04-01	Pancreas Transplant - Experience from Taipei Veterans General Hospital, Taiwan Yi-Ming Shyr, Taiwan, Republic of China Y.-M. Shyr Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China Pancreas transplant is a rare surgical procedure in Taiwan, even in Asian. Taipei Veteran General Hospital is one of the qualified 6 medical centers to do pancreas transplant in Taiwan. Our hospital has been on the leadership in not only quantity but also quality of pancreas transplant in Taiwan. We have performed more than 89% cases of pancreas transplant in Taiwan. Our pancreas transplant team have the ability to perform all techniques of pancreas transplant , not only the common ones including pancreas transplant alone (PTA), pancreas after kidney transplant (PAK) and simultaneous pancreas and kidney transplant (SPK), but also the unique technique “pancreas Before Kidney Transplant (PBK)” which is developed at our hospital and is not performed at other countries in the world, and pancreas after liver transplant (PAL) which is very rare in other countries. Our technical success rate in pancreas transplant is 97%. The 1-year pancreas graft survival rate is 98%, 5-year pancreas graft survival rate 91%, 10-year pancreas graft survival rate 59%.
PT04-02	Pancreas Transplant for T2DM Shin-E Wang, Taiwan, Republic of China S.-E. Wang Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China Type 2 diabetes mellitus (T2DM) was once considered a contraindication to simultaneous pancreas-kidney transplant, a growing body of evidence has revealed that similar graft and patient survival can be achieved when compared to type 1 diabetes mellitus recipients. 146 cases of pancreas transplantation were included for study, with 115 (79%) for T1DM and 31 (21%) for T2DM. Pancreas transplantation for T2DM was mainly indicated for the uremic groups such as SPK (32%), PAK (19%) and PBK (42%). After pancreas transplantation, 106 (73%) patients suffered from complications, including 70 (48%) early complications before discharge and 79 (54%) late complication during follow-up period. There was no significant difference regarding the complications between T1DM and T2DM groups. Overall, rejection of pancreas graft occurred in 37 (25%) patients, including 27 (19%) acute rejection and 13 (9%) chronic rejection. Rejection rates were also of no significant difference between T1DM and T2DM groups. The graft loss occurred in 35 (30%) T1DM patients and 12 (39%) T2DM patients. Endocrine outcomes regarding fasting blood sugar and serum HbA1c before and after pancreas transplantation were of no significant difference between T1DM and T2DM groups. T2DM patients presented significantly higher levels of serum C-peptide either before or after pancreas transplantation, as compared with T1DM patients. There was no significant difference regarding the graft survival between T1DM and T1DM groups. In conclusion, outcomes for T2DM were similar to T1DM after pancreas transplantation. Therefore, pancreas transplantation could be an effective option to treat uremic T2DM patients without significant insulin resistance.
PT04-03	Simultaneous Pancreas and Kidney Composite Graft Transplant Bor-Uei Shyr, Taiwan, Republic of China B.-U. Shyr Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China Purpose: Limited vascular access could be encountered in an obese or re-transplant patient. We described modifications that facilitated an en bloc simultaneous pancreas and kidney (SPK) composite graft transplant in an obese type 2 diabetic patient with renal failure under hemodialysis. Methods: At the back-table, the superior mesenteric artery and splenic artery of the pancreas graft were reconstructed with a long "Y" iliac artery graft. The smaller left renal artery is anastomosed end-to-side to the larger and longer common limb of the arterial Y graft and the shorter portal vein is anastomosed end-to-side to the longer graft left renal vein. Thus, this en bloc composite graft allowed to facilitate “real” SPK transplant using single common graft artery and vein for anastomosis to one recipient arterial and venous site. The en bloc pancreas and kidney composite graft was implanted by suturing the graft left renal vein to IVC and graft common iliac artery the recipient distal aorta. Exocrine drainage was provided by anastomosis of the graft duodenum to a roux-en-y jejunum limb in an side-to-side fashion. Immunosuppressants included basiliximab, tacrolimus, mycophenolate mofetil, and methylprednisolone. Results: The operative time was 7 hours with cold ischemic time of 6 hours and 25 min. and warm ischemic time of 47 min. The patient was discharged on postoperative day 20, with a serum creatinine level of 1.4 ng/ml and a blood glucose level of 121 mg/dL. Conclusion: En bloc pancreas and kidney composite graft might be an option for patients with limited vascular access.
PT04-04	Reduced the Occurrence of Graft Thrombosis Using the Technique of Allograft “Triple Inflow” Arterial Reconstruction for Pancreas Transplantation Shifeng Li, United States S. Li, A. Hawxby, A. Sebastian Oklahoma Transplant Center, OU Medical Center, United States Graft thrombosis (GT) accounts for the majority of graft loss in the early postoperative phase of pancreas transplantation (PT). Low microvascular flow in the allograft makes it vulnerable to GT. The technique of allograft "dual inflow" (DI) arterial reconstruction is currently practiced. We herein describe another technique of allograft "triple inflow" (TI) arterial reconstruction to reduce the occurrence of GT. Of the last 33 PT (26 simultaneous pancreas-kidney transplants, 6 pancreas-after-kidney transplants and 1 pancreas transplant alone) in our center, the techniques of DI and TI were used in 22 and 11 allografts separately. The DI technique includes ligation and division of the gastroduodenal artery (GDA) followed by anastomoses of the superior mesenteric artery (SMA) and splenic artery (SA) of the pancreatic graft to the external iliac artery (EIA) and internal iliac artery (IIA) of the donor “Y” iliac artery (YIA). The TI technique includes preservation of the GDA during procurement. More branches of the donor YIA are preserved. Of these branches, the largest small branch (BIA) is used for the “third” anastomosis to the GDA of the pancreatic graft as well as with the SMA and SA anastomoses described in the DI technique. (Fig.) Following PT, 3 of 22 (13.6%) allografts using DI technique developed GT 24-48 hours postoperatively which resulted in graft losses. None of the 11 allografts using TI technique developed GT. The technique of allograft TI arterial reconstruction used for PT increases blood flow to the pancreas transplant and reduces the risk of GT. [Fig. Allograft “triple inflow” arterial reconstruction for pancreas transplantation.]
PT04-05	Kidney-Pancreas Transplant Recipients Experience Higher Risk of Complications Compared to the General Population after Undergoing Coronary Artery Bypass Grafting Jordyn Perdue, United States A. Chiodo Ortiz¹, A. Parsikia², C. Chiodo Ortiz², J. Perdue², J. Ortiz² ¹Albany Medical College, United States, ²University of Toledo Medical Center, United States Introduction: Kidney-pancreas transplant (KPT) is treatment for type 1 diabetics with renal failure. Due to their risk of developing coronary artery disease, there is a need to identify the outcomes associated with KPT undergoing CABG. Methods: NIS data from 2005 to 2014 were analyzed. KPT who underwent CABG were evaluated for complications, length of stay and total hospital charges. Weighted data were analyzed using multivariate logistic regression test and linear regression test. Results: We identified 1,799,302 CABG patients with 438 having a history of pancreas transplant (184 pancreas-alone and 254 pancreas and kidney). The weighted multivariate analysis revealed KPT was associated with a significant odds ratio for developing any complication for CABG (OR 3.103, p< 0.001) and emergency CABG (OR 4.952, p< 0.001). Emergency CABG patients with a history of KT alone were more likely to develop complications while pancreas alone showed no statistical significance in the occurrence of complications. The same pattern was observed in transplant centers. The odds ratio of KPT was greater (OR 7.906, P < 0.001). CABG patients with history of PT alone showed higher chance for increased total hospital charge and length of stay. At transplant centers the same escalating rise of OR for developing any complication was noted in kidney alone (OR 1.362), pancreas alone (OR 2.542), and KPT (OR 3.045). Conclusion: KPT experience higher risk of complications compared to the general population after undergoing CABG in both transplant centers and non-transplant centers. These outcomes should be considered when providing perioperative care.
PT04-06	Outcomes of Pancreas Transplant Patients Undergoing Colorectal Resection Lauren Weaver, United States L. Weaver¹, A. Parsikia², J. Ortiz³ ¹Department of Surgery, University of Minnesota, United States, ²University of Pennsylvania, United States, ³Department of Transplant Surgery, Albany Medical Center, United States Introduction: This study analyzes differences between pancreas transplant patients and non-transplant patients undergoing colorectal resection at both transplant and non-transplant centers in order to identify areas of surgical risk. Methods: Multivariate logistic regression tests and linear regression tests computed odds ratios (OR) by analyzing weighted data from the National Inpatient Sample from 2005-2014 to identify differences in mortality, complications, length of stay (LOS), and total hospital charges between four patient groups 1)pancreas transplant alone (PTx), 2)kidney transplant alone (KTx), 3)pancreas with kidney transplant (PKTx), and 4)non-transplant patients (non-Tx) undergoing colorectal resections at transplant and non-transplant centers. Results: Of the 2,452,422 colorectal resection patients identified, 215 patients had a history of pancreas transplant with 118(54.9%) of those patients experiencing a complication. Complication occurrence was more likely in PKTx (p0.003;OR1.958) compared to non-Tx. Prolonged LOS was more likely in PTx (p< 0.001;OR0.007) and PKTx (p< 0.001;OR0.002) compared to non-Tx. Costs were more likely to be higher for PTx (p< 0.001;OR0.006) and PKTx (p< 0.003;OR0.002) compared to non-Tx. There was no significant difference in hospital mortality between transplant and non-transplant groups. In transplant centers, PTx and PKTx were not more likely to experience complications compared to non-Tx. Conclusion: PKTx experience higher complication rates. PTx and PKTx are more likely to have higher hospital costs and LOS compared to non-Tx undergoing colorectal resection. However PTx and PKTx did not experience higher complication rates in transplant centers. Surgeons and pancreas transplant patients should be aware of the increased risk of complications when considering a colorectal resection. [Weighted Multivariate Adjusted Outcome for Pancreas Transplant Patients]
PT04-07	Outcomes of Pancreas Transplant Patients Undergoing Appendectomy Mckenzie Clapp, United States M. Clapp¹, A. Parsikia², L. Weaver³, J. Ortiz⁴ ¹University of Toledo College of Medicine, United States, ²University of Pennsylvania, United States, ³University of Minnesota, United States, ⁴Department of Transplant Surgery, Albany Medical Center, United States Introduction: This study analyzes differences between pancreas transplant patients and non-transplant patients undergoing appendectomy in transplant and non-transplant centers to identify areas of surgical risk. Methods: Multivariate logistic regression tests and linear regression tests computed odds ratios (OR) by analyzing weighted data from the National Inpatient Sample database from 2005-2014 to identify differences in mortality, complications, length of stay (LOS), and total hospital charges between 4 patient groups 1)pancreas transplant alone (PTx) 2)kidney transplant alone (KTx), 3)pancreas and kidney transplant (PKTx), and 4)non-transplant patients (non-Tx) undergoing appendectomy for the diagnosis of appendicitis in transplant and non-transplant centers. Results: Of the 1,819,283 appendectomy procedures, 145 pancreas transplant patients were identified. No mortalities occurred among pancreas transplant patients. On univariate analysis, pancreas transplant patients had higher complication rates compared to non-transplant patients (17.0% vs 10.0%, p=0.012). On multivariate analysis, PKTx demonstrated a decreased odds ratio for developing any complication (OR 0.343; p0.003) compared to non-Tx. This was not observed in PTx or KTx. In transplant centers, PKTx (OR 0.196; p=0.002) and KTx (OR 0.461; p< 0.001) demonstrated significantly decreased odds ratios for developing any complication. In transplant centers, there were no significantly higher odds ratios for LOS or total charges in PTx or PKTx groups. Conclusion: PKTx were less likely to develop a complication when undergoing an appendectomy. In transplant centers, PKTx and KTx were both less likely to develop a complication. It appears pancreas transplant patients undergoing appendectomy are not at higher risk for complications compared to the general population.
PT04-08	Is There an Increased Risk of Spinal Ischemia in Pancreas Transplantation? Alejandro Ortiz, United States A. Ortiz¹, A. Parsikia², L. Weaver³, M. Shanidze³, J. Ortiz⁴ ¹Albany Medical College, United States, ²University of Pennsylvania, United States, ³University of Toledo College of Medicine, United States, ⁴Department of Transplant Surgery, Albany Medical Center, United States Introduction: This study investigates if there is an increased risk for spinal cord ischemia in patients undergoing pancreas transplantation. Methods: The National Inpatient Sample (NIS), a large U.S. national database, identified patients from 2004 to 2015 who underwent a pancreas transplantation procedure (ICD 52.8) and had either a diagnosis of spinal cord ischemia (ICD 336.1 vascular myelopathies), MRI of the spinal cord (ICD 88.93), or MRI of the brain and brain stem (ICD 88.91). Results:* Of the 2,346 pancreas transplant patients (PTx) identified, 1,440 (61.4%) also underwent a kidney transplant. Zero PTx were identified who had a pancreas transplant procedure code and a diagnostic code for spinal cord ischemia (336.1). Zero PTx received a MRI of the spinal cord (88.93). Four PTx underwent MRI of the brain and brain stem (88.91). Conclusion: A previous U.K. study by Phillips et al. proposed a 1:440 risk of spinal cord ischemia in pancreas transplantation procedures. The NIS database yielded no PTx with spinal cord ischemia and in addition, no MRI of the spinal cord. Four PTx underwent MRI of the brain and brain stem but those cases were most likely due to cerebrovascular accidents. This discrepancy indicates large databases do not capture rare conditions. Better reporting systems may be needed if this association is to be further explored.
PT04-09	A “Pancreatectomy First" Approach Improves Both Hepatectomy and Pancreatectomy Times in Cadaveric Multi-organ Abdominal Retrieval Martyn Stott, United Kingdom M. Stott, C. Wong, O. Vaz, Z. Moinuddin Manchester University NHS Foundation Trust, United Kingdom Introduction: The aim of organ retrieval is safe procurement of transplantable organs with acceptable warm ischaemia times. In the United Kingdom, organ retrieval is a centrally coordinated service delivered by 10 teams. Despite this, there is no standardised retrieval technique. Practiced techniques include hepatectomy first or en-bloc organ retrieval. Hepatectomy first approach exposes the pancreas to prolonged warm ischaemia while the liver is being retrieved and packed. While the en-bloc technique ensures swift and timely removal of both organs, extra time is spent at the back-table splitting the organs. We report on the Manchester “pancreatectomy first approach” which we believe is safe and time efficient for both organs. Methods: A retrospective analysis of a prospectively maintained database of a single centre's organ retrieval activity between 2016-2019 was performed. Primary outcomes were hepatectomy and pancreatectomy times. Secondary outcomes were organ damage and transplant outcomes. Results: 546 donor operations were conducted. Using the hepatectomy first approach, mean hepatectomy time when performing liver alone was comparable to liver/pancreas (30mins vs 33mins). The proportion taking more then 30 minutes increased when both organs were retrieved (41.3% vs 56.3%). Mean pancreatectomy time was 14mins after hepatectomy. 10 operations were performed using a “pancreatectomy first” approach. Median pancreatectomy time was 21 minutes with hepatectomy occurring 6 minutes later. There was no difference in organ damage or transplant outcomes. Conclusion: This small case series suggests that a pancreatectomy first approach at multi-organ retrieval is feasible, safe, efficient, and reduces warm ischaemia times for both liver and pancreas.
PT04-10	Pancreas Transplantation in Clinica Santa María, Chile. Results after 5 Years of Sustained Growth Carlos Derosas, Chile J. Chapochnick^1,2, C. Derosas^1,2, R. Iñiguez^1,2, J. Pefaur², G. Enciso², X. Roca², M. Alarcon², L. Oliva² ¹Department of Surgery, Clinica Santa María, Chile, ²Transplant Center, Clinica Santa María, Chile Introduction: Since the opening of the pancreas transplant program in our institution in 2014, this treatment alternative has been reactivated in Chile. To date, 36 patients have been successfully transplanted. The aim of this study is to report our experience and results. Method: Descriptive and prospective study of a case series of single center experience, from 2014 to January 2020. Complete follow-up has been achieved. Analysis in SPSS 20.0. Results: Since March 2014, 36 patients, 34 simultaneous pancreas-kidney transplants and 2 Pancreas Transplant Alone have been transplanted. Main indication was DM1 and end stage renal desease. 61.1% were women, median age 36,4 years (23-51), 83.3% of the patients were on dialysis. 11.1% of patients are type 2 diabetics. Average waiting list is 18 months. No delayed function (DGF) of the pancreatic graft was observed, 2 patients presented renal DGF. All patients are free of insulin from the time of reperfusion. 1 patient died at 20 months post transplant secondary to lower limb sepsis with both functioning grafts. 2 patient have lost the renal graft, one has been retransplanted. Median follow-up is 28.4 months. Overall survival is 100% per year and 97.2% at 2 years. Discussion: This series represents the largest experience in the country and demonstrates the consolidation of a program that few years ago showed its initial results. Our program has undergone a cautious maturation process, increasing number of transplants year after year with outstanding results.