in upcoming decade, pancreas transplant have to be considered if IAT result is not promising in the management of DM and pancreatic tumor

1. Pancreas transplant
DR MD AB QUIYUM
Phase B
Hepatobiliary Surgery, BSMMU,Bangladesh

2.  A pancreas transplant is an organ transplant that involves
implanting a healthy pancreas (one that can produce insulin) into
a person who usually has diabetes.

3. History
 1809….Dr Leonard sheep pancreas into child ….died
after 3 days.
 1966…Dr Kelly….(Belgium ,University of Meneosita)
vascularized pancreas transplant along with kidney
 1973…Dr Ballinger and lacy …islets cell transplant
 At present ,<1000 transplant per year due to…
less suitable diseased donor
less suitable recipient

4. Type
four main types of pancreas transplantation:
 1.PTA Pancreas transplant alone < 10%
 the patient with type 1 diabetes who usually has severe,
frequent hypoglycemia, but adequate kidney function).
 2.SPK Simultaneous pancreas-kidney transplant >80%
 3.PAK Pancreas-after-kidney transplant (PAK), 10%
 when a cadaveric, or deceased, donor pancreas
transplant is performed after a previous, and different, living or
deceased donor kidney transplant.
This method is usually recommended for diabetic patients after having a
successful kidney transplant
 4.SPLK Simultaneous deceased donor pancreas and live donor kidney
(SPLK) has the benefit of lower rate of delayed graft function than SPK and significantly reduced waiting
times, resulting in improved outcomes.[4]

5.  1.diseased donor ( after brain stem death) most common.(whole organ)
 2.living donor ( close relative ,identical twins) partial
 younger, leaner, and more hemodynamically stable deceased donors.
 Donors with hemodynamic instability or those that require high doses of vasopressors are
considered at higher risk for graft failure and graft-related complications.
 pancreata with significant steatosis are usually avoided, because they are associated with a
greater likelihood of postoperative complications, such as pancreatitis, peripancreatic fat
necrosis, and infection.

6. indication
 Commonly in type 1 diabetes mellitus ( some type 2 also)and renal failure.
Aim : The normal glucose control achieved by the pancreas
transplant protects the transplanted kidney from recurrent
diabetic nephropathy

9. contraindication
1.ongoing infectious process
2. malignancy.
3.Cardiac contraindications
no correctable coronary artery disease,
significantly decreased ejection fraction,
or myocardial infarction within the preceding 6 months.
4. recipients older than 50 years ( relative)

10. Transplant anatomy
After retrieval
Bladder and systemic
drainage
Small gut and systemic
drainage

11. Steps : Donor operation
 procurement of the pancreas must be performed in conjunction with the liver
procurement
 Laparotomy….opening of lesser sac ..pancreas examination…portal traid
dissection…duodenum kockerization….pancreas full mobilization…Liver remove 1st
…then
 1. cbd devided at superior border of pancreas
 2.portal vein 1 cm distal to origin
 3.SMA from aorta
 4. donor common iliac artery with bifurcation
 5. The donor pancreas is retrieved en bloc with the duodenum, which is transected and
stapled proximally just beyond the pylorus and distally in the third part of the
duodenum

12. Back table preparation
 Back table preparation is performed in ice-cold preservation solution to
minimize any further ischemic injury .
 1. The duodenum is often shortened with a GIA stapler, being careful to
exclude any gastric tissue and careful not to compromise the opening of
the ampulla of Vater.
 2. The spleen is removed by dividing the vessels in the splenic hilum,
being careful not to injure the tail of the gland.
 3 arterial reconstruction using the donor iliac artery as a bifurcated Y
graft. The internal iliac artery is joined to the splenic artery, and the
external iliac artery is joined to the SMA
 4. a portal vein extension graft using donor iliac vein if needed but
increase the risk of venous thrombosis of the pancreas graft.

13. Recipient operation
 There are two common locations in the abdomen where the
transplant is placed based on the type of venous drainage
planned:
 either in the pelvis, usually on the right side, for systemic venous drainage
the graft can be oriented with the duodenum in an inferior position, if bladder drainage is
planned or
with the duodenum in either the superior or inferior position, if enteric drainage is
planned.
 in the mid abdomen for portal venous drainage
 below the transverse colon with the duodenum oriented superiorly

15.  Duodenum…anastomosis to RNY loop of
small gut/ urinary bladder
 (Exocrine drainage)
 Donor artery …to recipient Rt Common
iliac artery/external ileac artery
 Donor vein… into IVC / SMV /PV
(endocrine drainage)

16. some video link
1. https://youtu.be/nIQl9KaLfSQ
2. https://youtu.be/-LPv40PSg6c

17. complication
 Most commonly
 1. pancreatic thrombosis (5-10% cases)
 2.graft pancreatitis ( 10-20% case ..due to ischaemia )
 3. pancreatic leakage ( from bladder or small gut)
 4.graft rejection ( hyperamylesimia ,biopsy ,hyperglycemia)
 5.other complication of solid organ transplant

18. MDCT images showing a
normal pancreatic graft
arterial supply after SPK
transplantation.
The donor’s superior
mesenteric artery (SMA)
supplies the pancreatic graft
head (white asterisk),
and the donor’s splenic
artery irrigates the graft
body and tail (black
asterisk)

19. the arterial phase of an MRA study demonstrates the arterial vessel anatomy of the pancreatic graft. Note
that the donor’s SMA (arrow) presents normal calibre and the donor’s splenic artery (arrowhead) shows a
stenosis with mild post-stenotic dilation.
b MR angiography in the arterial phase shows normal enhancement of the pancreas (arrow) and kidney
(arrowhead) transplants. At the lower pole of the kidney graft a large lymphocele is seen (asterisk)

20. intra-abdominal fluid collections
with contrast-enhancing wall, with
air-fluid levels (arrows), consistent
with abscesses.
Ascites and gas bubbles
(arrowhead) are noted near the
duodeno-enterostomy.
The pancreatic (white asterisk) and
renal grafts (black asterisk)
enhance homogeneously.
Duodenal dehiscence was
suggested. The patient underwent
surgery, which revealed a fistula at
the donor’s duodenal cuff

21. Abdominal ultrasound-Doppler performed 2
weeks after transplantation shows
the iliac arteries and the graft’s arterial
vessels (aarrow) permeable but with
aliasing and high resistive index (RI).
The iliac vein showed normal flow.
However,
no flow was detected at the graft’s portal
vein, suggesting thrombosis (barrow).

22. result
1.Graft survival

24. o 2.restores euglycemia and normal hemoglobin A1c levels,
o diabetic complications should cease and perhaps reverse.
o Neuropathy appears to stabilize and slowly improve
o whereas retinopathy progression slows after several years of graft function.
3.diabetic nephropathy appears to stabilized or prevented after transplantation

25. SPK available in…..

26. India
In india,
An islet transplantation costs about $20,000 dollars,
SPK/PAK/PTA about SD 30, 000-70,000
5 year SR SPK 73% ,PAK 65 %, PTA 53%. Source : MEDMONK

27. Summary
 Pancreatic transplant done in uncontrolled complicated diabetes with or without CRF.
 Mainly either SPK or PAK is performed.
 Drainage may be gut ( best ) or bladder and systemic or portal (better)
 SPK graft survival 5 year > 70%
 Venous thrombosis and graft pancreatitis is most common complication

28. Bangladesh perspective
 No transplant yet.
 A matter of great opportunity

29. Bibliography
 1.Blumgurd 6th edition.
 2.NCBI
 3.MEDMONK

30. Thank you