The surgical risk of pancreas transplantation in the cyclosporine era

An overview

Rainer W G Gruessner, David E R Sutherland, Christoph Troppmann, Enrico Benedetti, Nadey Hakim, David L. Dunn, Angelika C Gruessner

Research output: Contribution to journalArticle

118 Citations (Scopus)

Abstract

Background: Pancreas transplants are still associated with the highest surgical complication rate of all routinely performed solid organ transplants. To date, the impact of serious surgical complications in the cyclosporine era on perioperative patient morbidity, graft and patient survival, and hospital costs has not been analyzed in detail. Study Design: We retrospectively studied surgical complications after 445 consecutive pancreas transplants (45% simultaneous pancreas-kidney [SPK], 24% pancreas after kidney [PAK], and 31% pancreas transplant alone [PTA]). Of these, 80% were primary transplants, 20% were retransplants. Cadaver donors were used in 92%, living related donors in 8%. To develop guidelines for their prevention and management, we studied the impact of significant surgical complications (intraabdominal infections, vascular graft thrombosis, and anastomotic leak) requiring relaparotomy on graft and patient survival. Results: Relaparotomy was required after 32% of all pancreas transplants (SPK: 36%, PAK: 25%, PTA: 16% [p = 0.04]). Perioperative mortality was 9%. Graft and patient survival rates were significantly lower for recipients with (versus without) relaparotomy. The most common procedures were drainage of intra-abdominal abscess with graft necrosectomy (50% of all relaparotomies) and transplant pancreatectomy (34%). The most common causes of relaparotomy were intra- abdominal infection, vascular graft thrombosis, and anastomotic leak. Intra- abdominal infection occurred in 20% (SPK: 18%, PAK: 24%, PTA: 20% [p = NS]). The rate was significantly higher for living related donor (42%) versus cadaver donor (18%) recipients and for those with enteric-drained (39%) versus bladder-drained (18%) transplants. Graft and patient survival rates were significantly lower for recipients with (versus without) intraabdominal infection. Outcome was better after bacterial (versus fungal) infections. For SPK recipients, those not on dialysis before the transplant had significantly higher graft survival than those on dialysis. Vascular graft thrombosis occurred in 12% of all recipients. The rate was significantly higher for PAK (21%) than for PTA (10%) and SPK (9%) recipients. It was significantly lower for recipients of grafts with donor iliac Y-graft reconstruction (versus all other types of arterial reconstruction) and with right-sided (versus left- sided) graft placement. Of note, patient survival was not different for recipients with versus without vascular graft thrombosis. The incidence of anastomotic or duodenal stump leaks was 10%; of these recipients, 70% required relaparotomy. Patient and graft survival rates were no different for recipients with versus without leaks. Conclusions: Serious surgical complications occurred in 35% of pancreas recipients and had a significant impact on patient and graft survival. Based on multivariate risk factor analyses, we recommend the following: donors over 45 years and those dying of cerebrocardiovascular disease should not be used; recipients over 45 years and those with a history of cardiac disease should be considered for a kidney transplant alone (KTA); surgical technique for graft procurement, preparation, and implantation should be meticulous; right-sided implantation and arterial Y-graft reconstruction should be performed when possible, since they had the highest success rates; when complications require relaparotomy, the focus must switch from graft salvage to life preservation; and the threshold for pancreatectomy should be low. Diagnosis should be timely, and treatment and relaparotomy expeditious. These cornerstones of success should help decrease the risk of surgical complications and mortality after pancreas transplants.

Original languageEnglish (US)
Pages (from-to)128-144
Number of pages17
JournalJournal of the American College of Surgeons
Volume185
Issue number2
StatePublished - 1997
Externally publishedYes

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Pancreas Transplantation
Cyclosporine
Transplants
Pancreas
Graft Survival
Kidney
Intraabdominal Infections
Blood Vessels
Thrombosis
Tissue Donors
Anastomotic Leak
Pancreatectomy
Survival Rate
Living Donors
Cadaver
Dialysis

ASJC Scopus subject areas

  • Surgery

Cite this

The surgical risk of pancreas transplantation in the cyclosporine era : An overview. / Gruessner, Rainer W G; Sutherland, David E R; Troppmann, Christoph; Benedetti, Enrico; Hakim, Nadey; Dunn, David L.; Gruessner, Angelika C.

In: Journal of the American College of Surgeons, Vol. 185, No. 2, 1997, p. 128-144.

Research output: Contribution to journalArticle

Gruessner, RWG, Sutherland, DER, Troppmann, C, Benedetti, E, Hakim, N, Dunn, DL & Gruessner, AC 1997, 'The surgical risk of pancreas transplantation in the cyclosporine era: An overview', Journal of the American College of Surgeons, vol. 185, no. 2, pp. 128-144.
Gruessner RWG, Sutherland DER, Troppmann C, Benedetti E, Hakim N, Dunn DL et al. The surgical risk of pancreas transplantation in the cyclosporine era: An overview. Journal of the American College of Surgeons. 1997;185(2):128-144.
Gruessner, Rainer W G ; Sutherland, David E R ; Troppmann, Christoph ; Benedetti, Enrico ; Hakim, Nadey ; Dunn, David L. ; Gruessner, Angelika C. / The surgical risk of pancreas transplantation in the cyclosporine era : An overview. In: Journal of the American College of Surgeons. 1997 ; Vol. 185, No. 2. pp. 128-144.
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abstract = "Background: Pancreas transplants are still associated with the highest surgical complication rate of all routinely performed solid organ transplants. To date, the impact of serious surgical complications in the cyclosporine era on perioperative patient morbidity, graft and patient survival, and hospital costs has not been analyzed in detail. Study Design: We retrospectively studied surgical complications after 445 consecutive pancreas transplants (45{\%} simultaneous pancreas-kidney [SPK], 24{\%} pancreas after kidney [PAK], and 31{\%} pancreas transplant alone [PTA]). Of these, 80{\%} were primary transplants, 20{\%} were retransplants. Cadaver donors were used in 92{\%}, living related donors in 8{\%}. To develop guidelines for their prevention and management, we studied the impact of significant surgical complications (intraabdominal infections, vascular graft thrombosis, and anastomotic leak) requiring relaparotomy on graft and patient survival. Results: Relaparotomy was required after 32{\%} of all pancreas transplants (SPK: 36{\%}, PAK: 25{\%}, PTA: 16{\%} [p = 0.04]). Perioperative mortality was 9{\%}. Graft and patient survival rates were significantly lower for recipients with (versus without) relaparotomy. The most common procedures were drainage of intra-abdominal abscess with graft necrosectomy (50{\%} of all relaparotomies) and transplant pancreatectomy (34{\%}). The most common causes of relaparotomy were intra- abdominal infection, vascular graft thrombosis, and anastomotic leak. Intra- abdominal infection occurred in 20{\%} (SPK: 18{\%}, PAK: 24{\%}, PTA: 20{\%} [p = NS]). The rate was significantly higher for living related donor (42{\%}) versus cadaver donor (18{\%}) recipients and for those with enteric-drained (39{\%}) versus bladder-drained (18{\%}) transplants. Graft and patient survival rates were significantly lower for recipients with (versus without) intraabdominal infection. Outcome was better after bacterial (versus fungal) infections. For SPK recipients, those not on dialysis before the transplant had significantly higher graft survival than those on dialysis. Vascular graft thrombosis occurred in 12{\%} of all recipients. The rate was significantly higher for PAK (21{\%}) than for PTA (10{\%}) and SPK (9{\%}) recipients. It was significantly lower for recipients of grafts with donor iliac Y-graft reconstruction (versus all other types of arterial reconstruction) and with right-sided (versus left- sided) graft placement. Of note, patient survival was not different for recipients with versus without vascular graft thrombosis. The incidence of anastomotic or duodenal stump leaks was 10{\%}; of these recipients, 70{\%} required relaparotomy. Patient and graft survival rates were no different for recipients with versus without leaks. Conclusions: Serious surgical complications occurred in 35{\%} of pancreas recipients and had a significant impact on patient and graft survival. Based on multivariate risk factor analyses, we recommend the following: donors over 45 years and those dying of cerebrocardiovascular disease should not be used; recipients over 45 years and those with a history of cardiac disease should be considered for a kidney transplant alone (KTA); surgical technique for graft procurement, preparation, and implantation should be meticulous; right-sided implantation and arterial Y-graft reconstruction should be performed when possible, since they had the highest success rates; when complications require relaparotomy, the focus must switch from graft salvage to life preservation; and the threshold for pancreatectomy should be low. Diagnosis should be timely, and treatment and relaparotomy expeditious. These cornerstones of success should help decrease the risk of surgical complications and mortality after pancreas transplants.",
author = "Gruessner, {Rainer W G} and Sutherland, {David E R} and Christoph Troppmann and Enrico Benedetti and Nadey Hakim and Dunn, {David L.} and Gruessner, {Angelika C}",
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TY - JOUR

T1 - The surgical risk of pancreas transplantation in the cyclosporine era

T2 - An overview

AU - Gruessner, Rainer W G

AU - Sutherland, David E R

AU - Troppmann, Christoph

AU - Benedetti, Enrico

AU - Hakim, Nadey

AU - Dunn, David L.

AU - Gruessner, Angelika C

PY - 1997

Y1 - 1997

N2 - Background: Pancreas transplants are still associated with the highest surgical complication rate of all routinely performed solid organ transplants. To date, the impact of serious surgical complications in the cyclosporine era on perioperative patient morbidity, graft and patient survival, and hospital costs has not been analyzed in detail. Study Design: We retrospectively studied surgical complications after 445 consecutive pancreas transplants (45% simultaneous pancreas-kidney [SPK], 24% pancreas after kidney [PAK], and 31% pancreas transplant alone [PTA]). Of these, 80% were primary transplants, 20% were retransplants. Cadaver donors were used in 92%, living related donors in 8%. To develop guidelines for their prevention and management, we studied the impact of significant surgical complications (intraabdominal infections, vascular graft thrombosis, and anastomotic leak) requiring relaparotomy on graft and patient survival. Results: Relaparotomy was required after 32% of all pancreas transplants (SPK: 36%, PAK: 25%, PTA: 16% [p = 0.04]). Perioperative mortality was 9%. Graft and patient survival rates were significantly lower for recipients with (versus without) relaparotomy. The most common procedures were drainage of intra-abdominal abscess with graft necrosectomy (50% of all relaparotomies) and transplant pancreatectomy (34%). The most common causes of relaparotomy were intra- abdominal infection, vascular graft thrombosis, and anastomotic leak. Intra- abdominal infection occurred in 20% (SPK: 18%, PAK: 24%, PTA: 20% [p = NS]). The rate was significantly higher for living related donor (42%) versus cadaver donor (18%) recipients and for those with enteric-drained (39%) versus bladder-drained (18%) transplants. Graft and patient survival rates were significantly lower for recipients with (versus without) intraabdominal infection. Outcome was better after bacterial (versus fungal) infections. For SPK recipients, those not on dialysis before the transplant had significantly higher graft survival than those on dialysis. Vascular graft thrombosis occurred in 12% of all recipients. The rate was significantly higher for PAK (21%) than for PTA (10%) and SPK (9%) recipients. It was significantly lower for recipients of grafts with donor iliac Y-graft reconstruction (versus all other types of arterial reconstruction) and with right-sided (versus left- sided) graft placement. Of note, patient survival was not different for recipients with versus without vascular graft thrombosis. The incidence of anastomotic or duodenal stump leaks was 10%; of these recipients, 70% required relaparotomy. Patient and graft survival rates were no different for recipients with versus without leaks. Conclusions: Serious surgical complications occurred in 35% of pancreas recipients and had a significant impact on patient and graft survival. Based on multivariate risk factor analyses, we recommend the following: donors over 45 years and those dying of cerebrocardiovascular disease should not be used; recipients over 45 years and those with a history of cardiac disease should be considered for a kidney transplant alone (KTA); surgical technique for graft procurement, preparation, and implantation should be meticulous; right-sided implantation and arterial Y-graft reconstruction should be performed when possible, since they had the highest success rates; when complications require relaparotomy, the focus must switch from graft salvage to life preservation; and the threshold for pancreatectomy should be low. Diagnosis should be timely, and treatment and relaparotomy expeditious. These cornerstones of success should help decrease the risk of surgical complications and mortality after pancreas transplants.

AB - Background: Pancreas transplants are still associated with the highest surgical complication rate of all routinely performed solid organ transplants. To date, the impact of serious surgical complications in the cyclosporine era on perioperative patient morbidity, graft and patient survival, and hospital costs has not been analyzed in detail. Study Design: We retrospectively studied surgical complications after 445 consecutive pancreas transplants (45% simultaneous pancreas-kidney [SPK], 24% pancreas after kidney [PAK], and 31% pancreas transplant alone [PTA]). Of these, 80% were primary transplants, 20% were retransplants. Cadaver donors were used in 92%, living related donors in 8%. To develop guidelines for their prevention and management, we studied the impact of significant surgical complications (intraabdominal infections, vascular graft thrombosis, and anastomotic leak) requiring relaparotomy on graft and patient survival. Results: Relaparotomy was required after 32% of all pancreas transplants (SPK: 36%, PAK: 25%, PTA: 16% [p = 0.04]). Perioperative mortality was 9%. Graft and patient survival rates were significantly lower for recipients with (versus without) relaparotomy. The most common procedures were drainage of intra-abdominal abscess with graft necrosectomy (50% of all relaparotomies) and transplant pancreatectomy (34%). The most common causes of relaparotomy were intra- abdominal infection, vascular graft thrombosis, and anastomotic leak. Intra- abdominal infection occurred in 20% (SPK: 18%, PAK: 24%, PTA: 20% [p = NS]). The rate was significantly higher for living related donor (42%) versus cadaver donor (18%) recipients and for those with enteric-drained (39%) versus bladder-drained (18%) transplants. Graft and patient survival rates were significantly lower for recipients with (versus without) intraabdominal infection. Outcome was better after bacterial (versus fungal) infections. For SPK recipients, those not on dialysis before the transplant had significantly higher graft survival than those on dialysis. Vascular graft thrombosis occurred in 12% of all recipients. The rate was significantly higher for PAK (21%) than for PTA (10%) and SPK (9%) recipients. It was significantly lower for recipients of grafts with donor iliac Y-graft reconstruction (versus all other types of arterial reconstruction) and with right-sided (versus left- sided) graft placement. Of note, patient survival was not different for recipients with versus without vascular graft thrombosis. The incidence of anastomotic or duodenal stump leaks was 10%; of these recipients, 70% required relaparotomy. Patient and graft survival rates were no different for recipients with versus without leaks. Conclusions: Serious surgical complications occurred in 35% of pancreas recipients and had a significant impact on patient and graft survival. Based on multivariate risk factor analyses, we recommend the following: donors over 45 years and those dying of cerebrocardiovascular disease should not be used; recipients over 45 years and those with a history of cardiac disease should be considered for a kidney transplant alone (KTA); surgical technique for graft procurement, preparation, and implantation should be meticulous; right-sided implantation and arterial Y-graft reconstruction should be performed when possible, since they had the highest success rates; when complications require relaparotomy, the focus must switch from graft salvage to life preservation; and the threshold for pancreatectomy should be low. Diagnosis should be timely, and treatment and relaparotomy expeditious. These cornerstones of success should help decrease the risk of surgical complications and mortality after pancreas transplants.

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