Effect of donor pancreas extraction time on pancreas transplantation-a Swiss tertiary center experience.

We aimed to assess the effect of donor pancreas extraction time (ET) on postoperative complications and graft function after pancreas transplantation (PT). We analyzed all consecutive donor pancreas procurements for the simultaneous pancreas and kidney transplantation (SPK) and the associated PT in a Swiss transplant center over a 20-year period. Pancreas ET was defined as the time from cold flush to static storage of the pancreas on ice. The primary endpoint was the effect of extraction time on surgical complications. Secondary endpoints comprised the effect of ET on graft function (insulin-free survival) and graft pancreatitis. Of 115 procured pancreas grafts the median donor pancreas ET was 65 min (IQR: 48-78 min). In multivariable analysis, ET did not negatively affect major complications (OR 1.41 [95% CI: .59-3.36]; p = .438) and insulin-free survival (HR 1.42 [95% CI: .55-3.63]; p = .459). The median CIT was 522 (441-608) min. CIT was associated with major complications (OR 2.51 [95% CI: 1.11-5.68]; p = .027), but without impact on insulin-free survival (HR 1.94 [95% CI: .84-4.48]; p = .119). Patients with and without graft pancreatitis had no statistically significant differences in ET and CIT (p = .164 and p = .47, respectively). In multivariable analysis, Amylase levels > 270 U/L on postoperative day 1 were significantly associated with major complications (OR 3.61 [95% CI: 1.06-12.32]; p = .040). Our results suggest that although no effect of ET on complications and graft function after PT was found, shorter CIT and less graft pancreatitis can have a positive impact on surgical complications. Results could possibly be influenced by the exceptional quality of the pancreas donors, with short travel distances and preservation times in Switzerland.

Minimally invasive multivessel coronary bypass surgery: Angiographic patency data.

OBJECTIVE: Minimally invasive multivessel coronary artery bypass grafting (MIM CABG) has demonstrated its safety, effectiveness and high rate of reproducibility. However, minithoracotomy CABG is still rarely performed. In this study, we retrospectively analyze the CT-angiographic graft patency rates for the patients subjected to this operation. METHODS: A total of 245 patients were subjected to MIM CABG by a left minithoracotomy approach between 2014 and 2018. The left internal thoracic artery (LITA) harvesting, proximal, and distal anastomoses were performed under direct vision. The patients then underwent 128-slice computed tomography coronary angiography (CTA). The angiographic results were obtained for 127 (51.8%) patients (the follow-up period of 31.1 ± 7.8 months, from 15 to 45 months). Of the total patients, 204 (83.2%) were followed clinically during the time period from 12 to 56 months. RESULTS: Complete revascularization was performed for all the patients. The mean number of grafts was 2.6 ± 0.5. The perioperative mortality was 0.4% (1 patient). There were two conversions to sternotomy (0.8%), four reopenings for bleeding (1.6%), three myocardial infarctions (1.2%), and one stroke (0.4%). Twenty-two patients (9.0%) received transfusions. The long-term mortality was 4.4% (nine patients). Three patients (1.5%) suffered from a stroke during the follow-up period. For five patients (2.4%), repeat revascularization was necessary. For the examined patients, the overall graft patency rate was 89.8%, the LITA graft patency rate was 98.4%, the radial artery patency was 100%, and the saphenous vein graft patency was 84.0%. CONCLUSIONS: MIM CABG allows complete surgical revascularization with excellent clinical outcomes and promising angiographic graft patency rates.

Segmental clamp and distal perfusion technique for reducing myocardial ischemia during coronary onlay grafting on a beating heart.

We present a segmental clamp with distal perfusion technique to reduce myocardial ischemia during onlay grafting, on a beating heart. After a proximal coronary arteriotomy for 2-3 cm, the distal artery is perfused through a cannula, with femoral arterial blood (distal perfusion with external shunt). During proximal and distal coronary snare clamping with distal perfusion, onlay anastomosis is performed, from the heel toward the point of cannula insertion. We then move the proximal clamp to the onlay area and open the graft, to get early proximal coronary reperfusion. The arteriotomy is extended, and this procedure is repeated to achieve complete beating heart onlay anastomosis. We safely performed this procedure on the beating heart off-pump or on-pump in 95 patients with no perioperative myocardial infarction, no intraoperative hemodynamic deterioration, no 30-day mortality. This technique reduces regional myocardial ischemic and secures the safety for onlay grafting on the beating heart.

Incidence and Histologic Features of Transplant Graft Pancreatitis: A Single Center Experience.

OBJECTIVES: Pancreas transplant is an effective long-term treatment modality for complicated type 1 diabetes mellitus. However, allograft failure or severe concomitant rejection remain an obstacle to successful transplant outcome, occurring in approximately 21% of recipients within 1 year. Most histologic studies investigating the cause of pancreas transplant failure have concentrated on the presence and severity of acute and chronic cellular or vascular rejection. After vascular thrombosis, graft pancreatitis is the second most frequent complication after transplant. MATERIALS AND METHODS: We conducted a retrospective analysis, collecting information from a contemporaneously maintained database of patients after pancreas transplant. RESULTS: We identified 44 patients with rejected allografts from a database of 196 pancreas transplant patients (44/196, 22%). In these identified rejected allografts, 27 patients (61%) had histopathology reports containing 1 or more terms associated with pancreatitis, with the most common histologic finding was being fat necrosis (21/27, 83%), followed by inflammatory or neutrophil infiltrate (13/27, 48%). Sixteen of these patients (60%) had two 2 or more terms histology terms descriptive of pancreatitis records. Ten of the 44 rejected allografts, 10 patients had histologic evidence of vascular or cellular rejection. There was no significant difference in the proportions showing evidence of rejection between groups with (2/27 patients [26%]) and without (3/17 patients [18%]) descriptions of pancreatitis in their medical records (P = .70). When time from transplant to pancreatectomy was analyzed, a larger proportion of pancreatectomies occurred late for patients with descriptions of pancreatitis in their medical records versus patients without (17/26 [65%] vs 4/16 [25%]; P = .05). CONCLUSIONS: This case series demonstrates that 61% of rejected allografts over a span of 13 years at a single center had histologic features of graft pancreatitis, suggesting that pancreatitis may be a contributory mechanism to graft failure.

Five-year clinical outcome and patency rate of device-dependent venous grafts after clampless OPCAB with PAS-port automated proximal anastomosis: the PAPA Study.

OBJECTIVE: To evaluate long-term clinical performance and angiographic patency of automated proximal venous anastomoses following clampless coronary artery bypass (C-CAB). METHODS: Observational study in patients submitted for isolated C-CAB and at least one proximal aortosaphenous anastomosis performed with an automated connector (Cardica PAS-Port) including 152 consecutive patients (165 devices and 199 device-dependent distal anastomoses), with LVEF > 30% and saphenous vein diameter of 4-6 mm. Clinical follow-up was 96% complete (4101/4269 pt-months). Graft patency rate was assessed with 64-slice CT-scan or coronary angiography. Freedom from major adverse cardiac and cerebrovascular events (MACCE) was reported as actuarial probability with 95% confidence limits and venous graft patency as actual rate at every year interval. RESULTS: Early operative mortality was 1.9%; incidence of neurologic injury was zero. Freedom from MACCE was 92.7 ± 2.1 at one year and 85.2 ± 4.8 at five years. The actual patency rate of device-dependent venous grafts was 90%, 85%, 84%, 84%, and 93% for one-, two-, three-, four-, and five-year-old grafts, respectively. CONCLUSIONS: The device is a well-performing system for proximal anastomoses. The incidence of neurologic complications seems to be reduced with this clampless approach. The high patency rate is stable over time.

Imaging spectrum after pancreas transplantation with enteric drainage.

Since the introduction of pancreas transplantation more than 40 years ago, surgical techniques and immunosuppressive regiments have improved and both have contributed to increase the number and success rate of this procedure. However, graft survival corresponds to early diagnosis of organ-related complications. Thus, knowledge of the transplantation procedure and postoperative image anatomy are basic requirements for radiologists. In this article, we demonstrate the imaging spectrum of pancreas transplantation with enteric exocrine drainage.

Risk factors for and management of graft pancreatitis.

PURPOSE OF REVIEW: Systematic and detailed analysis of risk factors, pathophysiology, clinical manifestation, diagnosis and management of graft pancreatitis in its different forms, that is acute and chronic graft pancreatitis (A-GP and C-GP), and A-GP being further distinguished into: physiological (P-AGP), early (E-AGP) and late AP (L-AGP). RECENT FINDINGS: Graft pancreatitis is the second most-frequent complication following pancreas transplantation. P-AGP is an unavoidable entity related to ischemic reperfusion injury. It is usually clinically silent. It is a timely and prognostically self-limited process. E-AGP occurs within 3 months after pancreas transplantation (PTx) in 35% of cases and is associated with high rates of graft loss (78-91%). Clinical signs are pain, systemic inflammatory response (SIRS) and haematuria. Therapy can be medical, interventional and surgical. L-AGP occurs 3 months following PTx in 14-25% of cases and represents an uncommon cause of graft loss. Typical clinical signs are pain, abdominal tenderness and fever. Typical laboratory signs are hyperamylasaemia, hyperglycaemia and hypercreatininaemia. Therapy is usually conservative. C-GP is difficult to be distinguished from chronic rejection and is associated to graft loss in 4-10% of cases. Recurrent A-GPs and infections are the main risk factors. Specific symptoms are chronic abdominal malaise, constipation and recurrence of DM. Isolated hyperglycaemia is typical of C-GP. The therapy is usually conservative. SUMMARY: This systematic analysis of different manifestations of graft pancreatitis provides the basis for a clinical approach to tackling this complex entity.

Cyclosporin a, but not FK506, induces osmotic lysis of pancreas zymogen granules, intra-acinar enzyme release, and lysosome instability by activating K+ channel.

OBJECTIVES: The immunosuppressant tacrolimus (FK506) has improved pancreas allograft survival compared with cyclosporin A (CsA), possibly because of reduced acute pancreatitis following ischemia-reperfusion injury. Ion permeabilities in zymogen granule (ZG) membranes, including a KCNQ1 K channel, promote hormone-stimulated enzyme secretion. We investigated whether a differential modulation of ZG and lysosomal ion permeabilities and enzyme secretion by CsA/FK506 contributes to pancreatitis. METHODS: Rat ZGs and lysosomes were isolated by gradient centrifugation, ion permeabilities assayed by osmotic lysis, and single-channel currents recorded in a planar lipid bilayer. Amylase release was measured in permeabilized acini and lysosomal cathepsin B release detected by immunoblotting. RESULTS: CsA (1-10 µM), but not FK506, enhanced ZGs osmotic lysis by selectively increasing K permeability up to 5-fold. Zymogen granule membrane K channels showed ∼2-fold increased single-channel open probability with CsA only. Cyclosporin A selectively increased basal (∼2-fold), but not cholecystokinin-octapeptide (1 nM)-induced amylase secretion in K medium only. Cyclosporin A (5 µM), but not FK506, increased cathepsin B release from lysosomes. CONCLUSIONS: Cyclosporin A selectively opens the ZG K channel and induces cathepsin B release from lysosomes, which cause increased in situ lysis of ZGs and may aggravate or fuel acute allograft pancreatitis following hypoxia-reperfusion injury.

Hyaluronidase treatment of graft pancreatitis in rats: marked effects on the blood perfusion of the transplanted pancreas.

Hyaluronan is known to accumulate in tissues during inflammatory diseases associated with graft implantation and rejection of organ allografts. The aim was to evaluate whether hyaluronidase treatment affected hyaluronan content and blood perfusion in graft pancreatitis. Syngeneic rat pancreatic-duodenal transplantations were performed. Two days later blood flow measurements were made with a microsphere technique in both grafted and endogenous pancreas in animals treated with daily injections of vehicle or hyaluronidase (20.000 U/kg). Non-transplanted rats served as controls. Also, samples for analysis of hyaluronan and water content were taken. The hyaluronan content of the pancreatic graft was increased after transplantation. Hyaluronidase treatment markedly reduced total pancreatic and islet blood flow in both grafted and endogenous pancreas, whereas duodenum blood flow was unaffected. No blood flow effects were seen in non-transplanted control rats. Hyaluronan content was increased in the grafted pancreas, but hyaluronidase treatment decreased it to levels comparable to those of the endogenous gland. There were no differences in hyaluronan content in the endogenous pancreases of transplanted and non-transplanted rats. Graft pancreatitis after rat pancreas transplantation is associated with an increased hyaluronan content, which can be reduced by treatment with hyaluronidase. Hyaluronidase treatment of the graft recipients effected a 50% reduction in total pancreatic and islet blood flow in the graft, as well as in the endogenous pancreas. The functional importance of this is at present unknown.

Acute pancreatic graft fistula and peripancreatic fluid collection: demonstration by secretin-stimulated MRI.

Peripancreatic fluid collections are among the common post pancreas transplant complications, which are mainly due to leakage from the anastomosis site to bowel and graft pancreatitis. Differentiation between these two entities is important because they are treated differently. In this case, secretin stimulated magnetic resonance cholangiopancreatography revealed gradual intraperitoneal fluid collection and accumulation of fluid in small bowel excluded leakage from the anastomosis of the pancreas to bowel and changed the management from surgery to medical treatment.