The Pancreas After Kidney Transplant is a Competitive Option, Comparable to the Simultaneous Pancreas and Kidney Transplant.

BACKGROUND: Simultaneous pancreas and kidney transplant (SPK) is the most common type of pancreas transplant performed worldwide. In contrast, there are a few drawbacks to pancreas after kidney transplant (PAK), such as the requirement for an additional operation, the immunologic risk, etc. SPK is the best option, but because of a lack of deceased donors and a lengthy waiting period, it is not always possible to use it. METHODS: From 2015 to 2022, we performed 23 SPKs and 21 PAKs at the Pusan National University Yangsan Hospital in Korea. We compared the findings of PAK and SPK conducted within the same time period. RESULTS: The waiting time for pancreatic graft was significantly shorter in the PAK than SPK group (345 days vs 1350 days, P ≤ .001). Throughout the monitoring period, just 1 pancreatic graft was lost in patients who underwent PAK, and the 7-year graft survival was 95%, with no statistically significant difference compared to SPK (90.3%, P = .600). Moreover, the graft survival of SPK or PAK was superior to that of pancreatic transplant alone (63.7%, P = .016). Only 1 pancreatic graft loss was a case of mortality with a functioning graft. No additional kidney transplant loss was observed in PAK recipients. There was no variation in creatinine levels between the pretransplant and posttransplant periods. There were 2 incidents of pancreatic graft and kidney graft rejection, respectively, but the grafts entirely recovered following rejection treatment. CONCLUSION: According to our experiences, PAK could be another best choice for individuals with diabetic end-stage renal disease, especially in cases where deceased donors were severely deficient but living donor kidney transplants were actively performed in countries like Korea.

Errate: Modification of Venous Outflow to Avoid Thrombotic Graft Failure in Pancreas Transplantation.

The authors asked for an errata to correct the affiliation information. The corrected affiliations are as follows:Je Ho Ryu1,2, Jae Ryong Shim1, Tae Beom Lee1, Kwang Ho Yang1, Taeun Kim3, Seo Rin Kim4, Byung Hyun Choi1,21 Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, South Korea2 Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea3 Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea4 Department of Internal medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine,  Yangsan, South KoreaThe change of affiliation does not affect the content or findings of the publication in any way. It is solely an update to the -authors' institutional affiliations.Reference:Je Ho Ryu, Jae Ryong Shim, Tae Beom Lee, Kwangho Yang, Taeun Kim, Seo Rin Kim, Byunghyun Choi. Modification of Venous Outflow to Avoid Thrombotic Graft Failure in Pancreas Transplantation. Ann Transplant. 2022; 27: e937514. DOI: 10.12659/AOT.937514.

Modification of Venous Outflow to Avoid Thrombotic Graft Failure in Pancreas Transplantation.

BACKGROUND Even with recent data, 5-10% of pancreas transplants experience early technical failure. Graft thrombosis is the primary cause of early technical failure, even when only optimal grafts are used, as is the case in Korea. The purpose of this study was to determine whether we can avoid thrombotic graft failure by modifying venous outflow. MATERIAL AND METHODS Between March 2017 and December 2021, a total of 59 pancreas transplantations were performed. Until May 2019, 31 cases of fence-angioplasty with cadaveric vena cava were performed to graft portal veins (the vena cava group). Since then, a total of 28 aortic interposition grafts have been performed to graft portal veins (the aortic group). RESULTS Between the 2 groups, there was no significant difference in baseline characteristics. Each group had 1 instance of technical failure. Early graft failure rates were 3.2% and 3.4%, respectively (P=1.000), while 1-year graft survival rates were 96.8% and 94.4%, respectively (P=0.991). Although a graft-threatening thrombosis occurred in the vena cava group, neither group experienced thrombotic graft failure, despite the decreased (vena cava group) or absence of heparin use (aorta group). CONCLUSIONS When the optimal graft is used, both techniques of modifying venous outflow can significantly reduce thrombotic graft failure.

Technical factors that minimize the occurrence of early graft failure in pancreas transplantation.

Pancreatic transplantation is the only treatment for insulin-dependent diabetes resulting in long-term euglycemia without exogenous insulin. However, pancreatic transplantation has become debatable following the improvements in the results of islet transplantation and artificial pancreas. Therefore, surgeons who perform pancreas transplants require the best surgical technique that can minimize technical failure. We aimed to report our experiences with pancreatic transplantations. We transplanted 65 pancreatic grafts between 2015 and 2020. Except for one death due to hypoxic brain damage after surgery, no postoperative technical failure was observed. We usually perform duodeno-duodenal anastomosis using the transperitoneal approach, with retrocolic placement of the graft pancreas. There was no leakage from the duodenum even after immunologic graft failure. To prevent venous thrombosis, which is the most common cause of technical failure, we used the inferior vena cava for anastomosis and added graft venoplasty with a patch of donor vena cava or aortic interposition graft to the bench procedure; subsequently, there were no cases of technical failure due to thrombosis post-transplantation. Therefore, the 1-year graft survival (insulin-free) rate was more than 95%. The improving the surgical technique will maintain pancreatic transplantation as the best treatment for insulin-dependent diabetes.

ABO-Incompatible Living Donor Liver Transplantation With a Simplified Desensitization and Immunosuppression Protocol: A Single-Center Retrospective Study.

OBJECTIVES: New desensitization strategies have made ABO-incompatible living donor liver transplant an attractive option for patients with end-stage liver disease. We aimed to report our experience with 20 consecutive patients who underwent ABO-incompatible living donor liver transplant using a simplified desensitization and immunosuppression regimen. MATERIALS AND METHODS: We retrospectively analyzed 20 ABO-incompatible living donor liver transplant cases (August 2015 to July 2019). The ABO-incompatible living donor liver transplant protocol involved rituximab administration (375 mg/m2 body surface area) at 2 to 3 weeks before transplant, subsequent plasma exchanges (target isoagglutinin titer of ≤1:8), basiliximab administration (20 mg on day of surgery and on postoperative day 4), and intravenous immunoglobulin administration (2 g/day from day of surgery to postoperative day 7). No graft local infusion therapy or splenectomy was performed. RESULTS: The living donor liver transplant procedure involved a modified rightlobe graft(18 patients), a right posterior segment graft (1 patient), or a left lobe (1 patient). The most common reason for liver transplant was hepatitis B virus-associated liver cirrhosis (16 patients); 14 patients had hepatocellular carcinoma. The mean age was 55.4 ± 6.3 years, mean Model End-stage LiverDisease score was 14.7 ± 7.7, and mean graft-to-recipient weight ratio was 1.07 ± 0.2%. The median initial anti-ABO antibody titers were 1:16 forimmunoglobulin M (range, 1:2 to 1:256) and 1:48 for immunoglobulin G (range, 1:4 to 1:>2048). The median number of plasma exchanges was 2 (range, 0-12). No patients had biopsy-confirmed antibody-mediated rejection. No bacterial or fungal infections were observed. Biliary anastomotic stricture was observed in 9 patients. CONCLUSION: This ABO-incompatible living donor liver transplant protocol with rituximab, plasma exchange, low-dose intravenous immunoglobulin, and immunosuppression (equivalent to ABO-compatible living donor liver transplant) could be a safe and effective way to overcome antibody-mediated rejection and other complications.

Successful defibrotide treatment of a patient with veno-occlusive disease after living-donor liver transplantation: A case report.

RATIONALE: Veno-occlusive disease (VOD) is characterized by painful hepatomegaly, ascites, weight gain, and jaundice with nonthrombotic, fibrous obliteration of the centrilobular hepatic veins. VOD after liver transplantation is a rare complication, with an incidence of approximately 2%; however, it can be life-threatening in severe cases. The precise etiology and mechanism of VOD after liver transplantation remains unclear. Acute cellular rejection, antibody-mediated rejection, and treatment with tacrolimus or azathioprine may be associated with the development of VOD after liver transplantation. Additionally, the optimal treatment of VOD after liver transplantation has not yet been established and focuses on supportive care. Defibrotide is an anti-ischemic and antithrombotic drug with no systemic anticoagulant effects. Moreover, only a few reports have investigated the use of defibrotide for VOD after liver transplantation, which has shown promising results. PATIENT CONCERNS: A 39-year-old woman with primary biliary cholangitis underwent living-donor liver transplantation at our center. She experienced right upper quadrant pain with increased ascites, pleural effusion, and weight gain on postoperative day 14. DIAGNOSES: Imaging and pathological tests showed no evidence of rejection or vessel complications. VOD was diagnosed clinically based on the findings of weight gain, ascites, jaundice, and pathological biopsy. INTERVENTIONS: Defibrotid, 25 mg/kg/day, was administered intravenously for 21 days. OUTCOMES: She showed complete clinical resolution of the VOD. LESSONS: Herein, we report a case of successful defibrotide treatment of VOD after living-donor liver transplantation.

Usefulness of Preoperative Magnetic Resonance Spectroscopy to Improve the Safety of a Living Liver Donor.

OBJECTIVES: The steatosis of graft liver is an important factor in liver transplant that determines the graft function in the recipient and the recovery of the remnant liver in the living donor. We analyzed the data of living donors from our center to evaluate whether magnetic resonance imaging and magnetic resonance spectroscopy can replace liver biopsy. MATERIALS AND METHODS: From May 2010 to May 2019, data from a total of 239 living donors was collected. There were 84 patients who had no magnetic resonance imaging or magnetic resonance spectroscopy data, and they were excluded. The result of preoperative liver biopsy was compared with preoperative magnetic resonance imaging and magnetic resonance spectroscopy data. The steatosis was defined by the degree of macrosteatosis. RESULTS: The magnetic resonance imaging of the fat fraction was a good parameter to predict fatty changes between normal and fatty liver groups (3.09 ± 3.38% for normal 7.48 ± 4.07% for fatty liver; P < .001). The magnetic resonance spectroscopy was also a good parameter to predict fatty changes between normal and fatty liver groups (2.09 ± 1.43% for normal and 6.89 ± 2.68% for fatty liver; P < .001). Linear regression showed that pathology results were significantly correlated with magnetic resonance spectroscopy (P < .001, R2 = 0.604) but not with magnetic resonance imaging (P < .001, R2 = 0.227). CONCLUSIONS: Magnetic resonance spectroscopy has several benefits for quantifying hepatic steatosis during a living donor liver transplant evaluation, including no radiation exposure, and a noninvasive procedure. Moreover, preoperative magnetic resonance spectroscopy can determine an anatomic variation of the bile duct, which helps improve the safety of the living donor. However, more clinical data and further studies are needed to ensure that preoperative magnetic resonance spectroscopy is essential.

Epidermoid cyst in an intrapancreatic accessory spleen in the pancreas head: a case report.

BACKGROUND: An epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS) in the pancreas head is an extremely rare condition. The natural course of this condition is not well known, and it is difficult to diagnose before surgery due to the lack of specific imaging findings. CASE PRESENTATION: A tumor was found in the head of the pancreas in a 68-year-old man with abdominal distension and discomfort. Magnetic resonance imaging (MRI) suggested a malignant tumor, such as a colloid cancer. The tumor was removed surgically, with pathologic examination showing that it was an ECIPAS. CONCLUSION: ECIPAS cannot be easily distinguished from other pancreatic cystic tumors, making it necessary to include ECIPAS in the differential diagnosis of these tumors. Unnecessary surgical resection may be avoided by more accurate preoperative diagnosis based on clinical and imaging characteristics.

Efficacy and Safety of Weight Reduction of the Donor in Hepatic Steatosis for Living Donor Liver Transplantation.

BACKGROUND Use of steatotic livers is a known risk factor for increased primary nonfunction after liver transplantation. This study investigated the efficacy and clinical outcome of simple weight reduction of steatosis for donors undergoing living-donor liver transplantation (LDLT). MATERIAL AND METHODS We defined two groups: the reduction group, which included donors with >30% macrovesicular steatosis and body mass index (BMI) >25 kg/m², and the conventional group, which included donors with.

Liver Transplant Patients with High Preoperative Serum Bilirubin Levels Are at Increased Risk of Postoperative Delirium: A Retrospective Study.

Postoperative delirium is a common complication after liver transplantation (LT). A high model for end-stage liver disease (MELD) score is an independent risk factor for postoperative delirium, but it is unclear which of the components of this score are risk indicators. The aim of this study was to analyze the incidence of postoperative delirium according to the preoperative serum bilirubin level, a component of the MELD score, in patients who underwent LT. The medical records of 325 patients who underwent LT from January 2010 to February 2019 at a single university hospital were retrospectively reviewed. The patients were divided into two groups: those who experienced postoperative delirium (Delirium group, n = 69) and those who did not (Control group, n = 256). Data on the patients' demographic characteristics, perioperative management, and postoperative complications were collected. Mean preoperative bilirubin level was higher in the Delirium group than in the Control group (p < 0.0001). In the Delirium group, 54 (78.26%) patients had preoperative bilirubin levels above 3.5 mg/dL. In the multivariate analysis, preoperative bilirubin above 3.5 mg/dL was associated with postoperative delirium (p = 0.002). Therefore, preoperative hyperbilirubinemia is an independent risk factor for postoperative delirium.

Eosinophil-to-monocyte ratio is an excellent predictor of acute cellular rejection in pancreas transplant alone recipients.

Serum pancreatic enzymes (serum amylase and lipase) are sensitive markers for monitoring acute rejection in pancreatic transplant recipients. However, those enzymes are not specific, as their levels are elevated in other conditions. We evaluated the eosinophil-to-monocyte ratio (EMR) in peripheral blood as a biomarker of acute rejection in the clinical setting in recipients of pancreatic transplant alone. We performed 32 cases of pancreatic transplantation alone since 2015. Nine patients were diagnosed with rejection. Serum amylase and lipase levels and eosinophil and monocytes counts were analyzed and compared retrospectively between the non-rejection and rejection groups. The serum eosinophil count, eosinophil fraction of the complete blood count, and serum amylase and lipase levels were significant predictors of rejection according to the receiver operation characteristic (ROC) curve. However, the EMR was the best indicator of rejection based on the ROC curve (area under the curve 0.918, sensitivity 100%, specificity 76.2% at the cutoff value 0.80, P < .001). The combination of EMR and the lipase level had 100% sensitivity and 90.5% specificity. The EMR is a simple and excellent predictor of acute rejection in recipients of pancreatic transplant alone.

Progression of diabetic nephropathy after successful pancreas transplantation alone: a case report.

Pancreas transplantation is the only method that can nearly cure insulin-dependent diabetes mellitus. However, the effect of pancreas transplantation on patients with diabetic nephropathy has recently been considered controversial. In this report, we present a case of abrupt aggravation of proteinuria after successful pancreas transplantation alone without evidence of calcineurin inhibitor (CNI) toxicity. A 22-year-old female patient with type I diabetes mellitus underwent pancreas transplantation alone. The patient already had retinopathy and mild proteinuria, which in this case, may mean diabetic nephropathy. Her glucose levels were managed within the normal range after successful pancreas transplantation. However, the amount of proteinuria fluctuated. Kidney needle biopsy was performed owing to severe elevation of proteinuria, 2 years after the transplantation. Electron microscopy revealed diabetic glomerulosclerosis without evidence of CNI toxicity. This case indicates that diabetic nephropathy can be aggravated after pancreas transplantation, despite well-managed glucose levels and absence of CNI toxicity.

Outcomes of liver resection in patients with colorectal liver metastases by laparoscopic or open surgery.

BACKGROUNDS/AIMS: Colorectal cancer is found with liver metastases about 20-25% due to characteristics of cancer itself. Approximately 20% of liver metastases are found to be resectable. The objective of this study was to evaluate short-term outcomes of patients who received liver resection with colorectal cancer operation in our center by laparoscopic surgery or open surgery. METHODS: Short-term outcomes of laparoscopic surgery of liver resection (LSLR) group who underwent liver resection for colorectal liver metastases (CRLM) at a single institute from 2013 to 2016 were compared to those of open surgery of liver resection (OSLR) group. RESULTS: A total of 123 patients underwent liver resection for CRLM, including 101 (82.1%) patients in the OSLR group and 22 (17.9%) patients in the LSLR group. There were significant differences in tumor characteristics between the two groups, including synchronous and metachronous (p=0.004), tumor number (p<0.001), and tumor margin (p=0.002). For postoperative outcomes, only the length of hospital stay (LOS) was significantly different between the two groups (8.5 days in LSLR vs. 11 days in OSLR, p<0.001). There was no significant difference in overall rate of postoperative complications between the two groups (9.1% in LSLR vs. 23.8% in OSLR, p=0.158). CONCLUSIONS: There are no significant differences in postoperative outcomes between LSLR and OSLR except LOS, liver metastasis number, and resection margin. LSLR may be favorable for highly selected patients with CRLM.

Two cases of bronchobiliary fistula: Case report.

A bronchobiliary fistula, or a biliobronchial fistula (BBF), is a rare condition. It results from an abnormal connection between the biliary and bronchial trees, and is characterized by pathognomonic bilious sputum with suspicious pneumonia. Traditionally, an infectious disease, such as a hydatid infection, has been known to cause a BBF, but BBFs have recently become associated with tumors. In every case, procedures and treatments differ between centers, from simple conservative management to invasive surgical procedures. This case report presents two patients who had BBF after liver resection. Symptoms of each patients were treated and controlled successfully by percutaneous transhepatic biliary drainage tube insertion. We hope that this report helps in the management of BBF in other cases.

A comparison of desensitization methods: Rituximab with/without plasmapheresis in ABO-incompatible living donor liver transplantation.

BACKGROUND: Plasmapheresis is a desensitization method used prior to ABO-incompatible (ABO-I) living donor liver transplantation. However, studies on its usefulness in the rituximab era are lacking. METHODS: Fifty-six adult patients underwent ABO-I living donor liver transplantation between January 2012 and October 2015. A single dose of rituximab (300 mg/m2) was administered 2 weeks before surgery with plasmapheresis in all patients until February 2014 (RP group, n = 26). Patients were administered rituximab only, without plasmapheresis between March 2014 and October 2015 (RO group, n = 30). RESULTS: The 6-, 12- and 18-month overall survival rates were 92.3%, 80.8% and 76.9% in the RP group and 96.6%, 85.4% and 85.4% in the RO group, respectively (P = 0.574). When the initial isoagglutinin titers < 16, neither group showed a rebound rise of isoagglutinin titers. For patients with initial isoagglutinin titers ≥ 16, the rebound rise of isoagglutinin titers was more prominent in the RP group. There was no difference in time-dependent changes in B cell subpopulations and ABO-I-related complications. CONCLUSIONS: Sufficient desensitization for ABO-I living donor liver transplantation can be achieved using rituximab alone. This desensitization strategy does not affect the isoagglutinin titers, ABO-I-related complications and patient survival.

Prognostic significance of 18F-FDG PET/CT in patients with colorectal cancer liver metastases after hepatectomy.

INTRODUCTION: Colorectal cancer liver metastasis (CRLM) can be cured with surgery. To improve survival, optimal selection of CRLM patients should be done cautiously, which may be facilitated by preoperative [F-18] fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). METHODS: A total of 245 patients with CRLM between February 2007 and January 2015 were retrospectively studied. All clinical variables, pathological data, and various PET/CT parameters were correlated with disease-free survival (DFS) and overall survival (OS). Metastatic tumor maximum standardized uptake value (SUVmax) and normal liver mean SUV (SUVmean) ratio was selected for group classification. RESULTS: The median DFS in months were 24.5 months and median OS were 41.7 months. Multivariate analysis found an increased risk of worse prognosis in DFS for primary colon cancer T3∼T4, N2 stage, neoadjuvant chemotherapy, synchronous metastasis, multiple metastatic tumor number and metastatic tumor SUVmax/normal liver SUVmean ratio >4.3. The DFS rate of each group classified by SUV ratio was 58.1%, 39.0%, and 33.6% vs. 39.3%, 20.8%, and 15.8% at 1, 3, and 5 years (p = 0.017). Patients with multiple tumors and SUV ratio of >4.3 showed worst survival (OS rate: 74.2%, 41.5%, and 24.2%, p = 0.001 at 1, 3, and 5 years, respectively). CONCLUSIONS: PET/CT variables can be a valuable prognostic factor in patients with CRLM for the prediction of recurrence. Preoperative PET/CT may improve risk stratification and optimize outcomes of patients with CRLM.

Are you prepared for pancreas bifidum? A case report.

Pancreas divisum-failure of fusion of the dorsal and ventral pancreatic ducts-is relatively well known as the most common congenital anomaly of the pancreatic duct, of with an incidence approximately 10% of all embryos. And there is a rare anomaly similar to pancreas divisum in which doubled ducts are formed. This condition is a rare developmental anomaly called pancreas bifidum or bifid pancreas or fish tail pancreas. This report describes a patient with pancreas bifidum who had 2 separated ducts within the pancreas from tail to neck but did not have a separated parenchyma. We hope that this report helps pancreatic surgeons to have knowledge of pancreas bifidum and helps them to be prepared for this anatomical variant.