after cardiac death (DCD) remains relatively limited (only 1.5% of all pancreas transplants in 2011),

outcomes have been good with careful donor selection.50,59,60 Laboratory values, including serum

amylase and lipase, play a relatively minor role in donor selection. Insulin administration is generally

not considered a contraindication to pancreas donation. While the presence of donor hyperglycemia may

raise concerns about latent diabetes, in most donors this reflects the rapid administration of dextrosecontaining solutions, corticosteroids for cerebral edema, and high-dose catecholamines for blood

pressure support rather than latent pancreatic endocrine insufficiency. Abnormal HbA1C has been

utilized as a relative contraindication, but is not well studied and is not uniformly available for use.

Evidence of injury to other organs such as liver and kidneys, as a marker of abdominal ischemia, while

not ordinarily a contraindication, may be considered in marginal cases.

Donors with a history of type 2 diabetes, excessive alcohol use or pancreatitis may be used. A history

of cardiovascular disease or cardiac risk factors are also not contraindications but may influence

decision making or be associated with mesenteric atherosclerotic disease. A social history which

suggests an increased risk of transmission of hepatitis or HIV should be evaluated, as with other organs,

in the context of the degree of perceived risk relative to the benefit of the transplant.

Intraoperative evaluation of the donor organ is said to be the most important determinant of donor

selection. Evidence of inflammation or fibrosis, which may manifest as focal or diffuse firmness to

palpation, is considered to be a contraindication. Fatty infiltration of the pancreas, trauma and

pancreatic edema are also adverse findings, although the latter may be correctable with donor

management. Traumatic injury to the pancreas or hematoma within the substance of the pancreas would

preclude transplantation. However, a prior splenectomy is not a contraindication, provided that the tail

can be dissected atraumatically.

Factors not intrinsic to the donor may bear on the decision to perform a transplant. The higher risk of

graft failure associated with solitary pancreas transplants leads some centers to have more stringent

selection criteria for PTA and PAK. While cold ischemia is a risk factor for graft survival, pancreata

from selected donors can be transplanted with cold ischemic times approaching 24 hours with good

outcomes. Attention to HLA matching varies widely by center; the many analyses performed suggest

that any relationships between matching and graft outcome that may exist are not likely to be very

significant.56,58,61

As for deceased donor livers and kidneys, a Donor Risk Index for pancreas has been described.53 The

pancreas DRI (PDRI) is based on 10 factors demonstrated to have significant impact on pancreas

transplant outcomes. These include age, gender, race (black or Asian), BMI, height, CVA as cause of

death, cold ischemia time, DCD, and terminal creatinine greater than 2.5 (Table 40-1). There is great

variation in outcome by PDRI: the difference in graft survival at 1 year between the lowest 20% of

PDRI (best outcomes) and the highest 20% is about 11% for SPK transplants and 16% to 17% for

solitary transplants (Table 40-2). In addition to predicting outcomes for individual patients, indices like

the PDRI are useful in assessing trends in pancreas utilization, which is quite variable by geography and

by transplant center.53

Procurement Technique

The importance of the pancreatic procurement cannot be overstated. It is thought by many pancreas

transplant surgeons to be more critical to the success of the transplant than the recipient procedure.

Because the pancreas is susceptible to traumatic injury, it must be carefully dissected and manipulated

to avoid injury to the pancreatic parenchyma. Typically the pancreas is procured along with the liver

and kidneys. This is performed in standard fashion through a midline incision which extends from the

sternal notch to the pubic symphysis. After a generous Kocher maneuver, mobilization of the right

colon, and isolation of the distal and supraceliac aorta to prepare these vessels for clamping, the

pancreas is mobilized. This is most commonly achieved by entering the lesser sac, dividing the

gastrocolic omentum. This dissection continues with division of the short gastric vessels and the

avascular gastrosplenic ligament. The pancreas is dissected from the pancreatic bed using the spleen as a

handle. The tail is lifted from the pancreatic bed using blunt dissection and the occasional use of

electrocautery. The proximal jejunum is dissected at the ligament of Treitz. An antibiotic and/or

betadine containing solution are frequently instilled into the duodenum through a nasogastric tube for

decontamination. The duodenum is divided both at the ligament of Treitz and at the pylorus using a

stapler. Division of the middle colic vessels permits exposure of the proximal small bowel mesentery,

which is divided distal to the pancreas with a vascular stapler. The mobilization of the pancreas may be

performed either prior to or following the aortic perfusion procedure described below.

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Perfusion of the pancreas is generally achieved through an intra-arterial cannula placed in the distal

aorta following clamping of the supraceliac aorta and the aortic bifurcation. This is typically achieved

with approximately 3 L of University of Wisconsin or HTK (histidine–tryptophan–ketoglutarate)

solution while the entire abdominal organs are packed in saline slush. Preservation solutions are

generally regarded to be equivalent, although a few studies suggest slightly worse outcomes with

HTK.58,62,63 Some centers will also perfuse the abdominal viscera with a portal perfusion cannula,

typically through the inferior mesenteric vein, although some surgeons maintain that overperfusion of

either the arterial or the venous circulation may result in pancreatic edema and an increased risk of

complications.

Table 40-1 Summary of Pancreas DRI

Table 40-2 Results: Unadjusted 1-year Pancreas Allograft Survival by DRI and

Transplant Type

The pancreas can be removed either en bloc with the liver and kidneys, en bloc with the liver, or

separately, following removal of the liver. Whatever the technique, the portal triad is dissected out in

cooperation with the liver procurement team. Typically the portal vein is shared by dividing it at the

level of the coronary vein. Only in the rarest of circumstances should there be any difficulty using both

the liver and the pancreas from the same donor even in the presence of hepatic arterial anomalies. In

the presence of a replaced right hepatic artery, the superior mesenteric artery (SMA) can be divided just

distal to the replaced right hepatic artery, leaving a very short cuff of SMA on the pancreas.

Alternatively, the replaced right hepatic artery, if large enough to be safely reconstructed by the liver

transplant team without a cuff of SMA, can be transected as it exists superiorly from behind the head of

the pancreas. This is also true in the rare case where a completely replaced hepatic artery emerges from

the superior aspect of the head of the pancreas; usually the artery in this case is long enough and large

enough to be used for liver transplant without a celiac axis or aortic cuff. The bile duct and

gastroduodenal artery are ligated on the pancreas side and divided on the liver side. Dissection then

proceeds along the superior aspect of the pancreas along the proper hepatic artery. The splenic artery,

which constitutes the other arterial blood supply to the pancreas, is divided a few millimeters from its

origin to allow for adequate length on the pancreas while allowing the stump to be oversewn without

compromising flow to the liver. Once the pancreas is removed or split from the liver, the pancreas is

packed in preservation solution; the entire common iliac artery and its two main branches, the internal

and external iliac arteries, are packaged along with the pancreas for back-table reconstruction. A graft

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of donor iliac vein is also included in case the portal vein needs to be extended, which is done by some

surgeons. Although most centers transplant the pancreas as soon as possible, up to 24 hours of cold

ischemia time (time between perfusate infusion and organ reperfusion) has not been associated with

reduced graft survival in carefully selected donors.53,56

Back-Table Preparation of the Pancreas

The pancreas is placed on ice and remains cold at all times on the back table. The spleen is removed by

dividing all vessels near the spleen, either by ligature or stapling, taking care to avoid injury to the tail

of the pancreas which should be clearly identified. Some surgeons elect to wait until reperfusion of the

pancreas in the recipient to remove the spleen. Significant peripancreatic fat, if left on at the time of

procurement, should be trimmed. Both ends of the distal duodenum are shortened to the point where

they are immediately adjacent to the head of the pancreas. Both stapled ends of the duodenum may be

oversewn with silk or polypropylene sutures. Some surgeons elect to reinforce the mesenteric staple line

by oversewing with polypropylene suture. The iliac artery Y-graft is typically attached by anastomosis

of the internal iliac artery to the splenic artery and anastomosis of the externally iliac artery to the SMA

(Fig. 40-4). In the absence of a Y-graft, the splenic artery may be implanted in end-to-side fashion to the

SMA. The portal vein is mobilized by freeing from surrounding adventitial tissue to the confluence of

the splenic vein and superior mesenteric vein. This should allow an adequate length of portal vein for

anastomosis, as only 1 to 2 cm of portal vein length is generally needed.

Figure 40-4. Simultaneous pancreas–kidney transplantation performed with drainage of the pancreatic exocrine secretions into the

proximal jejunum (enteric drainage). This technique has been adopted by most transplant centers in the United States for

simultaneous pancreas–kidney transplants. For solitary pancreas transplantation, some centers still utilize bladder drainage to

allow monitoring of the urinary amylase. Note that the donor portal vein drains into the recipient superior mesenteric vein (portal

venous drainage), preventing peripheral hyperinsulinemia. Many centers continue to place the pancreas in the pelvis, combining

enteric drainage and systemic venous drainage. This placement requires enteric anastomosis to a more distal segment of jejunum

or ileum.

Recipient Operation

The pancreas transplant is typically performed through a midline incision, although a lower quadrant

incision similar to a kidney transplant incision may be used. The recipient should receive broad

spectrum antibiotics preoperatively. The pancreas transplant, for systemic venous drainage, is placed in

the iliac fossa, preferably on the right side. After dissection of the recipient artery and vein, the portal

vein is anastomosed in end-to-side fashion to the systemic vein. The distal inferior vena cava, common

iliac vein, or external iliac vein may be used; the recipient vein segment should be mobile enough for

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