Pancreaticoduodenal transplantation in humans

Abstract

Whole cadaveric pancreata were transplanted to the pelvic extraperitoneal location in four patients with diabetes who previously had undergone successful cadaveric renal transplantation. One graft was lost within a few hours from venous thrombosis but with patient survival. The other three are providing normal endocrine function after two and a half, 11 and 12 months. The exocrine pancreatic secretions were drained into the recipient jejunum through enteric anastomoses. Because mucosal slough of the graft duodenum and jejunum in two patients caused a protein losing enteropathy and necessitated reoperations, we now do the pancreatic transplantation with only a blister of graft duodenum large enough for side-to-side enteroenterostomy. The spleen has been transplanted with the pancreas mainly for technical reasons, and this technique should have further trials in spite of the fact that delayed graft splenectomy became necessary in two recipients to treat graft induced hematologic complications.

FIG. 1

Composite graft removed from donors in preparation for pancreaticoduodenal transplantation. The long jejunal segment was kept in Patients 1 and 2 but removed at the backtable along with the distal part of the duodenum in Patients 3 and 4. The spleen was retained in all except Patient 3.

FIG. 2

Technique of implantation into the left side used in Patient 1. The graft jejunum which provided an exit for the pancreatic exocrine secretions became a major source of morbidity, and eventually, it was removed (Fig. 3.).

FIG. 3

Operative revisions in Patient 1. a, The entire specimen shown in Figure 1 was transplanted. b, Splenectomy was performed after six and one-half days. c, The graft jejunum was detached from its anastomosis to recipient jejunum and brought to the skin of the left lower quadrant. d, The graft jejunum and distal part of the duodenum were resected and a “bubble” of duodenum retained for anastomosis to the recipient jejunum. (See text for details).

FIG. 4

Pancreaticoduodenal and splenic transplantation to the right side of the pelvis in Patient 4. Note that all of the jejunum and most of the duodenum were removed, leaving a short segment of duodenum closed at both ends which was anastomosed side-to-side to the recipient jejunum.

FIG. 5

The most recent glucose tolerance tests of the three patients with functioning grafts, performed after an overnight fast as recommended by the Diabetes Data Group (28), using an glucose challenge of 75 grams taken orally. Impaired glucose tolerance is defined as two-hour plasma glucose values between 140 and 200 milligrams per cent with an intervening value above 200 milligrams per cent. Fasting plasma glucose values exceeding 140 milligrams per cent or two-hour plasma glucose values above 200 milligrams per cent accompanied by an intervening value above 200 milligrams per cent are diagnostic of diabetes mellitus. All tests are within normal limits by these definitions.