Perioperative management of isolated pancreas and simultaneous pancreas kidney transplantation

Question 1

Indications for isolated pancreatic transplantation

Answer 1

Type One or Two Diabetes with…
- A history of severe and frequent metabolic complications
- Problems with exogenous insulin therapy that are incapacitating
- Consistent failure of insulin-based management to prevent acute complications
Chronic pancreatitis
Malignancy requiring pancreatectomy

Question 2

Pre-assessment of patients having pancreas transplantation

Answer 2

Mainly focussed on assessing end-organ damage due to hyperglycaemia
- Hba1c
- Functional exercise testing
- Evidence of peripheral vascular disease
- 12-lead ECG and lying/ standing BP- if autonomic neuropathy high risk of intraop hypotension
- Consider coronary angiography
- Check Hb and Iron studies- IV Iron good in this cohort
- Renal function
- If on dialysis- time of the last dialysis, pass urine, fistula etc

Question 3

Physiological changes associated with poorly controlled diabetes

Answer 3

Airway- often stiff neck, obesity
Resp- microangiopathy of blood vessels and changes in collagen leading to reduced lung compliance, decreased cough sensitivity and risk of respiratory infections
Cardiovascular- autonomic neuropathy- orthostatic hypotension and bradycardia, myocardial ischaemia secondary to atheroma
Haem- Anaemia secondary to CKD
Renal- CKD

Question 4

Pancreatic transplant surgical technique

Answer 4

Intraperitoneal- donor duodenum anastomosed on to jejunum or distal ileum
Extraperitoneal- placement in the right iliac fossa with donor duodenum anastomosed to bladder for drainage
If pancreas and kidney transplant pancreas is done first as cold ischaemia time is 12 hrs pancreas 24 hrs kidney

Question 5

Intraoperative Considerations for Pancreatic Transplant

Answer 5

Monitoring
- Standard
- Art line
- Maybe CVP if vasopressors likely

Induction and Maintenance
- Consider RSI if gastroparesis
- Possibly volatiles are better than TIVA as alleviating ischaemia-reperfusion injury
- Avoid sux if hyperkalaemic

Pain
- Paracetamol
- Regional- ESP, rectus sheath, quad lumborum, TAP
- Low dose opioids

Fluids
- Aim normovolaemia
- Aim MAP >70 throughout
- Mannitol or furosemide is sometimes given before reperfusion

Glucose Regulation
- VRII pre-op
- Turn off when donor pancreas re-perfused
- Often need to check glucose every 5-15mins after this until normoglycemia

Question 6

Post-operative Considerations for Pancreatic Transplant

Answer 6

Anticoagulation
- Often combination of LMWH and anti-platelet to reduce risk of early thrombosis

Analgesia
- Multimodal
- Consider nerve catheters
- Avoid large dose opioids

Glucose management
- Often tricky as patients are started on steroids for anti-rejection
- Very close monitoring, usually replace insulin as required
- Persistent hyperglycaemia/ increase in exogenous insulin demand is a sign of graft failure

Question 7

Early complications following pancreatic transplant

Answer 7

• Acute rejection- treat with high dose steroids, plasmapheresis and rituximab
• Graft thrombosis
• Pancreatitis
• Pancreatic fistula
• Graft infection
• Bleeding