PancreasTx i Norge -Kirurgiske komplikasjoner

Transkript

1 PancreasTx i Norge -Kirurgiske komplikasjoner PancreasTx har en potensiell stor oppside, men prosedyren er befengt med en høy komplikasjonsrate. Rundt 8-10% taper graftet i perioperative komplikasjoner. Samarbeidsmøtet Rune Horneland Section for Transplant Surgery

2 Number/type of PTx in Norway

3 Pancreas-Tx per mill. population Section for Transplant Surgery

4 PANCREAS-Tx Anatomy Technically demanding localisation The desired Insulinproducing β-cells only account for 1-2 % >95 % exocrine tissue

5 Surgical technique: Transplantation Simultaneous Pancreas + Kidney Tx (SPK) Entero-anastomosis: Tx-duodenum Jejunum Tx-Kidney anastomoses: External Iliac Vein/Artery Urinary bladder Systemic venous anastomosis: Portal Vein Vena Cava Arterial anastomosis: Coeliac Trunk + Sup Mes Art Common Iliac Art dxt

6 Pancreas-Tx in Norway: HISTORY Era I: Era III: Era II: Era IV: Era V: 2018-???

7 Utfordringer Short term: KOMPLIKASJONER Long term: REJEKSJONER

8 Typiske komplikasjoner Blødning / Trombose Hb / BT / Dren / BS / Mikrodialyse / Smerter / Ul / CT Infeksjon / Abscess / Tarmlekkasje Eksokrin lekkasje / peripancreatisk væske Ileus / Tarmparalyse Sårruptur / Sårinfeksjon Hydronefrose (Rejeksjon) Mors

9 PTx in Norway Overall results (n=61) Reoperation (within 30 d) 18 patients (30%) 35 reoperations Rejection 18 (29,5%) Patient Survival (SPK) 1y: 94,9% 3y: 91,5% Pancreas Survival (SPK) 1y: 83,1% 3y: 81,4% Kidney Survival (SPK) 1y: 94,9% 3y: 91,5% Section for Transplant Surgery

10 Outcomes in Pancreas Transplantation Alone versus Simultaneous Pancreas and Kidney Transplantation with Exocrine Drainage through a Duodenoduodenostomy Lindahl JP. Horneland R. et al. AJT DD-PTx ( ) vs 167 DJ-PTx ( ): (..) Postoperative bleeding and vein thrombosis requiring relaparotomy occurred in 18% and 9% of DD- PTx respectively, versus 10% (p=0,039) and 6% (p=0,28) in DJ-PTx ( ) Section for Transplant Surgery

11 Outcomes in Pancreas Transplantation Alone versus Simultaneous Pancreas and Kidney Transplantation with Exocrine Drainage through a Duodenoduodenostomy Lindahl JP. Horneland R. et al. AJT 2017 Variable (Pancreas graft-related complications in the first three months posttransplant) DD a technique (n=117) DJ b technique (n=167) DD technique vs DJ technique Patients with reoperation c, n (%) 39 (33%) 53 (32%) p=0.78 Complications leading to reoperation: Bleeding 21 (18%) 16 (10%) p=0.039 Graft vein thrombosis 11 (9%) 10 (6%) p=0.28 Infection 6 (5%) 15 (9%) p=0.22 Anastomotic leak 6 (5%) 7 (4%) p=0.71 Other d 18 (15%) 25 (15%) p=0.92 Patients with wound infection 36 (31%) 44(26%) p=0.42 Pancreas graft loss, n (%) 12 (10%) 13 (8%) p=0.47 Section for Transplant Surgery

12 Outcomes in Pancreas Transplantation Alone versus Simultaneous Pancreas and Kidney Transplantation with Exocrine Drainage through a Duodenoduodenostomy Lindahl JP. Horneland R. et al. AJT 2017 (..)14 PTA DD and 6 SPK DD transplants of a total of 26 DD-PTx (77%) pancreas graft losses occurred during the first yearafter transplantation( ) (..)Pancreas graft rejectionwas the single most commonly observed cause of graft loss, followed by pancreas graft vein thrombosis( ) (..)Graft loss by rejection was the only statistically different causeof graft loss between the two groups( ) Section for Transplant Surgery

13 Komplikasjonspanorama med mikrodialysemonitorering Total number n=34 Absolute number / % Pancreas Transplantation Alone (PTA) - Events (total) - Leakage - Haemorrhage - Thrombosis* Simultaneous Pancreas-Kidney (SPK) - Events (total) - Leakage - Haemorrhage - Thrombosis* Re-laparotomies *Successful percutaneous extraction of thrombosis *Thrombosis resulting in graftectomy 17 / / 70 3 / 18 3 / 18 6 / / 50 7 / 35 0 / 0 4 / 24 3 / 18 9 / 26 4 (out of 9) 4 (out of 9)

14 Endringerprotokoll 2016 Sopprofylaksegjeninnsettes: Ecalta 200mg ved perop. og 100 mg dag 1 Antikoagulasjon: Macrodex500ml før reperfusjon og dag 1 Section for Transplant Surgery

15 History: ANTICOAGULATION : Macrodex + ASA 500 ml Macrodex Day ASA from day : Fragmin + ASA Heparin ca 30ie/kg peroperative Fragmin ie until day 7 ASA from day : Macrodex + Fragmin + ASA Heparin ca 30ie/kg peroperative 500 ml Macrodex Day Fragmin 5000ie from day 0 until 6 wks biopsy ASA from day 3

16 Exokrine leakage: Stenting of the pancreatic duct

17 Challenges: Percutaneous intervention on venous thrombi (#69) Section for Transplant Surgery

18 Risc factor analysis ( , n=80) Horneland et al AJT 2015 Cox regression Dependent var.: Pancreas graft loss Independent covar. w/ statistical significance at p < 0.15 included p Univariate analysis Hazard Ratio (95% CI) p Multivariate analysis Hazard Ratio (95% CI) Time on waiting list 0.007* 1.00 ( ) ( ) HLA -A+B mismatches - DR mismatches 0.038* ( ) 0.76 ( ) ( ) - Patient death Recipient age 0.009* 1.21 ( ) 0.066* 1.24 ( ) Time on waiting list 0.008* 1.00 ( ) ( ) HLA -A+B mismatches - DR mismatches 0.038* ( ) 0.36 ( ) ( ) - Binary logistic Regression Dependent var.: Reoperation Per patient; (one or more reop.) Independent variables w/ statistical significance at p < 0.15 included p Univariate analysis Odds Ratio (95% CI) p Multivariate analysis Odds Ratio (95% CI) Recipient BMI 0.040* 1.17 ( ) 0.039* 1.30 ( ) Donor age: - Continous var. - <50 vs > 50 - <45 vs > 45 - <40 vs > * 0.035* 0.005* 0.042* 1.04 ( ) 3.41 ( ) 4.16 ( ) 2.61 ( ) 0.021* 1.08 ( )

19 Donorseleksjon 19 Alder <55, helst under 45. I praksis ingen nedre aldersgrense Normal HbA1c Ingen historie på pankreatitt/sykdom i pancreas BMI <30 Komorbiditet bør unngås, spesielt uttalt aterosklerose og nyresvikt Endelig godkjenning av graftet gjøres peroperativt

20 Spørsmål? Section for Transplant Surgery

21 Takk for oppmerksomheten! Ønsker dere ett fortsatt komplikasjonsfritt Samarbeidsmøte Section for Transplant Surgery