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 01.02.2017 Rune Horneland Section for Transplant Surgery
Number/type of PTx in Norway 1983-2017
Pancreas-Tx per mill. population - 2014 Section for Transplant Surgery
PANCREAS-Tx Anatomy Technically demanding localisation The desired Insulinproducing β-cells only account for 1-2 % >95 % exocrine tissue
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
Pancreas-Tx in Norway: HISTORY Era I: 1983-1988 Era III: 1997-2012 Era II: 1988-1997 Era IV: 2012-2017 Era V: 2018-???
Utfordringer Short term: KOMPLIKASJONER Long term: REJEKSJONER
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
PTx in Norway 2006-2010 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
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 117 DD-PTx (2013-16) vs 167 DJ-PTx (1998-12): (..) 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
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
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
Komplikasjonspanorama med mikrodialysemonitorering 04.2015-06.2016 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 / 50 12 / 70 3 / 18 3 / 18 6 / 35 17 / 50 7 / 35 0 / 0 4 / 24 3 / 18 9 / 26 4 (out of 9) 4 (out of 9)
Endringerprotokoll 2016 Sopprofylaksegjeninnsettes: Ecalta 200mg ved perop. og 100 mg dag 1 Antikoagulasjon: Macrodex500ml før reperfusjon og dag 1 Section for Transplant Surgery
History: ANTICOAGULATION 1983-2012: Macrodex + ASA 500 ml Macrodex Day 0 + 1 + 3 + 5 ASA from day 6 2012-2016: Fragmin + ASA Heparin ca 30ie/kg peroperative Fragmin 5000-7500ie until day 7 ASA from day 7 2016 : Macrodex + Fragmin + ASA Heparin ca 30ie/kg peroperative 500 ml Macrodex Day 0 + 1 Fragmin 5000ie from day 0 until 6 wks biopsy ASA from day 3
Exokrine leakage: Stenting of the pancreatic duct
Challenges: Percutaneous intervention on venous thrombi (#69) 1 2 3 4 Section for Transplant Surgery
Risc factor analysis (2011-2013, 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 (1.00-1.00) 0.493 1.00 (1.00-.1.00) HLA -A+B mismatches - DR mismatches 0.038* 0.549 0.51 (0.27-0.96) 0.76 (0.31-1.87) 0.323 0.69 (0.34-1.43) - Patient death Recipient age 0.009* 1.21 (1.05-1.41) 0.066* 1.24 (0.99-1.56) Time on waiting list 0.008* 1.00 (1.00-1.00) 0.906 1.00 (1.00-1.01) HLA -A+B mismatches - DR mismatches 0.038* 0.211 0.33 (0.11-0.94) 0.36 (0.07-1.79) 0.437-0.51 (0.09-2.79) - 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 (1.01-1.36) 0.039* 1.30 (1.01-1.67) Donor age: - Continous var. - <50 vs > 50 - <45 vs > 45 - <40 vs > 40 0.028* 0.035* 0.005* 0.042* 1.04 (1.00-1.08) 3.41 (1.09-10.66) 4.16 (1.55-11.19) 2.61 (1.03-6.57) 0.021* 1.08 (1.01-1.14)
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
Spørsmål? Section for Transplant Surgery
Takk for oppmerksomheten! Ønsker dere ett fortsatt komplikasjonsfritt Samarbeidsmøte Section for Transplant Surgery