Elective Allograft Pancreatectomy Prior to Pancreas Retransplantation?

Robert J. Stratta, MD

Disclosures

April 22, 2002

Question

Is there a role for elective allograft pancreatectomy prior to pancreas retransplantation in simultaneous kidney-pancreas (SKP) transplant recipients?

Ivonne Daly, MD

Response from Robert J. Stratta, MD

There may be a limited role for "elective" allograft pancreatectomy prior to pancreas retransplantation in SKP transplant recipients. In general, the incidence of allograft pancreatectomy is about 20% to 25%, but is largely dependent on the timing and cause of pancreas graft loss. The need for allograft pancreatectomy may be considered as an index of technical morbidity after pancreas transplantation. For pancreas grafts lost in the first 6 months after transplantation, the incidence of pancreatectomy is 75%. For pancreas grafts lost after 6 months, the incidence of pancreatectomy is 25%. Among all pancreas grafts lost, the overall incidence of pancreatectomy is over 50%.

The main causes of pancreas graft loss leading to pancreatectomy include thrombosis, rejection, infection, and pancreatitis. The incidence of pancreatectomy may be slightly higher with enteric vs bladder drainage of the exocrine secretions because of the higher risk of intra-abdominal infection with the former technique. The vast majority of pancreas grafts lost due to either thrombosis or infection result in pancreatectomy, whereas graft loss due to rejection or pancreatitis may not necessarily result in pancreatectomy. If graft loss is due to acute rejection (which is often associated with thrombosis), then pancreatectomy may be indicated. However, in SKP transplant recipients, this scenario is unusual in the absence of kidney rejection. If graft loss is due to chronic rejection, then pancreatectomy is usually not indicated in the absence of infection, bleeding, or an exocrine leak. Consequently, not only the timing and cause but also the tempo of the process leading to graft loss may play a role in the decision to perform pancreatectomy.

In general, however, if the patient does not appear to have a surgical indication for pancreatectomy, the decision can be made at the time of pancreas retransplantation. Another "indication" for pancreatectomy may be space considerations at the time of retransplantation, but again this judgment can be made at the time of retransplantation. Pancreas graft loss alone is not an indication for pancreatectomy in the absence of other signs or symptoms (ie, fevers, exocrine leak, unrelenting pancreatitis, pain, abscess, bleeding), so interval or elective pancreatectomy is not warranted in the absence of a specific clinical indication.

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