Surgical techniques for pancreas transplantation

Purpose of review: From the beginning, pancreas transplantation proved to be effective but was associated with high rates of surgical complications and technical failure. Duct management and venous drainage were soon identified as major issues. The purpose of this review is to examine recent surgical advances with special reference to their possible metabolic and immunologic implications. Recent findings: The new surgical techniques described in the period reviewed mainly address the issue of difficult vascular reconstruction possibly encountered with grafts from small pediatric donors or in patients with limited access to possible anastomotic sites. Portal-enteric drainage with retroperitoneal pancreas placement was also described. This technique facilitates arterial anastomosis using short Y grafts and improves graft accessibility for percutaneous biopsy. Systemic venous drainage (vs. portal) is associated with hyperinsulinemia, but the relevance of increased insulin concentrations on the metabolic pathways of transplanted patients is still unclear. The immunologic advantage of portal pancreas drainage on kidney rejection was not confirmed in a large UNOS survey. Other small studies, although not specifically designed to address this issue, do not highlight a clear immunologic benefit. Summary: Pancreas transplantation remains an unfinished procedure. Enteric drainage is currently predominant in simultaneous pancreas-kidney transplantation but bladder drainage remains largely used in solitary transplants. Portal drainage is as safe as systemic drainage, but there is still no convincing evidence that it is immunologically or metabolically convenient. Future research should better address these issues in the setting of standardized, prospective, randomized studies, possibly enrolling patients without irreversible diabetic complications.