Portal v. sytemic drainage of solitary pancreas transplantation: new views on old concepts

M. Cooper, J. Scalea, R. Barth, S. Fayek, J. Bromberg, B. Philosophe, S. Bartlett
University of Maryland School of Medicine, Surgery, Baltimore, USA

Objective: Venous outflow in pancreas transplantation may be via the systemic (SV) or portal (PV) circulation. Initial reports from our institution demonstrated improved graft survival via PV thought due, in part, to decreased incidence of acute rejection. As technical and immunologic improvements have been made over last decade, a review of outcomes between these methods was necessary.

Methods: A retrospective analysis was undertaken to evaluate various outcome variables for patients that underwent pancreas transplantation over the last 10 years (2000-2010). Cox regression and student’s t-test was used to determine significance.

Results: Sixty-five patients were evaluated. 18 patients underwent systemic drainage; 15 via iliac vein, 3 via IVC, and 47 underwent portal drainage via the SMV. 11/18 patients that underwent SV had a prior transplant (pancreas or kidney). Overall mean recipient age was 46.7 yr, mean donor age was 24.1 yr, mean BMI at transplant was 26.1 kg/m² and 53.8% were women without statistical differences between groups. CIT (mean 19.4 hrs) and degree of HLA mismatch was also similar between groups. All patients received Thymoglobulin induction and equivalent maintenance IS. Overall one-year graft survival for patients was 89.4%; four patients (4PV) lost grafts due to early acute rejection, and 5 grafts (4PV, 1SV) lost to thrombosis. Seven grafts required pancreatectomy; all were PV. Rates of acute rejection were 17% SV v 21% PV (p=NS). Mean graft survival was 2.10 yr longer for patients that had PV vs. SV (p<0.01). Overall mean serum creatinine pre-transplantation was 1.09 mg/dL vs. 1.45 mg/dL (p<0.01) at 4.1 +2.3 yrs. There were no statistically significant differences in creatinine between PV v SV at any point.

Conclusion: Despite equivalence in overall allograft rejection and an increased rate of early technical complications with PV, a survival advantage continues to be demonstrated in PV solid organ pancreas transplant recipients.