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Abstract: Aims: The incidence of intraductal papillary mucinous neoplasm (IPMN) is rising and these neoplasms now represent up to 25% of resected pancreatic neoplasms. The optimal postoperative management of resected invasive IPMN is still debated in the absence of large prospective clinical trials and of validated prognostic factors in this setting. The objective of our study was to identify potential prognostic factors and to investigate the role of adjuvant therapies for patients radically resected for invasive IPMN. Methods: We retrospectively reviewed clinical and pathological data regarding a large series of patients with invasive IPMN who underwent surgical resection in the last six years at University Hospital of Pisa. Results: Sixty-four patients were considered for the analysis, thirty-three of whom received adjuvant chemotherapy with gemcitabine. In our series node involvement and high tumoral grade emerged as the major pathologic prognostic factors. Patients treated with adjuvant chemotherapy with gemcitabine experienced a longer disease-free survival than those who received surgery alone. Conclusions: Gemcitabine-based chemotherapy seems beneficial as adjuvant treatment for patients with resected invasive IPMN. [Copyright &y& Elsevier]

Abstract: Background and aims: GPR40 is a membrane-bound receptor paired with medium and long-chain fatty acids (FFA) as endogenous ligands. Its acute activation potentiates insulin secretion from beta cells, whereas prolonged binding might contribute to the deleterious effects of chronic exposure to FFA. Little information is available on the expression of GPR40 and its regulation in human islets (HI). Material and methods: HI were prepared by enzymatic digestion and gradient separation from the pancreas of 20 non-diabetic (Ctrl) and 13 type 2 diabetic (T2DM) multiorgan donors, and functional and molecular studies were then performed. Results: By qualitative and quantitative PCR experiments, mRNA expression was shown in HI. Both in T2DM islets and in Ctrl islets pre-exposed for 24h to 1.0mmol/l FFA (palmitate:oleate, 2:1), GPR40 mRNA expression was significantly reduced (p <0.01) in the T2DM cells as compared to Ctrl cells. A significant positive correlation was found between glucose-stimulated insulin secretion and GPR40 expression. Conclusions: These results show the expression of GPR40 in human pancreatic islets which are regulated by FFA. The finding that T2DM islets have a lower GPR40 expression, and the correlation of these genes with insulin secretion, raises the possibility of an involvement of GPR40 in human diabetes beta-cell dysfunction. [Copyright &y& Elsevier]

Abstract: Background and aim: Our study was aimed to compare multiphasic multi-detector computed tomography after secretin stimulation and mangafodipir trisodium-enhanced magnetic resonance imaging plus MR cholangiopancreatography in the characterization of solid pancreatic lesions. Patients and methods: Forty patients with ultrasound diagnosis of solid pancreatic lesion prospectively underwent both multi-detector computed tomography and magnetic resonance imaging. Three minutes after intravenous administration of secretin, post-contrast computed tomography scans were performed 40, 80, and 180s after contrast medium injection. MR protocol included axial/coronal, thin/thick-slab, single-shot T2w sequences and axial/coronal T1w breath-hold spoiled gradient-echo images before and 30–40min after intravenous infusion of manganese dipyri-doxal diphosphate. Different observers blindly evaluated the ability of computed tomography and magnetic resonance imaging to characterize focal pancreatic lesions. Surgery, biopsy, and/or follow-up were considered as our diagnostic gold standard. Results: Thirty-five focal pancreatic lesions (adenocarcinoma, n =18; focal chronic pancreatitis, n =4; endocrine tumor, n =6; metastasis, n =1; cystic tumor, n =3; indeterminate cystic lesions, n =3) were present in 34 patients since the remaining 6 subjects showed no pathological finding. Both multi-detector computed tomography and magnetic resonance imaging showed a statistically significant correlation with the gold standard and between themselves in the characterization of 29 solid lesions of the pancreas (p <0.05). Conclusion: Both imaging techniques well correlate to final diagnosis of non-metastatic solid pancreatic lesions and particularly of adenocarcinomas with a slight advantage for mangafodipir trisodium-enhanced magnetic resonance imaging plus MR cholangiopancreatography. [Copyright &y& Elsevier]

Abstract: Background: Technical failure rates are higher for pancreas allografts (PA) compared with other solid organs. Posttransplant surveillance and prompt availability of rescue teams with multidisciplinary expertise both contribute to improve this result. We herein report a single institution’s experience with posttransplant surveillance and rescue of PA. Methods: A retrospective survey was performed of a consecutive series of 177 whole organ pancreas transplants in 173 patients. Antithrombotic prophylaxis was used in all recipients and tailored on anticipated individual risk of thrombosis. During the first posttransplant week, all PA were monitored with daily Doppler ultrasonography. Surgical complications were defined as all adverse events requiring relaparotomy during the initial hospital stay or the first 3 posttransplant months. Results: A total of 26 relaparotomies were performed in 25 patients (14.7%). One recipient needed two relaparotomies (0.6%). Graft rescue was attempted in patients without permanent parenchymal damage at repeat surgery and in 12 recipients diagnosed with nonocclusive vascular thrombosis. Overall 25 grafts (96.3%) were rescued and one was lost. One-year recipient and graft survivals in patients with versus without complications potentially leading to allograft loss were 92.6% and 63.0% versus 94.4% and 94.3%, respectively. Excluding complications for which graft rescue was not possible, 1-year graft survival rate increased to 78.7%. Conclusions: Close posttransplant surveillance can allow rescue of a relevant proportion of PA developing nonocclusive venous thrombosis or other surgical complications. Further improvement awaits better understanding of biological reasons for posttransplant complications jeopardizing PA survival and the development of more effective preventive measures. [Copyright &y& Elsevier]

Abstract: Aims: Portal-enteric drainage (PED) might be particularly suitable for pancreas transplantation alone (PTA), since it has been associated with an immunologic advantage and achieves excellent metabolic results. We describe our experience with a consecutive series of 40 PTAs with PED. Methods: Between April 2001 and March 2004, 40 consecutive PTAs were performed with PED. Recipients were selected according to the American Diabetic Association recommendations. Donors were selected according to standard criteria irrespective of HLA match, although matching for A and B loci was considered at the time of graft allocation. Immunosuppression consisted of induction treatment with basiliximab (n = 34) or thymoglobulin (n = 6), and maintenance therapy with steroids, mycophenolate mofetil, and tacrolimus. Results: After a mean cold ischemia time of 690 minutes (range, 517¿965 min) all pancreases functioned immediately. Three grafts were lost due to hyperacute or accelerated rejection. No graft was lost to vascular thrombosis, although 5 (12.5%) nonocclusive thromboses were identified and the grafts were rescued with intravenous heparin infusion. A repeat laparotomy was required in 7 recipients (17.5%) No patient required multiple repeat laparotomies, and none died. After a mean follow-up of 16.4 months (range, 1¿36 mo), 2 recipients were diagnosed with rejection episodes, which were reversed with steroid boluses. Actuarial 3-year patient, and graft survival rates were 100% and 94.9%, respectively. The following parameters showed significant improvement compared with pretransplantation evaluation: hemoglobin A1C concentration, total and high-density lipoprotein cholesterol levels, arterial blood pressure, cardiac performance, retinopathy, proteinuria, and neuropathy. Conclusions: Pancreas transplantation alone with PED provides high rates of long-term insulin-independence. [Copyright &y& Elsevier]

Abstract: Aim: The organ shortage and aging donor population force transplant centers to accept donors previously considered unusable for kidney transplantation. We report the experience of two Italian transplant centers with single (SKTx) and dual (DKTx) kidney transplantation from donors aged 65 years or more. Methods: The study population comprised 75 SKTx (mean donor age 70.5 years) and 28 DKTx (mean donor age 75.0 years). Kidneys from donors with a calculated admission creatinine clearance <50 mL/min, a Karpinski''s score on kidney biopsy between 5 and 7, or both were allocated to DKTx. Grafts with better function or lower biopsy scores were employed for SKTx. Results: Delayed graft function occurred in 45.3% of SKTx and in 39.3% of DKTx. After a mean follow-up period of 30.0 ± 19.5 months, the acute rejection rate was 24.0% in SKTx and 7.1% in DKTx. Mean serum creatinine was 1.8 ± 0.9 and 1.8 ± 1.3 mg/dL in SKTx, and 1.8 ± 1.6 mg/dL and 1.3 ± 0.2 mg/dL in DKTx at 1 and 5 years, respectively. Patient survival was 93.3% and 91.2% in SKTx, and 92.9% and 92.9% in DKTx at 1 and 5 years, respectively. Graft survival was 92.0% and 88.3% in SKTx, and 89.3% and 89.3% in DKTx at the same time intervals. Keeping preservation time below 16 hours and avoiding calcineurin inhibitors were both associated with improved graft survival and function. Conclusion: Careful donor selection, short preservation time, and tailored immunosuppression allow safe and efficient use of elderly donor kidneys. [Copyright &y& Elsevier]

: BackgroundPortal-enteric drainage (PED) is the latest refinement in the surgical technique for pancreas transplantation (PTx). We herein describe the results of a modified technique for PED that places the pancreas in a totally retroperitoneal position.: MethodsBetween April 2001 and June 2003, 79 PTx were performed using a retroperitoneal PED technique.: ResultsNo graft was lost due to surgical complications and the relaparotomy rate was 11.4%. Mean hospital stay averaged 25.9 days (±14.4 days) with a 30-day redamission rate of 12.7%. One graft was lost due to delayed (6 months) arterial thrombosis and three to acute rejection. The overall 1-year patient and graft survivals were 98.7% and 93.7%, respectively.: ConclusionsOur data confirm that PED of pancreas grafts is associated with low morbidity and mortality rates. Whether retroperitoneal graft placement has actual advantages over the “classical” intraperitoneal position remains to be ascertained. [Copyright &y& Elsevier]

: BackgroundThe organ shortage mandates that grafts with complex vascular lesions be considered for graft rescue.: MethodsSurgical graft rescue was attempted in 8 patients bearing 8 kidneys and 2 pancreata that showed complex vascular lesions deemed not suitable for interventional radiology procedures.: ResultsAll procedures but 1 were performed under elective conditions. Seven grafts were repaired in situ, while cooling the organ through retrograde venous perfusion, and 3 kidneys were explanted, repaired extracorporeally, and retransplanted. All vascular reconstructions remain patent after a mean follow-up period of 3.3 years (±2.1 years).: ConclusionsCareful patient selection, multidisciplinary evaluation, and personalized surgical technique may allow the rescue of kidney and pancreas grafts with complex vascular lesions that, otherwise, would be lost. [Copyright &y& Elsevier]

: BackgroundThere are no agreed criteria to predict the outcome of elderly donor kidneys or to decide between single (SKG) or dual (DKG) kidney graft transplantation.: MethodsBetween January 1999 and January 2003, 46 SKG and 14 DKG were performed from elderly donors (mean donor age 71.6 years; range: 66 to 87). Kidney biopsies were scored according to Karpinski. A calculated admission creatinine clearance <50 mL/min and/or a biopsy score of 5 or 6 were used to select kidneys for DKG. Grafts with better function or lower biopsy scores were employed for SKG.: ResultsMean cold ischemia time (CIT) was 16.8 hours (range 8.1 to 28.6) in SKG, and 16.3 hours (range 4.6 to 24.3) for the first kidney and 17.4 hours (range 5.1 to 25.9) for the second graft in DKG. Delayed graft function (DGF) occurred in 34.1% SKG and in 28.5% DKG. Acute rejection rates were 9.1% for SKG and 0% for DKG. Three-year actuarial patient survival rates were 97.7% for SKG and 92.9% for DKG; for kidneys, 95.4% and 92.9%. One-year mean serum creatinine levels were 1.8 mg/dL (range 1.1 to 4.0) for SKG and 1.2 mg/dL (range 1.0 to 1.8) for DKG (P = .01). CIT longer than 16 hours was related to increased rates of DGF for both SKG (45.4% vs 22.7%) or DKG (42.9% vs 14.3%) and reduced 3-year graft survival rates (SKG: 90.9% vs 100%; DKG: 85.7% vs 100%).: ConclusionsWith stringent selection criteria and short CIT (<16 hours), elderly donor kidneys may show good results, thus meaningfully expanding the donor pool. [Copyright &y& Elsevier]

: BackgroundThere are no data concerning the national experience with laparoscopic live donor nephrectomy (LLDN) in Italy. A survey was therefore conducted in May 2003 to establish current practice patterns and to describe the outcome of this procedure.: MethodsA self-administered questionnaire was mailed to the 37 Italian kidney transplant centers. Items covered each center''s attitude toward LLDN, number of cases performed, and the outcome of donors and recipients.: ResultsThe return rate was 100%. The surveyed centers performed 4818 kidney transplants between January 2000 and May 2003, including 401 (8.3%) from living donors of whom 113 (28.2%) used grafts retrieved by laparoscopy. Despite an absolute increase in the number of living donors, the occurrence of a similar trend in cadaveric donation did not significantly change the overall living donor rate. Sixty-eight percent of LLDNs were done at only two centers. There was no mortality or graft loss and only a minor morbidity related to LLDN. Italian transplant surgeons showed a positive attitude toward LLDN; only a few of those not performing it had no plans to begin an LLDN program.: ConclusionsThree years after the first national case, LLDN had not yet change the living donor rate, although an increasing number of donor nephrectomies were now performed by laparoscopy. Overall the results with the new technique are encouraging, although the pattern of diffusion of LLDN between different areas is heterogeneous and will demand continous efforts on training programs in laparoscopic techniques for transplant surgeons. [Copyright &y& Elsevier]

Abstract: Background: We have recently described a technique for retroperitoneal pancreas transplantation (RPTx) with portal-enteric drainage (PED). Further experience with 118 RPTx is detailed herein. Methods: Between April 2001 and August 2004, 118 patients underwent RPTx with PED among 125 recipients (94.4%) scheduled for this procedure. Surgical complications and patient and graft survivals were recorded prospectively. Results: After a minimum follow-up period of 3 months (mean 27.8 ± 13.0 months), 18 recipients (15.2%) required relaparotomy because of bleeding (n = 6; 5.1%), allograft pancreatectomy due to either hyperacute/accelerated rejection (n = 3; 2.5%) or vein thrombosis (n = 3; 2.5%), leak from duodenojejunal anastomosis (n = 2; 1.7%), bleeding and vein thrombectomy (n = 1; 0.8%), or small bowel occlusion due to bezoar (n = 1; 0.8%). One patient had a negative relaparotomy and one underwent two relaparotomies. Most patients with hemorrhage (5/7; 71.4%) were recipients of solitary pancreas grafts managed with heparin infusion. No venous thrombi extended into recipient’s superior mesenteric vein. Nonocclusive venous thrombosis was diagnosed with duplex ultrasonography and confirmed at computed tomography in seven patients (5.1%). None of these patients lost graft function. Ten patients (8.5%) were diagnosed with peripancreatic fluid collections, all successfully treated by observation (n = 7) or percutaneous drainage (n = 3). Enteric bleeding occurred in eight recipients (6.8%). Overall, 1-year patient and pancreas survival rates were 97.4% and 92.0%, respectively. Conclusions: We conclude that RPTx with PED is a technical option that may be included in the repertoire of pancreas transplant surgeons. [Copyright &y& Elsevier]

Abstract: Background: The preferential use of tacrolimus (Prograf) over cyclosporine microemulsion (Neoral) in simultaneous pancreas-kidney transplantation (SPKTx) is mainly based on historical, retrospective studies. We herein report the 3-year results of a single-center, prospective, randomized comparison of the two calcineurin inhibitors in the setting of mycophenolate mofetil (MMF)-based immunosuppression and portal drainage of pancreas allografts. Methods: Between May 2001 and August 2004, 47 SPKTx recipients who were stratified by recipient sex, were alternatively assigned to treatment with Neoral (n = 22) or Prograf (n = 25). Concurrent immunosuppression included induction treatment with basiliximab and maintenance with MMF and steroids. Results: After a median follow-up of 24.0 months, all patients remained in the study arm into which they were initially enrolled. No pancreas rejection episode was observed. One acute kidney rejection was recorded in the Neoral arm (4.5%) as compared with 7 (28.0%) including one steroid-resistant episode, in the Prograf arm (P = .03). The cumulative incidence of adverse events was 31.8% (n = 7) in the Neoral arm compared with 92.0% (n = 23) in the Prograf arm (P &#60; .0001). One patient died in each study arm. Patient, pancreas, and kidney survivals overlapped at 1- and 3-years posttransplant, namely all 95.4% for the Neoral arm compared with 95.8%, 91.8%, and 95.8%, respectively, for the Prograf arm (P > .05). Conclusions: We conclude that in MMF-based immunosuppression there is no convincing evidence that Prograf should be preferred to Neoral in SPKTx. [Copyright &y& Elsevier]

Abstract: Aims: Since donor age of 45 years or more is considered a relative contraindication for pancreas transplantation (PTx), we herein report our experience with these donors. Methods: Pancreases from donors aged 45 years or older were used in 16 of 147 PTx procedures (11%). The final decision to accept a graft for PTx was based mainly on the quality of visceral perfusion and the gross appearance of the pancreas and the vessels. There were 9 men and 7 women, ranging in age from 45 to 55 years (average, 48.9 years) who were donors, due to cerebrovascular accidents (n = 11; 68.7%). Among the donor group, 5 patients were receiving multiple vasopressor agents (31.2%), and 2 had a history of cardiac arrest (12.5%). Pancreases were transplanted either simultaneously with a cadaveric kidney (n = 6) or as solitary grafts (n = 10). Results: After a mean period of cold preservation of 616 minutes (range, 475 to 844 min), delayed endocrine function occurred in 1 recipient (6%), who subsequently achieved insulin independence. Two recipients died suddenly, with functioning grafts. Two further grafts were lost due to portal vein thrombosis (6%) or late arterial thrombosis (6%). Three patients required repeat surgery (18.7%). After a mean follow-up period of 26.6 months, actuarial 1-year and 5-year patient survival rates were 87.5%, with insulin independence in 81.2% and 67.7%, respectively. Conclusions: Meticulons donor selection and short preservation times allow the safe use of pancreases procured from donors aged 45 years or older, thus expanding the donor pool for PTx procedures. [Copyright &y& Elsevier]

Abstract: Introduction: This study compared the safety and efficacy of University of Wisconsin solution (UW) and Celsior solution (C) in pancreas transplantation (PTx). Methods: A retrospective review of 154 PTx performed over a 61-month period included 77 grafts preserved with UW and 77 with C. The two groups were comparable for both donor and recipient characteristics. Results: After a mean cold ischemia time of 624 minutes (range 360 to 945 minutes) for UW versus 672 minutes (range 415 to 1005 minutes) for C (P = NS), no primary endocrine nonfunction occurred. Delayed endocrine function was diagnosed in two grafts in the UW group (2.6%) versus none in the C group (P = NS). After a minimum follow-up of 4 months (mean 26.5 ± 15.2 months), 22 recipients (UW = 11 vs C = 11; P = NS) required relaparotomy. Overall, 18 pancreata were lost due to either patient death with functioning graft (UW = 4 vs C = 1; P = NS) or graft loss due to other reasons (UW = 8 vs C = 5; P = NS). Actuarial 1- and 5-year patient survival rates were 93.5% and 86.8% for UW compared with 98.7% and 98.7% for C (P = .04). Actuarial graft survival rates at the same times were 88.3% and 75.0% for UW compared with 90.4% and 90.4% for C (P = NS). Conclusions: Within the range of cold ischemia times reported in this study, UW and C show similar safety and efficacy profiles for PTx. [Copyright &y& Elsevier]

Background: Most solitary pancreas transplants (SPTx) fail due to unrecognized rejection episodes. Consequently, SPTx are monitored by draineage into the bladder or by surveillance biopsies.Methods: Between April 2001 and June 2003, a consecutive series of 48 SPTx were performed using portal enteric drainage (PED). Rejection episodes were diagnosed empirically, based on the elevated pancreatic enzymes without a surveillance biopsy. Immunosuppression consisted of basiliximab (n = 42) or ATG (n = 6), low-dose steroids, MMF, and tacrolimus. Donors (mean age 28.9 year; range 9 to 54 year) were selected according to standard criteria irrespective of HLA match, although the best HLA matching was considered at the time of graft allocation.Results: After a mean cold ischemia time of 676 minutes (range 475 to 900 minutes), all but two pancreata (95.8%) functioned immediately. Relaparotomy was required in seven cases (14.6%). Three grafts were lost in the early posttransplant period due to hyperacute rejection. Two additional grafts were lost later due to arterial thrombosis or to chronic rejection. After a median follow-up period of 12.2 months (range 0.2 to 27 months) three further recipients were diagnosed with rejection episodes that were reversed with steroid boluses. Actuarial 1-year patient and graft survival rates were 100% and 93.1% and 2-year figures 100% and 88.7%, respectively. At the longest follow-up no recipient was diagnosed with a malignancy.Conclusions: With current immunosuppression protocols SPTx achieves high rates of insulin independence even without surveillance biopsy or routine use of T-cell–depleting therapies. [Copyright &y& Elsevier]

Background: Shortage of suitable donors and current graft allocation priorities reduce the number of cadaveric kidneys available to diabetic recipients. The concurrent excess of solitary cadaveric pancreata and the excellent results of living kidney transplantation make simultaneous cadaveric pancreas-living kidney transplantation (SPLKTx) an attractive alternative to simultaneous pancreas-kidney transplantation (SPKTx).Methods: Between June 2001 and June 2003, 80 recipients were enrolled in the SPKTx waiting list. Each recipient''s family was counseled about living kidney donation (LKD). Twenty-nine (36.2%) candidates were evaluated for LKD and 8 (27.6%) were disqualified. The remaining 21 candidates were scheduled for LKD and 18 actually donated.Results: Thanks to LKD 18 additional recipients were transplanted, thus expanding the donor pool from 33 to 51 (P = .004). The median waiting time for SPLKTx was 14 days as compared with 95 days for SPKTx (P = .006). Without LKD the median waiting time for SPKTx would have been 198 days (P = .02). Similarly, 1 year after the enrollment on the waiting list 60% of recipients had been transplanted, while without LKD only 42% would had been grafted (P = .01). Two-year recipient survival rate was 100% for SPLKTx compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx compared with 96.9% and 96.9% for SPKTx.Conclusions: LKD expanded the kidney donor pool, reduced the waiting time of recipients listed for a totally cadaveric procedure, and increased their chance to get a timely graft. One-year outcome of SPLKTx equaled that of SPKTx. [Copyright &y& Elsevier]

Background: Although tacrolimus (Prograf) is the calcineurin inhibitor usually employed in simultaneous pancreas-kidney transplantation (SPKTx), no prospective randomized studies have compared its efficacy to cyclosporine (Neoral), when either drug is used in combination with mycophenolate mofetil (MMF) and the pancreas is drained into the portal vein.Methods: Between May 2001 and June 2003, 16 SPKTx recipients were randomized to be prescribed Neoral and 17 Prograf in addition to basiliximab, steroids, and MMF. All pancreata were drained into the portal vein.Results: After a median follow-up of 15.6 months, six kidney acute rejection episodes were observed with Prograf (36.5%; one steroid-resistant) and one Neoral (n = 1, 6.2%; P = .04). No pancreas rejection episode was recorded. Two infections occurred in two recipients from each group. No major adverse events were noted other than a severe hematological toxicity (Prograf). Metabolic parameters were equivalent in the two groups, save for higher total cholesterol (212 ± 39 mg/dL vs 173 ± 23 mg/dL; P = .008), LDL (129 ± 33 mg/dL vs 101 ± 21 mg/dL; P = .029), and triglyceride (191 ± 86 mg/dL vs 126 ± 40 mg/dL; P = .028), values with Neoral, although the same differences were already present at baseline. One recipient (Neoral) died with functioning grafts. Patient, pancreas, and kidney survival rates were all 94% for Neoral versus 100% for Prograf.Conclusions: Although a larger series and a longer follow-up are needed, Neoral and Prograf used in combination with MMF seem to achieve equivalent success rates among primary SPKTx when the pancreas is drained into the portal vein. [Copyright &y& Elsevier]

: BackgroundMarginal donor organs are a supplementary source of grafts that has not been fully exploited for pancreas transplantation (PTx).: MethodsA total of 100 PTx were performed with grafts procured from either 48 nonmarginal donors (NMD) or 52 marginal donors (MD), namely age greater than 45 years and/or severe hemodynamic instability at the time of procurement. PTx outcome was evaluated as the incidence of delayed endocrine pancreas function (DEPF), the complication rate, and the patient and graft survivals.: ResultsThe DEPF rate was 6.2% for NMD as compared to 0 for MD (P > .05). Relaparotomy rate was 12.5% for NMD and 9.6% for MD (P > .05). Actuarial 1-year graft survival was 91.7% and 94.2% for NMD and MD, respectively (P > .05). Equivalent figures for patients were 97.9% and 98.1%, respectively (P > .05).: ConclusionsPancreas from MD may be safely employed and significantly expand the donor pool for PTx. [Copyright &y& Elsevier]

: BackgroundThe expansion of the donor pool achieved with living kidney donation (LKD) is particularly beneficial for diabetic patients, who have a worse prognosis during dialysis when compared to other kidney recipients. Simultaneous cadaver pancreas–living kidney transplantation (SPLKTx) merges the advantages of LKD with those of cadaver donation, and may be an attractive alternative to simultaneous pancreas kidney transplantation (SPKTx).: MethodsThe outcomes of 18 SPLKTx were compared with those of 33 SPKTx.: ResultsLKD expanded the donor pool from 33 to 51 (P = .004). Median wait time was shorter for SPLKTx (14 days) than for SPKTx (95 days) (P = .006). The risk for surgical complications was not increased by SPLKTx, as witnessed by relaparotomy rates (SPLKTx: 2/18, 11.1%; SPKTx: 2/33, 6.1%; P > .05). Hospital stay averaged 26.1 ± 11.2 days for SPLKTx and 27.1 ± 16.3 for SPKTx (P > .05) with equivalent 30-day readmission rates (SPLKTx: 5.5%; SPKTx: 6.1%); (P > .05). One acute kidney rejection occurred in SPLKTx (5.5%) as compared with four in SPKTx (12.1%); (P > .05). Equivalent rates for the pancreas were 5.5% (1/18) for SPLKTx and 3.0% (1/33) for SPKTx (P > .05). Two-year recipient survival rates were 100% for SPLKTx as compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx and 96.9% and 96.9% for SPKTx.: ConclusionsSPLKTx is a valuable alternative to SPKTx. Further development of SPLKTX relies on increased rates of living kidney donation. [Copyright &y& Elsevier]

: BackgroundAlthough the use of Celsior has been recently described for heart, lung, liver, and kidney transplantation, no data are available on its use for clinical pancreas preservation.: MethodsWe herein describe the results of 112 pancreas transplants preserved with either University of Wisconsin (UW; (n = 56) or Celsior (n = 56) solution at two Italian transplant centers. The groups were comparable with regard to all donor and recipient characteristics.: ResultsMean cold and warm ischemia times were 10.1 ± 2.2 hours and 37.2 ± 8.2 minutes for UW compared to 10.8 ± 2.4 hours and 38.3 ± 6.7 minutes for Celsior (P = NS). Delayed endocrine pancreas function was recorded in two UW-preserved grafts (3.6%). Actuarial 1-year patient survival was 94.6% for UW as compared with 100% for Celsior (P = NS). Equivalent graft survival figures were 91.0% for UW as compared with 96.4% for Celsior (P = NS).: ConclusionsWithin the range of cold ischemia times reported in this study, UW and Celsior solutions have similar safety profiles for pancreas transplantation. [Copyright &y& Elsevier]

Abstract: Background: There are no data regarding the outcome of solitary pancreas transplantation (SPT) with portal venous drainage (PVD) following unsuccessful islet transplantation (ITx) after multiple islet injections into the portal vein. We herein describe the outcome of three SPTs with PVD performed after failed ITx. Methods: Between October 2002 and December 2003, three SPTs with PVD were performed following unsuccessful ITx with multiple intraportal islet injections (mean 2.3 injections: range 2 to 3 injections) in two women and one man, aged 26, 49, and 60 years. Panel reactive antibody titer was 0% in all recipients. Immunosuppression was based on induction with either basiliximab (n = 2) or thymoglobulin (n = 1); maintenance therapy included steroids, mycophenolate mofetil, and tacrolimus. During the recipient operation, the absence of venous hypertension was established by direct measurement of portal pressure, before making the final decision to drain the pancreas into the portal vein. Results: Portal pressures were 16 cm H2O, 14 cm H2O, and 13 cm H2O. Pancreas grafts were reperfused after a period of cold preservation of 638, 695, and 835 minutes, respectively. All grafts showed immediate endocrine function, mantaining their recipients insulin-independent for longest follow-ups of 8, 21, and 23 months, respectively. One recipient developed a nonocclusive venous thrombus that resolved with intravenous heparin infusion. Conclusions: Our experience showed that unsuccessful ITx with multiple intraportal injections does not necessarily preclude the possibility of subsequent successful SPT with PVD. Further experience is needed to define contraindications and possible complications of SPT with PVD following ITx. [Copyright &y& Elsevier]

: BackgroundDespite recent improvements, surgical complications continue to occur frequently after pancreas transplantation, remaining the leading cause of early graft loss. Small-bowel obstruction, however, is exceedingly rare; it has not been associated with an enhanced risk of graft loss.: MethodsIntestinal obstruction occurred 7 days after pancreas transplantation due to bezoar blockage at the level of the jejunojejunostomy of the Roux-en-Y loop, which had been constructed to drain the exocrine secretions of the pancreas graft.: ResultsCT scan promptly identified the foreign body and greatly facilitated graft rescue before duodenal rupture or the development of graft pancreatitis. Nineteen months after repeat laparotomy the patient is alive with good pancreatic endocrine function.: ConclusionsIn cases of pancreas transplantation with enteric drainage, obstruction of the Roux-en-Y loop may create a totally sealed system that may lead to severe duodenal dilation and eventually to duodenal rupture or graft pancreatitis. [Copyright &y& Elsevier]

Jehovah''s Witnesses refuse blood transfusions but accept solid organ transplants. Six Jehovah''s Witnesses received a kidney and/or a pancreas transplant in our center. After a mean follow-up of 31.4 months (range: 18 to 39) all the recipients are alive and well with functioning grafts. However, 1 month after grafting, one recipient required blood transfusions. Hemorrhage was ruled out and the anemia was attributed to drug-related toxicity. Thus, Jehovah''s Witnesses can receive a kidney and/or a pancreas transplant without blood transfusions at the time of surgery. However, lifesaving transfusions may be needed later on, which raises additional and unique medical and ethical issues. [Copyright &y& Elsevier]

Pancreas transplant alone (PTA) represents a growing proportion of overall pancreas transplantations, with 1-year patient and graft survivals of almost 100% and higher than 80%, respectively. PTA can restore normoglycemia without exogenous insulin administration and eliminate acute diabetic complications. In our series of 28 PTA, performed with portal-enteric drainage, 2-year patient and pancreas survivals were 100% and 87%, respectively. In patients with successful transplantation, rapid normalization of blood glucose level and HbA1c concentration was observed, due to restored endogenous insulin secretion. Several classical cardiovascular risk factors were measured before and after transplant, with significant improvements shortly after transplantation. Diabetic retinopathy improved in 58.8% of examined eyes, stabilized in 35.3%, and worsened in 5.9%. In conclusion, PTA represents a clinically relevant option for patients with type 1 diabetes without advanced renal disease. It restores normoglycemia in the vast majority of patients and seems to have a positive impact on late diabetic complications. [Copyright &y& Elsevier]

: BackgroundThe graft shortages make multiorgan procurements mandatory. We describe the results of a regional procurement team policy that has been employed over a 5-year period.: MethodsThree hundred forty-three multiorgan procurements were performed by a regional team using an en bloc harvesting method.: ResultsAmong 1374 grafts procured, none was discarded because of iatrogenic injuries. In three instances the liver, the pancreas, and the small bowel were procured simultaneously and transplanted to different recipients. In 42 instances the liver was not allocated to our center. Forty liver teams (95%) from 11 institutions agreed to allow the regional procurement team to run the donor procedure.: ConclusionsOur experience confirms that a regional team can successfully manage most multiorgan procurements including complex donor procedures, such as simultaneous procurement of liver, pancreas, and intestine from the same donor for transplantation to different recipients. [Copyright &y& Elsevier]