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PubMed2002

Simultaneous pancreas-kidney and pancreas transplantation.

The best available method currently for achieving steady normoglycemia in individuals with type 1 diabetes mellitus (DM) is replacing the pancreas, e.g. whole pancreas transplantation. Pancreatic transplantation, as either simultaneous pancreas-kidney (SPK) or solitary pancreas transplantation alone (PTA), has moved beyond simple metabolic or quality-of-life goals. It is now an effective treatment to reverse or minimize metabolic abnormalities and complications of type 1 DM as well as potentially extend the life span of those afflicted by type 1 DM and its many co-morbid complications. Candidates for SPK and PTA transplantation need to meet various criteria even to undergo the transplant procedure and receive a pancreatic allograft that is deemed suitable. SPK and PTA recipients, though free from insulin use, still may encounter common post-transplant medical complications, e.g. cardiovascular disease, high blood pressure, as well as complications unique to SPK and PTA transplantation. The advantages of PTA and SPK transplantation are frankly now more obvious as improvements in surgical technique and new immunosuppression have made an increasing number of PTA and SPK transplants viable and functional long-term. The idea of pancreas transplantation can be touted as a therapeutic advance for type 1 DM. It can improve survival and limit many diabetic-related complications, while improving quality of life, especially in those individuals also afflicted with diabetic-related kidney disease.

Drainage↗
PubMed1996

Pancreas transplantation in the United States (US) and non-US as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR).

As of November 1996, more than 8,800 pancreas transplants had been reported to the IPTR. There were 6,500 performed in the US, including more than 5,800 since the inception of the UNOS Registry in October 1987, and more than 1,000 in 1995. In Europe, more than 2,100 cases were reported to the IPTR, while fewer than 200 have been done in other locations. This report analyzes cases reported since 1987. In the US, BD has been used for the majority (92%). However, ED has recently increased in popularity, and for 1995, 15% of US cases were done by this method. In the SPK category results for 1994-1996 BD (n = 1,510) and ED (n = 221) were comparable, with one-year GSRs of 62% and 77%, respectively. When the 1987-1996 US data for BD cases were analyzed according to the 3 major recipient categories, SPK transplants (n = 3,989); PAK transplants (n = 375) and PAK transplants (n = 229), patient survival rates were no different (92%, 92% and 91%, respectively at one year). But one-year pancreas GSRs were significantly higher (p = 0.0001) in the SPK than in the PAK and PTA categories (79%, 60% and 57%, respectively). In the SPK group, the one-year kidney GSR was 88%. Retransplants and primary transplants fared similarly in the SPK category, with one-year GSRs of 79% (n = 3,947) and 77% (n = 42), respectively. But in the PAK category, primary transplants did better, 62% (n = 275) versus 47% (n = 100) functioning at one year. The PTA category outcome was also better for primary than retransplants, with GSRs of 57% (n = 191) and 51% (n = 38) at one year. An improvement in GSRs could be shown over the analyzed time period for all categories; for 1994-1996 cases in the SPK (n = 1,516), PAK (n = 141) and PTA (n = 64) categories, one-year pancreas GSRs were 81%, 71% and 64%, respectively (p = 0.004). The kidney GSR for 1994-96 SPK cases was 88% at one year. Preservation had minimal impact on outcome. In the SPK category, one-year GSRs for pancreases stored less than 12 (n = 1,400), 12-24 (n = 2,256) and more than 24 (n = 195) hours were 78%, 80% and 76%, respectively. The impact of FK506 immunosuppression on pancreas transplant survival was also analyzed for 1994-1996 cases. The results were comparable to those with CsA. For SPK cases, one-year GSRs were 82% with CsA (n = 1,247) and 81% with FK506 (n = 257). The one-year immunological loss rates were 2% and 3%, respectively. For PAK cases, one-year GSRs were 84% for FK506- (n = 42) and 65% for CsA- (n = 97) treated recipients (p < 0.04), and the immunological loss rates at one year were 11% and 7%, respectively. In PTA cases, the one-year GSRs were 66% with CsA (n = 37) and 64% with FK506 (n = 26) with immunological loss rates of 9% and 0%, respectively (p > 0.2). Outcomes were also compared according to whether recipients underwent induction immunotherapy with ALG/ATG/ATS, OKT3, or neither. In the SPK category, GSRs were 81% with OKT3 (n = 1,600), 75% with ALG/ATG/ATS (n = 1,715) and 75% with neither (n = 45) (p < 0.001). In the PAK category, the use of OKT3 (n = 81) was associated with lower graft survival rates than when ALG/ATG/ATS (n = 220) or neither (n = 49) was given (43%, 62%, and 54% at one year, respectively). In the PTA category the use of ALG/ ATG/ATS (n = 132) or OKT3 (n = 76) was associated with significantly higher graft survival (59% and 57%, respectively) than when neither (n = 13) was used (26% at one year). The effect of HLA-A,-B and -DR mismatching on outcome for US cases was determined on both overall graft survival rates and on risks for immunological loss. For SPK cases, the pancreas GSRs were significantly higher (p < 0.04) with zero-mismatched grafts (n = 30) than with higher degrees of mismatches (85% at one year versus 69%, 76% and 79% with one [n = 67], 2-3 [n = 925] and 4-6 [n = 2,836] mismatches, respectively). For PAK cases GSRs were progressively higher with decreasing numbers of mismatches (100%, 75%, 58% and 53% at one year with zero [n = 7], one [n = 35], 2-3 [

Adult↗
PubMed2005

Resection of a cancer developing in the remnant pancreas after a pancreaticoduodenectomy for pancreas head cancer.

We report a rare case of a curative resection performed on a carcinoma developing in the remnant pancreas at 3 years 7 months after a pancreaticoduodenectomy for pancreatic cancer. A 63-year-old man underwent a pancreaticoduodenectomy for pancreatic cancer on November 1999. Because the celiac trunk was occluded by atherosclerosis, an aortohepatic bypass with a saphenous vein graft was performed simultaneously. In May 2003, tumor marker levels increased, and a tumor was detected in the remnant pancreas on computed tomography. There were no findings such as invasion into the surrounding tissue or distant metastasis, and therefore we removed the remnant pancreas in July 2003. Histopathologically, the tumor consisted of a well-differentiated tubular adenocarcinoma and was limited to the pancreas. Moreover, the anastomotic site of the pancreaticojejunostomy was negative for cancer, and some foci of papillary hyperplasia and goblet cell metaplasia of the pancreatic ductal epithelium, which was thought to be the precursor of the pancreatic cancer, were seen. These findings suggested that the tumor was a second primary cancer developing in the remnant pancreas. This case provided suggestive evidence for the development of pancreatic cancer, and the surgical procedure for a pancreaticoduodenectomy with occlusion of the celiac trunk is discussed.

Adenocarcinoma↗
PubMed2004

Pancreatic pseudotumors: non-neoplastic solid lesions of the pancreas that clinically mimic pancreas cancer.

In the pancreas, a variety of non-neoplastic conditions may form solid masses that may mimic cancer. Up to 5% of pancreatectomies performed with the preoperative clinical diagnosis of carcinoma will prove to be non-neoplastic by pathologic examination, although this figure is decreasing with improved diagnostic modalities. Chronic inflammatory lesions are the leading cause of this phenomenon ("pseudotumoral pancreatitis"), and among these, autoimmune and paraduodenal pancreatitides (discussed separately in this issue) are most important. In this article, we will focus on the noninflammatory lesions that may form tumor-like lesions of the pancreas. Adenomyomatous hyperplasia of ampulla of Vater is a subtle lesion that is difficult to define; larger examples (>5 mm) have been found to be the cause of obstructive jaundice. Accessory (heterotopic) spleen may form a well-defined nodule within the tail of the pancreas and is typically mistaken for endocrine neoplasm. Lipomatous hypertrophy is the replacement of pancreatic tissue with mature adipose tissue that occasionally leads to moderate to marked enlargement of the pancreas. Hamartomas are very rare if the entity is defined strictly. They are characterized by irregularly arranged mature pancreatic elements admixed with stromal tissue. A cellular, spindle-cell variant with c-kit (CD117) expression is recognized. Pseudolymphoma forms well-defined nodules composed of hyperplastic lymphoid tissue. Rarely, foreign-body deposits, granulomatous inflammations (such as sarcoidosis or tuberculosis), and congenital lesions may form tumoral lesions. In conclusion, it is important to recognize the types of conditions that form pseudotumors in the pancreas so that they can be distinguished from ductal adenocarcinomas, especially clinically, but also pathologically. Nonspecific terms such as "inflammatory pseudotumor" ought to be avoided, and every attempt should be made to classify a "pseudotumor" into a more specific diagnostic category discussed above.

Adult↗
PubMed1987

Subtotal resection of the head of the pancreas combined with ductal obliteration of the distal pancreas in chronic pancreatitis.

Subtotal resection of the head of the pancreas combined with duct obliteration of the distal pancreas by prolamine was performed in 12 selected patients who had chronic alcohol-induced pancreatitis with most destruction in the proximal pancreas. The main indication for operation was intractable pain. There was no postoperative mortality but morbidity was high when no pancreaticojejunostomy was constructed. After a follow-up period of 32 months, lasting pain relief was obtained in 10 patients; pseudocyst formation occurred in three patients; calcification of the distal pancreas, absent before operation, was demonstrated in four of six patients; six of 11 nondiabetic patients became hyperglycemic either abruptly (1 patient) or progressively (5 patients); quality of life improved in most patients. This procedure preserves the stomach, duodenum, spleen, distal pancreas and common bile duct if possible. However, pancreatic ductal obliteration with prolamine does not prevent relapses of chronic pancreatitis.

Adult↗
PubMed1975

[Experimental xenogenic immune pancreatitis. 1. Histological findings in the mouse exocrine pancreas after treatment with anti-mouse pancreas rabbit serum (author's transl)].

QUESTION: In the pathogenesis of some forms of chronic pancreatitis an immunological influence has been discussed. Therefore, experimental studies of the exocrine pancreas after immunological damage should be done. In this communication histological findings on the mouse exocrine pancreas are presented after treatment with anti-mouse pancreas rabbit serum. MATERIAL AND METHODS: a total of 71 adult male white mice was divided into 4 groups treated in the following way: 1. 35 animals with anti-mouse pancreas rabbit serum 2. 14 animals with normal rabbit serum 3. 16 animals with physiological saline 4. 6 animals remained untreated. The sera under study and the saline were, without exception, administered intraperitoneally with single doses of 0.3 ml once, resp. twice daily for 0 up to 16 days. Constantly, 3 hours before sacrifice, the animals received the last injection. For histological examination, the fresh pancreas was fixed in formaline. After embedding in paraffin, sections were stained by the following methods: hematoxyline-eosin, trichrome according to Goldner, Giemsa staining, PAS-reaction, and tryptophane demonstration according to ADAMS (1957).

Animals↗
PubMedDate not supplied

Interleukin-10 gene transfection of donor pancreas grafts protects against rejection after heterotopic pancreas transplantation in a rat model.

OBJECTIVE: The aim of this study was to assess the effect of immunoregulatory cytokine interleukin-10 (IL-10) gene therapy on pancreas tissue rejection in a heterotopic pancreas transplantation model. BACKGROUND: Modulation of inflammatory responses by anti-inflammatory cytokines (e.g., IL-10) has been suggested to minimize organ rejection. In this context, modulation of cytokines using gene therapy could be a new therapeutic modality in preventing organ rejection. METHODS: The study was performed using male inbred Wistar rats as recipients and Sprague-Dawley rats as donors. 24 h before transplantation, groups of rats, named IL-10 (n = 20) and green fluorescent protein (GFP, n = 20), were injected with viral vectors Ad5CMVhIL10 or Ad5CMVGFP. Sham-operated rats (n = 20) underwent saline injection only before transplantation. The pancreatic tissue from each of these donor rats was subsequently transplanted into the corresponding groups of streptozotocin-induced diabetic recipient rats. Recipients were thus transfected with either IL-10 (n = 20), GFP-only carrying viral vectors (n = 20) or no viral vectors (normal saline, n = 20). A selected number of animals from each recipient group (n = 5) was sacrificed at weekly intervals for 3 weeks and some were further followed up to 12 weeks before sacrifice. Histological assessment of the pancreatic tissue was made based on rejection and GFP expression. Blood glucose levels were checked daily in all groups until sacrifice. Upon sacrifice, serum cytokine and insulin levels were measured. Histopathological correlations between blood glucose levels, serum insulin levels and serum IL-10 levels were made. RESULTS: IL-10 gene therapy significantly attenuated pancreas rejection compared to controls, provided more normal blood glucose levels and elevated plasma insulin levels. Upon assumed natural deactivation of transferred viruses after 4 weeks, differences between groups in terms of rejection, blood glucose and insulin levels disappeared. CONCLUSION: These findings suggest that IL-10 gene therapy significantly reduced pancreas rejection.

Animals↗
PubMed1996

Pancreas graft loss caused by intra-abdominal infection. A risk factor for a subsequent pancreas retransplantation.

OBJECTIVE: To investigate whether previous pancreas graft loss caused by intra-abdominal infection is a risk factor for a subsequent pancreas retransplantation. DESIGN: Retrospective case-series analysis. SETTING: Large university hospital. PATIENTS: Of 97 pancreatic retransplantations (July 1, 1985 to June 30, 1994), 13 (13%) were performed after previous pancreas grafts had been lost because of intra-abdominal infection. MAIN OUTCOME MEASURES: Cause of retransplant graft loss; patient survival. RESULTS: Of 13 cases of pancreatic retransplantations performed after previous grafts had been lost because of intra-abdominal infection, 12 (92%) were again complicated by intra-abdominal infection. Of these 12 retransplantation infections, 10 were caused by the same microbial species that had caused failure of the previous graft 1 to 5 years earlier (8 required graft pancreatectomy [mortality rate, 25%], and 2 were successfully treated) and 2 were caused by different microbial species (both required graft pancreatectomy [mortality rate, 0%]). In 1 of the 13 retransplantations, prophylactic antimicrobial treatment was directed at the microbial species that had caused failure of the previous graft; no recurrent intra-abdominal infection developed. CONCLUSIONS: Intra-abdominal infection after a previous pancreas transplantation is a risk factor for recurrence of infection by the same microbial species after a subsequent retransplantation. For the selected patients who are considered for retransplantation in spite of their previous graft loss caused by intra-abdominal infection, periretransplantation antimicrobial prophylaxis should include a prolonged course of an agent directed against the previously identified microbial species.

Abdomen↗
PubMed1996

Human pancreas-specific protein. A diagnostic and prognostic marker in acute pancreatitis and pancreas transplantation.

CONCLUSION: Human pancreas-specific protein (hPASP) is a very sensitive reflector of the extent of pancreatic necrosis on the cellular level, and is of both diagnostic and prognostic value in acute pancreatitis. Furthermore, it allows the estimation of the severity of graft pancreatitis soon after simultaneous renal and pancreatic transplantation. BACKGROUND: Diagnosis of acute pancreatitis (AP) has been improved in the past 15 yr as new methods for the determination of specific pancreatic enzymes have been developed. However, these enzymes have no prognostic implications. In this prospective study, we evaluated the role of human pancreas-specific protein (hPASP) in comparison with pancreatic amylase and C-reactive protein (CRP) in acute pancreatitis and pancreas transplantation. PATIENTS AND METHODS: The study included 40 patients (22 female, 18 male; mean age 51 yr, range 22-88 yr) with AP and 7 patients (2 female, 5 male; mean age 37 yr, range 25-49 yr) with type I diabetes and renal insufficiency who underwent simultaneous kidney and pancreas transplantation. By means of contrast-enhanced computed tomography (CT) and/or intraoperative findings, patients were judged to have edematous-interstitial (AIP, n = 20, mean age 55.2 yr, range 24-88 yr) or necrotizing pancreatitis (NP, n = 20, mean age 46.3 yr, range 22-81 yr). Serum hPASP concentration was measured daily by a commercial radioimmunoassay technique. In 25 healthy subjects and in several control groups (35 patients with chronic pancreatitis, 20 patients with pancreatic carcinoma and 80 patients with different gastrointestinal diseases) a single blood specimen was taken at hospital admission for the determination of the normal range of hPASP and for specificity analysis. RESULTS: The upper normal value for hPASP in healthy subjects was found to be 52 ng/mL. Serum hPASP was elevated in all patients suffering from AP, with a median of 343 ng/mL (lower-upper quartile: 192-478 ng/mL) at hospital admission. In the daily serum monitoring with respect to the onset of symptoms, significantly higher hPASP levels were found in NP compared with AIP after day 2 (p < 0.001). In patients with NP, peak values of hPASP correlated significantly with the extent of pancreatic necroses measured by contrast-enhanced CT-scanning, whereas CRP did not. Six patients of the transplantation group had the same serum hPASP course as AIP, with almost normal values on the third postoperative day. One patient had elevated levels throughout the observation period. This patient suffered from necrotizing graft pancreatitis, confirmed by relaparotomy, and died because of subsequent septic complications.

Acute Disease↗
PubMed1986

Visualization of c-Ki-ras-2 oncogene sequences in human pancreas, a chemically induced transplantable carcinoma, and carcinomas of pancreas by in situ hybridization.

c-Ki-ras-2 sequences were visualized in paraffin-embedded sections from normal fetal and adult human pancreases, a chemically induced transplantable human pancreas carcinoma (PT-1) and three carcinomas of pancreas by in situ hybridization technique. A biotinylated 1-kilobase-pair (kb) EcoRI fragment of pHiHi3 DNA was used as probe and the oncogene was visualized as one or two large grains of reaction products produced by streptavidin-peroxidase complex and diaminobenzidine tetrachloride in more than 9% of normal pancreas nuclei. Its amplification in the chemically induced cell line was detected as one or more large grains in 72% of the nuclei and numerous cytoplasmic grains. The detection of oncogene in normal pancreases and its amplification in PT-1 cells was validated by Southern analysis of EcoRI digests of genomic DNA extracted from normal pancreases and PT-1 cell line. The oncogene was also demonstrated to be equally amplified in two adenocarcinomas and one undifferentiated carcinoma of human pancreas by in situ hybridization.

Adenocarcinoma↗
PubMed1999

Cost-utility analysis of living-donor kidney transplantation followed by pancreas transplantation versus simultaneous pancreas-kidney transplantation.

For a type I diabetic with end-stage renal disease, the choice between a kidney-alone transplant from a living-donor (KA-LD) and a simultaneous pancreas kidney (SPK) transplant remains a difficult one. The prevailing practice seems to favor KA-LD over SPK, presumably due to the superior long-term renal graft survival in KA-LD and the elimination of the lengthy waiting time on the cadaver transplant list. In this study, two treatment options, KA-LD followed by pancreas-after-kidney (PAK) and SPK transplant, are compared using a cost-utility decision analysis model. The decision tree consisted of a choice between KA-LD + PAK and SPK. The analysis was based on a 5-yr model and the measures of outcome used in the model were cost, utility and cost-utility. The expected 5-yr cost was $277,638 for KA-LD + PAK and $288,466 for SPK. When adjusted for utilities, KA-LD + PAK at a cost of $153,911 was less cost-effective than SPK at a cost of $110,828 per quality-adjusted year. One-way sensitivity analyses were performed by varying patient and graft survival probabilities, utilities and cost. SPK remained the optimal strategy over KA-LD + PAK across all variations. Two-way sensitivity analysis showed that in order for KA-LD + PAK to be at least as cost-effective as SPK, 5-yr pancreas and patient survival rates following PAK would need to surpass 86 and 80%. In conclusion, according to the 5-yr cost-utility model presented in this study, KA-LD followed by PAK is less cost-effective than SPK as a treatment strategy for a type I diabetic with end-stage renal disease. For patients interested in the benefits of a pancreas transplant, it would be reasonable to offer SPK as the optimal treatment, even if a living kidney donor is available.

Cost-Benefit Analysis↗
PubMed1998

Pancreas and pancreas-kidney transplantation.

Pancreas transplantation consistently results in an insulin-independent normoglycemic state in insulin-dependent diabetic recipients. Registry data show insulin independence is achieved in 80% of simultaneous kidney and pancreas recipients, more than 70% of pancreas after kidney recipients, and more than 60% of nonuremic pancreas transplant alone recipients. Advances in immunosuppression and careful monitoring for rejection in conjunction with biopsies are largely responsible for improved results. However, complications do occur, and improvements in surgical technique and patient care continue to evolve.

Costs and Cost Analysis↗
PubMed2001

Trends and perspectives in pancreas and simultaneous pancreas and kidney transplantation.

Pancreas transplantation is still the best option to achieve normoglycaemia and insulin independence in patients with type I diabetes. As a result of improvements in surgical techniques, immunosuppression and patient selection, one year survival rates of 95, 83, and 88% for patient, pancreas, and kidney survival, respectively, are reported for patients with simultaneous pancreas and kidney transplantation. The main goals for the future are to reduce postoperative morbidity, to identify the relevant indications for single pancreas transplantation, to adopt the best surgical technique for individual patients' needs (bladder versus enteric drainage with or without portal venous delivery of insulin), and to develop immunosuppressive strategies with low nephrotoxic and diabetogenic potential.

Graft Rejection↗
PubMed2005

Calcineurin inhibitor- and steroid-free immunosuppression in pancreas-kidney and solitary pancreas transplantation.

BACKGROUND: Calcineurin inhibitors and steroids are standard immunosuppressants in solid organ transplantation, but (long-term) side effects are harmful to the recipient and the graft. The authors present a novel strategy for posttransplant immunosuppression that combines a depleting antibody with an antimetabolite, avoiding calcineurin inhibitors and steroids. METHODS: In a prospective, nonrandomized, observational cohort study, 75 pancreas-kidney and solitary pancreas recipients received alemtuzumab (4 doses for induction and up to 12 doses within the first year) and mycophenolate mofetil (> or = 2 g/day) for induction and maintenance therapy. Minimum follow-up was 6 months. We compared the results with a historical group of 266 consecutive pancreas recipients on Thymoglobulin (induction) and tacrolimus (maintenance). RESULTS: Differences in patient and graft survival rates between the study and control groups at 6 months were not statistically significant. However, the incidence of a first reversible rejection episode was significantly higher for simultaneous pancreas-kidney recipients in the study (vs. control) group. We noted a trend toward higher modification of renal disease levels at 6 months posttransplant in the study (vs. control) groups. CONCLUSIONS: The combination of alemtuzumab and mycophenolate mofetil was associated with an acceptable rejection rate, a good safety profile, and good (graft and native) kidney function; it eliminated undesired calcineurin inhibitor- and steroid-related side effects. Longer follow-up is warranted before expanded application can be recommended.

Alemtuzumab↗
PubMed2004

Cytomegalovirus prophylaxis with valganciclovir in kidney, pancreas-kidney, and pancreas transplantation.

Cytomegalovirus, seen in more than 50% of solid organ transplant recipients, is responsible for numerous direct and indirect consequences, including infection with opportunistic pathogens and allograft rejection. Prophylaxis with intravenous ganciclovir has been the gold standard for prevention; however, intravenous treatment is expensive and carries risks of its own. Oral ganciclovir, to be effective, must be given in large, divided doses. Valganciclovir, the valine ester of ganciclovir, at 900 mg/day, provides oral bioavailability equivalent to that of intravenous ganciclovir and superior to that of oral ganciclovir. This retrospective study assessed the efficacy of 3 months prophylaxis with valganciclovir in kidney, simultaneous pancreas-kidney, and pancreas transplantation. Of 161 patients, all of whom received potent immunosuppressive regimens and were followed for a mean of 440 days, only one developed cytomegalovirus infection, at 120 days post-transplantation. Two patients died, and two others lost their grafts. There were seven incidents of acute rejection. Only seven patients discontinued treatment early, five because of leukopenia. These results suggest that prophylaxis with 900 mg/day of valganciclovir for at least 3 months safely and effectively prevents cytomegalovirus infection in kidney, simultaneous pancreas-kidney and pancreas transplant recipients on highly potent immunosuppression.

Adolescent↗
PubMed2005

Current practices of donor pancreas allocation in the UK: future implications for pancreas and islet transplantation.

Recent refinements in technique mean islet cell transplantation offers the chance of a cure to an increasing patient cohort with diabetes. Such developments put pressure upon the scarce resource of donor organs, with potential competition between the modalities of cellular and solid organ transplantation. This questionnaire based study examines current patterns of donor pancreas procurement and use. Reasons for non procurement are studied together with the attitudes of transplant professionals to pancreas allocation. The minority of potentially useful pancreata are currently made available to either whole pancreas or islet transplant programs. Whilst professionals appreciate the role of each modality, there is a need to define criteria for pancreas allocation to avoid under use of donor organs.

Adolescent↗
PubMed2005

An evidence-based analysis of simultaneous pancreas-kidney and pancreas transplantation alone.

While pancreas transplantation has evolved within two decades from a frustrating and poorly-accepted therapeutic option to a highly successful procedure, the respective benefits of the successive surgical and immunosuppressive developments have remained unclear. The aim of this study was to determine using an evidence-based methodology, which novel approaches have contributed to the current results and whether pancreas transplantation is cost-effective. Out of 2481 articles, 102 analyzed either surgical or immunosuppressive aspects of pancreas transplantation. Urological complications were more frequent in bladder over enteric drainage (range: 62-63% vs. 12-20%, p = 0.0001), but without significant difference in patient or graft survival. Portal drainage was associated with a trend toward fewer complications and better hyperinsulinemia control over systemic drainage in retrospective studies. Immunosuppression combining induction therapy, a calcineurin inhibitor, mycophenolate mophetil (MMF) and corticosteroids were associated with a 40% decreased incidence of rejection (p = 0.01) and an increase in graft survival above 90% at 1 year (p < 0.05). Pancreas transplantation is highly cost-effective compared to conservative alternatives. We conclude that despite a paucity of large studies, enteric drainage should be recommended but the benefits of portal venous drainage remain debated. Quadruple immunosuppression protocols including induction therapy should be the standard regimen.

Evidence-Based Medicine↗
PubMed1986

A historical perspective on the discovery of the accessory duct of the pancreas, the ampulla 'of Vater' and pancreas divisum.

The discovery of the accessory duct of the pancreas is usually ascribed to Giovanni Domenico Santorini (1681-1737), after whom this structure is named. The papilla duodeni (ampulla 'of Vater', or papilla 'of Santorini') is named after Abraham Vater (1684-1751) or after GD Santorini. Pancreas divisum, a persistence through non-fusion of the embryonic dorsal and ventral pancreas is a relatively common clinical condition, the discovery of which is usually ascribed to Joseph Hyrtl (1810-1894). In this review I report that pancreas divisum, the accessory duct and the papilla duodeni (ampulla 'of Vater') had all been observed and the observations published during the 17th century by at least seven anatomists before Santorini, Vater, and Hyrtl. I further suggest, in the light of frequent anatomical misattributions in common usage, that anatomical structures be referred to only by their proper anatomical names.

Ampulla of Vater↗