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David E.r. Sutherland - One of the best experts on this subject based on the ideXlab platform.
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Controversies in Pancreas Transplantation.
Minerva chirurgica, 2015Co-Authors: Srinath Chinnakotla, Kaustav Majumder, David E.r. SutherlandAbstract:Pancreas transplants are now highly effective for patients with diabetes mellitus. Improvements in outcomes have primarily been due to significant reductions in technical failures and immunological graft loss. In this short review we discuss three areas of controversy in the field of Pancreas Transplantation. Notwithstanding the controversies we have highlighted, in line with the American Diabetic Association position statement, simultaneous Pancreas-kidney transplants and Pancreas after kidney transplants should be routine for diabetic kidney recipients, and a Pancreas transplant alone is appropriate for non-uremic labile diabetic patients.
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Pancreas Transplantation.
Gut and liver, 2010Co-Authors: Duck Jong Han, David E.r. SutherlandAbstract:Diabetes mellitus is generally treated with oral diabetic drugs and/or insulin. However, the morbidity and mortality associated with this condition increases over time, even in patients receiving intensive insulin treatment, and this is largely attributable to diabetic complications or the insulin therapy itself. Pancreas Transplantation in humans was first conducted in 1966, since when there has been much debate regarding the legitimacy of this procedure. Technical refinements and the development of better immunosuppressants and better postoperative care have brought about marked improvements in patient and graft survival and a reduction in postoperative morbidity. Consequently, Pancreas Transplantation has become the curative treatment modality for diabetes, particularly for type I diabetes. An overview of Pancreas Transplantation is provided herein, covering the history of Pancreas Transplantation, indications for Transplantation, cadaveric and living donors, surgical techniques, immunosuppressants, and outcome following Pancreas Transplantation. The impact of successful Pancreas Transplantation on the complications of diabetes will also be reviewed briefly.
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Pancreas Transplantation in the United States: a review.
Current opinion in organ transplantation, 2010Co-Authors: Angelika C. Gruessner, David E.r. Sutherland, Rainer W G GruessnerAbstract:Purpose of review The goal of Pancreas Transplantation is to restore normoglycemia in patients with labile diabetes. The results of this procedure improved over the years, but, although Pancreas Transplantation is not considered experimental anymore, there is often reluctance to recommend this procedure because of the complexity, especially for solitary Pancreas transplants. This article reviews the current status of Pancreas Transplantation. Recent findings Many improvements have been made in the surgical techniques and immunosuppressive regimens. The overall rate of technical problems decreased, yet immunologic graft loss is still a problem in solitary Pancreas transplants. Careful donor selection significantly decreased the risk of graft failure and therefore improved patient survival. Summary With modern immunosuppressive protocols and careful donor selection, patient survival rates and Pancreas transplant graft function can be further improved in all three Pancreas transplant categories.
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Pancreas Transplantation.
Lancet (London England), 2009Co-Authors: Steve A White, James A Shaw, David E.r. SutherlandAbstract:Since the introduction of Pancreas Transplantation more than 40 years ago, efforts to develop more minimally invasive techniques for endocrine replacement therapy have been in progress, yet this surgical procedure still remains the treatment of choice for diabetic patients with end-stage renal failure. Many improvements have been made in the surgical techniques and immunosuppressive regimens, both of which have contributed to an increasing number of indications for Pancreas Transplantation. This operation can be justified on the basis that patients replace daily injections of insulin with an improved quality of life but at the expense of a major surgical procedure and lifelong immunosuppression. The various indications, categories, and outcomes of patients having a Pancreas transplant are discussed, particularly with reference to the effect on long-term diabetic complications.
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decreased surgical risks of Pancreas Transplantation in the modern era
Annals of Surgery, 2000Co-Authors: Abhinav Humar, Rainer W G Gruessner, Angelika C. Gruessner, R. Kandaswamy, D K Granger, David E.r. SutherlandAbstract:ObjectiveTo document the decreased incidence of surgical complications after Pancreas Transplantation in recent times.Summary Background DataCompared with other abdominal transplants, Pancreas transplants have historically had the highest incidence of surgical complications. However, over the past f
Robert J. Stratta - One of the best experts on this subject based on the ideXlab platform.
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exocrine drainage in vascularized Pancreas Transplantation in the new millennium
World journal of transplantation, 2016Co-Authors: Hany Elhennawy, Robert J. Stratta, Fowler SmithAbstract:The history of vascularized Pancreas Transplantation largely parallels developments in immunosuppression and technical refinements in transplant surgery. From the late-1980s to 1995, most Pancreas transplants were whole organ pancreatic grafts with insulin delivery to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). The advent of bladder drainage revolutionized the safety and improved the success of Pancreas Transplantation. However, starting in 1995, a seismic change occurred from bladder to bowel exocrine drainage coincident with improvements in immunosuppression, preservation techniques, diagnostic monitoring, general medical care, and the success and frequency of enteric conversion. In the new millennium, Pancreas transplants are performed predominantly as pancreatico-duodenal grafts with enteric diversion of the pancreatic ductal secretions coupled with iliac vein provision of insulin (systemic-enteric technique) although the systemic-bladder technique endures as a preferred alternative in selected cases. In the early 1990s, a novel technique of venous drainage into the superior mesenteric vein combined with bowel exocrine diversion (portal-enteric technique) was designed and subsequently refined over the next ≥ 20 years to re-create the natural physiology of the Pancreas with first-pass hepatic processing of insulin. Enteric drainage usually refers to jejunal or ileal diversion of the exocrine secretions either with a primary enteric anastomosis or with an additional Roux limb. The portal-enteric technique has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion. Reports in the literature suggest no differences in Pancreas transplant outcomes irrespective of type of either venous or exocrine diversion. The purpose of this review is to examine the literature on exocrine drainage in the new millennium (the purported "enteric drainage" era) with special attention to technical variations and nuances in vascularized Pancreas Transplantation that have been proposed and studied in this time period.
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Pancreas Transplantation for type 2 diabetes mellitus
Current Opinion in Organ Transplantation, 2011Co-Authors: Giuseppe Orlando, Robert J. Stratta, Jimmy A LightAbstract:Purpose of reviewThis review will provide evidence that selected patients with type 2 diabetes mellitus (T2DM) may benefit from vascularized Pancreas Transplantation (PTX).Recent findingsInitial experience with simultaneous Pancreas–kidney Transplantation (SPKT) in patients with T2DM and end-stage r
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Review of immunosuppressive usage in Pancreas Transplantation.
Clinical transplantation, 1999Co-Authors: Robert J. StrattaAbstract:Throughout 1997, nearly 10,000 Pancreas transplants have been performed worldwide, with 88% being simultaneous kidney transplants (SKPT). The current 1 yr patient survival rate exceeds 90% and Pancreas graft survival (complete insulin independence) rate exceeds 80% for SKPT, 70% for sequential Pancreas after kidney transplant (PAKT), and 65% for Pancreas transplant alone (PTA). According to registry data, rejection accounts for 32% of graft failures in the first year after Pancreas Transplantation. However, improvements are expected to continue with the evolution of treatment protocols. Most Pancreas transplant centers employ quadruple drug immunosuppression with anti-lymphocyte induction with either a monoclonal or polyclonal antibody agent. In recent years, there has been an overall decline in the use of antibody induction therapy from 90% during the period 1987-1993 to 83% of Pancreas transplants performed during 1994-1997. Maintenance immunosuppression is triple therapy consisting of a calcineurin inhibitor (cyclosporine or tacrolimus), corticosteroids, and an anti-metabolite (AZA or MMF). Prior to 1995, nearly all Pancreas transplant recipients were managed with Sandimmune. In the last 2 yr, tacrolimus-based therapy has been used in approximately 20% of cases and a new microemulsion formulation of cyclosporine (Neoral) has replaced Sandimmune in contemporary post-transplant immunosuppression. In addition, MMF is replacing AZA as part of the standard immunosuppressive regimen after Pancreas Transplantation. At present, a number of centers are conducting various trials with new drug combinations including either Neoral or tacrolimus in combination with steroids and MMF with or without antibody induction therapy. From 1994 to 1997, the 1 yr rates of immunologic graft loss have decreased to 2% after SKPT, 9% after PAKT, and 16% after PTA. The current array of new immunosuppressive agents are providing more effective control of rejection and permitting solitary Pancreas Transplantation to become an accepted treatment option in diabetic patients without advanced complications. The apparent potency of new drug combinations has also resulted in a resurgence of interest in steroid withdrawal. Immunosuppressive strategies will continue to evolve in order to achieve effective control of rejection while minimizing injury to the allograft and risk to the patient. In addition, new regimens must not only address the issue of specific drug toxicities but also long-term economic, metabolic, and quality of life outcomes. Pancreas Transplantation will remain an important alternative in the treatment of diabetic patients until other strategies are developed that can provide equal glycemic control with less immunosuppression and overall morbidity.
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Evolution in Pancreas Transplantation techniques: simultaneous kidney-Pancreas Transplantation using portal-enteric drainage without antilymphocyte induction.
Annals of surgery, 1999Co-Authors: Robert J. Stratta, A. Osama Gaber, M. Hosein Shokouh-amiri, K. Sudhakar Reddy, Rita R. Alloway, M. Francesca Egidi, Hani P. Grewal, Lillian W. Gaber, Donna HathawayAbstract:The results of Pancreas Transplantation continue to improve as a result of refinements in surgical techniques and advances in immunosuppression. To date, most of the 10,000 Pancreas transplants reported to the International Pancreas Transplant Registry have been performed using the technique of systemic venous delivery of insulin and bladder drainage of the exocrine secretions (systemic-bladder). 1 Although systemic-bladder drainage is safe and effective, it results in peripheral hyperinsulinemia and is associated with unique metabolic and urologic complications. 2,3 Therefore, a resurgence of interest has occurred in primary enteric drainage of the exocrine secretions to avoid the complications of bladder drainage. The majority of Pancreas transplants with enteric drainage are performed with systemic venous delivery of insulin (systemic-enteric). To improve the physiology of Pancreas Transplantation further and avoid the potential complications of systemic hyperinsulinemia (e.g., dyslipidemia and accelerated atherosclerosis), a new surgical technique was developed at our center with portal venous delivery of insulin and enteric drainage of the exocrine secretions (portal-enteric [PE]). 4 We have previously reported that patient and graft survival rates were similar with PE drainage compared with systemic-bladder drainage, but there was a marked reduction in bladder-related complications and a greater improvement in the lipoprotein composition with PE drainage. 5,6 Most Pancreas transplant centers initially use quadruple drug immunosuppression with antilymphocyte induction (ALI) because of a high incidence of rejection and the general belief that the Pancreas is a highly immunogenic organ. 7 The evolution of surgical techniques has been in large part facilitated by the rapid changes in immunosuppressive therapy. Between 1989 and 1995, 94% of Pancreas transplants were performed with systemic-bladder drainage and 88% with quadruple immunosuppression with ALI. 1,7 The addition of an antilymphocyte agent provided enhanced immunosuppression in the early posttransplant period, but it was associated with added costs and adverse reactions. With the recent commercial availability of potent immunosuppressive agents such as tacrolimus and mycophenolate mofetil (MMF), the need for routine ALI therapy after Pancreas Transplantation is in question. 7 The purpose of this study was to evaluate an initial experience in simultaneous kidney and Pancreas transplants (SKPT) combining the PE drainage technique and an immunosuppression regimen of tacrolimus, MMF, and steroids without ALI.
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Vascularised Pancreas Transplantation.
BMJ (Clinical research ed.), 1996Co-Authors: Robert J. StrattaAbstract:In vascularised Pancreas Transplantation the organ is transplanted as a whole (as opposed to islet cell Transplantation, which is still experimental). The procedure re-establishes endogenous secretion of insulin that is responsive to normal feedback controls and is currently the only known treatment for diabetes that reliably achieves a euglycaemic state with complete normalisation of glycated haemoglobin concentrations.1 The costs that must be paid for normal glucose homeostasis are the operative risks of the procedure and the need for chronic immunosuppressive treatment. Between 1966 and 1995 over 7500 Pancreas Transplantations were performed worldwide and reported to the International Pancreas Transplant Registry.2 Most (87%) of these organs were transplanted in conjunction with kidneys as combined pancreatic and renal transplants into patients with impending or actual renal failure. The other operations included Transplantation of the Pancreas after the kidney (7.4%), Pancreas Transplantation done alone(5%), and Pancreas Transplantation in conjunction with a single organ other than the kidney or with multiple organs (less than 1%). The total number of Pancreas Transplantations done each …
Jon S. Odorico - One of the best experts on this subject based on the ideXlab platform.
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Frailty in Pancreas Transplantation
Transplantation, 2021Co-Authors: Sandesh Parajuli, Fahad Aziz, Neetika Garg, Rebecca E Wallschlaeger, Heather M Lorden, Talal Al-qaoud, Didier A. Mandelbrot, Jon S. OdoricoAbstract:There are a variety of definitions and criteria used in clinical practice to define frailty. In the absence of a gold standard definition, frailty has been operationally defined as meeting three out of five phenotypic criteria indicating compromised function: low grip strength, low energy, slowed walking speed, low physical activity, and unintentional weight loss. Frailty is a common problem in solid organ transplant candidates who are in the process of being listed for a transplant, as well as after Transplantation. Patients with diabetes or chronic kidney disease (CKD) are known to be at increased risk of being frail. As Pancreas Transplantation is exclusively performed among patients with diabetes and the majority of them also have CKD, Pancreas transplant candidates and recipients are at high risk of being frail. Sarcopenia, fatigue, low walking speed, low physical activity, and unintentional weight loss, which are some of the phenotypes of frailty, are very prevalent in this population. In various solid organs, frail patients are less likely to be listed or transplanted, and have high waitlist mortality. Even after a transplant, they have increased risk of prolonged hospitalization, readmission, and delayed graft function. Given the negative impact of frailty in solid organ transplants, we believe that frailty would have a similar or even worse impact in Pancreas Transplantation. Due to the paucity of data specifically among Pancreas transplant recipients, here we include frailty data from patients with CKD, diabetes, and various solid organ transplant recipients.
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Pancreas Transplantation in the Modern Era.
Gastroenterology clinics of North America, 2016Co-Authors: Robert R. Redfield, Michael R. Rickels, Ali Naji, Jon S. OdoricoAbstract:The field of Pancreas Transplantation has evolved from an experimental procedure in the 1980s to become a routine transplant in the modern era. With short- and long-term outcomes continuing to improve and the significant mortality, quality-of-life, and end-organ disease benefits, Pancreas Transplantation should be offered to more patients. In this article, we review current indications, patient selection, surgical considerations, complications, and outcomes in the modern era of Pancreas Transplantation.
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Induction therapy in Pancreas Transplantation.
Transplant international : official journal of the European Society for Organ Transplantation, 2013Co-Authors: Silke V. Niederhaus, Dixon B. Kaufman, Jon S. OdoricoAbstract:Induction therapy, the initial high-dose bolus of immunosuppression given perioperatively to transplant patients, is almost ubiquitous in Pancreas Transplantation. Despite the frequent use, scientific data on the risks and benefits of induction therapy are scarce, especially as it concerns use specifically for Pancreas Transplantation. Indeed, none of the currently used induction agents are approved as induction therapy for Pancreas Transplantation, yet potential benefit is largely extrapolated from trials in kidney transplant recipients. This review summarizes which induction therapy agents are available both now and historically, their mechanisms of action, and provides an overview of the published literature describing the use of these agents in simultaneous Pancreas-kidney transplant and solitary Pancreas transplant recipients. In summary, there are two multicenter randomized trials, several single-center randomized trials, and many other single-center descriptive reports. Overall, the main benefit of induction therapy is the ability to wean steroids earlier, and the main downside is a higher risk of opportunistic infections. Despite a lack of solid evidence, over 90% of Pancreas transplants performed annually in the United States receive some type of induction immunosuppression.
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Pancreas Transplantation: an overview
Transplantation Reviews, 2004Co-Authors: Antonio Di Carlo, Jon S. Odorico, Hans W. SollingerAbstract:Abstract Pancreas Transplantation has evolved to offer the most physiologic glucose regulation for patients with diabetes mellitus. This article describes the reported patient benefits of Pancreas Transplantation and highlights some of the evolving controversies in donor selection, indications for Transplantation, surgical options, and updates in immunosuppression.
Jimmy A Light - One of the best experts on this subject based on the ideXlab platform.
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Pancreas Transplantation for type 2 diabetes mellitus
Current Opinion in Organ Transplantation, 2011Co-Authors: Giuseppe Orlando, Robert J. Stratta, Jimmy A LightAbstract:Purpose of reviewThis review will provide evidence that selected patients with type 2 diabetes mellitus (T2DM) may benefit from vascularized Pancreas Transplantation (PTX).Recent findingsInitial experience with simultaneous Pancreas–kidney Transplantation (SPKT) in patients with T2DM and end-stage r
Ivo Tzvetanov - One of the best experts on this subject based on the ideXlab platform.
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Robotic Pancreas Transplantation.
Gastroenterology clinics of North America, 2018Co-Authors: Mario Spaggiari, Ivo Tzvetanov, Caterina Di Bella, Jose OberholzerAbstract:Obesity is considered a relative contraindication to Pancreas Transplantation due to an overall increased risk in wound-related complications and surgical site infections. The rationale for performing Pancreas Transplantation in a minimally invasive fashion is to reduce these risks, which can be associated with inferior patient and graft survival following Pancreas Transplantation in morbidly obese patients. At the University of Illinois at Chicago, the initial series of robotic-assisted Pancreas Transplantation in obese patient with type 1 and 2 diabetes has been performed. In this article, surgical technique and world experience in robotic Pancreas Transplantation are described.
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Robotic-assisted Pancreas Transplantation: where are we today?
Current opinion in organ transplantation, 2014Co-Authors: Ivo Tzvetanov, Giuseppe D’amico, Lorena Bejarano-pineda, Enrico BenedettiAbstract:PURPOSE OF REVIEW To analyze the current status of robotic-assisted Pancreas Transplantation as a treatment option for diabetic patients. RECENT FINDINGS Pancreas transplant recipients continue to suffer high rates of technical complications, including wound infections, fascial dehiscence, and postoperative ventral hernias. Robotic technology can potentially contribute to decreasing these dangerous complications and improve the postoperative course of Pancreas Transplantation. SUMMARY Current literature on both robotic Pancreas and robotic kidney transplant were reviewed in order to determine feasibility, safety, and efficacy of robotic Pancreas Transplantation. To date, only three cases of robotic Pancreas Transplantation, two of which were solely Pancreas Transplantation and one combined Pancreas-kidney Transplantation, have been reported in a single publication by an Italian group. Their preliminary data show that robotic Pancreas Transplantation is feasible and well tolerated. The authors believe that robotic Pancreas Transplantation could have a prominent role in lone Pancreas Transplantation performed in overweight recipients, in parallel to their experience with fully robotic kidney transplant in morbidly obese candidates. Broader experience with this innovative approach will be necessary to establish if robotic Pancreas Transplantation will be a beneficial option for diabetic patients needing beta-cell replacement.
