Intraperitoneal Transplantation of Immediately Vascularized Segmental Pancreatic Grafts Without Duct Ligation

Five diabetic patients with renal allografts (placed 2 to 6 years ago) received cadaveric segmental pancreatic grafts (body and tail attached to splenic artery and vein) i.p. with the duct left open and vascular anastomoses to the common iliac vessels. The procedure was performed without technical mishaps in the first three patients who remain well 8 to 10 months later. The fourth patient developed severe cytomegalovirus (CMV) sepsis, had poor graft function, and died. The fifth patient received a graft from a donor with a gastrostomy. Three weeks later peritonitis, secondary to the same organisms grown from the donor gastrostomy site was diagnosed; a functioning graft was removed, but the patient ultimately died of respiratory complications. The three survivors had minimal to no abdominal pain for 2 weeks and none thereafter; mild to no ascites; no fistulas; and no peritonitis, although serum amylase levels were high. All three patients became normoglycemic. Patient 1 remains off insulin with a functioning graft at 10 months after transplantation. Patients 2 and 3 needed no insulin until rejection occurred at 3% and 2 months. The rejected grafts were not removed, and only resumption of insulin therapy was necessary. This experience shows that the peritoneum can absorb pancreatic secretions and free pancreatic juice can be tolerated in the peritoneal cavity, but there must be no microbial or enteric contamination at operation. Rejection can also be tolerated; the grafts may not need to be removed if there are no other problems. In patient 1, serum amylase has gradually declined, suggesting either that the duct was closing or that exocrine atophy was occurring; however, plasma glucose levels have remained normal. Thus, if rejection or technical complications can be prevented, good endocrine function can be provided by unligated segmental pancreatic grafts.