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ABSTRACT: Type 1 diabetes is associated with high morbidity and mortality, mostly due to the acute and chronic complications of the disease. Restoration of the lost beta cell mass by pancreas transplantation is the treatment of choice in selected type 1 diabetic patients. Growing data show that successful pancreas transplantation normalizes the metabolic alterations of diabetes, and can slow the progression, stabilize, and even favor the regression of secondary complications of the disease, including those at the cardiovascular level.
Internal and Emergency Medicine 03/2013; · 2.06 Impact Factor
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Updates in surgery. 01/2013;
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Pancreatology 09/2012; 12(5):421-2. · 1.99 Impact Factor
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Ugo Boggi,
Fabio Vistoli,
Francesca Maria Egidi,
Piero Marchetti,
Nelide De Lio,
Vittorio Perrone,
Fabio Caniglia,
Stefano Signori,
Massimiliano Barsotti,
Matteo Bernini,
Margherita Occhipinti,
Daniele Focosi, Gabriella Amorese
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ABSTRACT: Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.
Current Diabetes Reports 07/2012; 12(5):568-79. · 2.50 Impact Factor
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ABSTRACT: Pancreatic fistula (PF) occurs frequently after central pancreatectomy (CP), but it is not clear from which pancreatic stump it arises and, consequently, which interventions can reduce its incidence and severity. The information could be obtained if the two pancreatic remnants were segregated into different body compartments.
In eight consecutive patients, the cut end of the distal pancreatic stump after CP was brought in the inframesocolic compartment through a small defect created in the transverse mesocolon. Pancreatojejunostomy was hence constructed in the intraperitoneal compartment, being divided by the retroperitoneal right-sided pancreatic stump by the transverse mesocolon itself. Five patients were operated on open, and three by robot-assisted laparoscopy. PF was defined according to the criteria proposed by the International Study Group on Pancreatic Fistula.
PF fistula developed in five out eight patients (three grade A and two grade B). Amylase concentration in the fluid obtained from surgical drains showed that the two pancreatic remnants were actually segregated into different body compartments and that four out of five PF originated from the right remnant. Mean hospital stay was 12.5 days. No patient was readmitted, developed peripancreatic fluid collections, required interventional radiology procedures, or underwent repeat surgery.
In CP, interposing an anatomic barrier, such as the transverse mesocolon, between the two pancreatic remnants is a simple maneuver that, if on one hand, adds little to the complexity of the operation, on the other, provides insights into the origin of PF after CP.
Langenbeck s Archives of Surgery 02/2012; 397(6):1013-21. · 1.81 Impact Factor
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Ugo Boggi,
Fabio Vistoli, Gabriella Amorese,
Rosa Giannarelli,
Alberto Coppelli,
Rita Mariotti,
Lorenzo Rondinini,
Massimiliamo Barsotti,
Stefano Signori,
Nelide De Lio,
Margherita Occhipinti,
Emanuela Mangione,
Diego Cantarovich,
Stefano Del Prato,
Franco Mosca,
Piero Marchetti
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ABSTRACT: Although combined pancreas and kidney transplantation is an established procedure for the treatment of type 1 diabetes (T1D) in patients with end-stage renal disease, the role of pancreas transplant alone (PTA) in the therapy of T1D subjects with preserved kidney function is still matter of debate.
We report our single-center experience of PTA in 71 consecutive T1D patients all with a posttransplant follow-up of 5 years. Patient and pancreas (normoglycemia in the absence of any antidiabetic therapy) survivals were determined, and several clinical parameters (including risk factors for cardiovascular diseases) were assessed. Cardiac evaluation and Doppler echocardiographic examination were also performed, and renal function and proteinuria were evaluated.
Actual patient and pancreas survivals at 5 years were 98.6% and 73.2%, respectively. Relaparotomy was needed in 18.3% of cases. Restoration of endogenous insulin secretion was accompanied by sustained normalization of fasting plasma glucose concentrations and HbA1c levels as well as significant improvement of total cholesterol, low-density lipoprotein-cholesterol, and blood pressure. An improvement of left ventricular ejection fraction was also observed. Proteinuria (24 hours) decreased significantly after transplantation. One patient developed end-stage renal disease. In the 51 patients with sustained pancreas graft function, kidney function (serum creatinine and glomerular filtration rate) decreased over time with a slower decline in recipients with pretransplant glomerular filtration rate less than 90 mL/min.
PTA was an effective and reasonably safe procedure in this single-center cohort of T1D patients.
Transplantation 02/2012; 93(8):842-6. · 4.00 Impact Factor
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ABSTRACT: Surgical complications are a major disincentive to pancreas transplantation, despite the undisputed benefits of restored insulin independence. The da Vinci surgical system, a computer-assisted electromechanical device, provides the unique opportunity to test whether laparoscopy can reduce the morbidity of pancreas transplantation.
Pancreas transplantation was performed by robot-assisted laparoscopy in three patients. The first patient received a pancreas after kidney transplant, the second a simultaneous pancreas kidney transplantation, and the third a pancreas transplant alone. Operations were carried out through an 11-mm optic port, two 8-mm operative ports, and a 7-cm midline incision. The latter was used to introduce the grafts, enable vascular cross-clamping, and create exocrine drainage into the jejunum.
The two solitary pancreas transplants required an operating time of 3 and 5 hr, respectively; the simultaneous pancreas kidney transplantation took 8 hr. Mean warm ischemia time of the pancreas graft was 34 min. All pancreatic transplants functioned immediately, and all recipients became insulin independent. The kidney graft, revascularized after 35 min of warm ischemia, also functioned immediately. No patient had complications during or after surgery. At the longer follow-up of 10, 8, and 6 months, respectively, all recipients are alive with normal graft function.
We have shown the feasibility of laparoscopic robot-assisted solitary pancreas and simultaneous pancreas and kidney transplantation. If the safety and feasibility of this procedure can be confirmed by larger series, laparoscopic robot-assisted pancreas transplantation could become a new option for diabetic patients needing beta-cell replacement.
Transplantation 01/2012; 93(2):201-6. · 4.00 Impact Factor
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Enzo Capocasale,
Maurizio Iaria,
Fabio Vistoli,
Stefano Signori,
Maria Patrizia Mazzoni,
Raffaele Dalla Valle,
Nelide De Lio,
Vittorio Perrone, Gabriella Amorese,
Franco Mosca,
Ugo Boggi
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ABSTRACT: Background. Chylous leakage (CL) is a rare complication of laparoscopic live donor nephrectomy (LLDN). It may lead to malnutrition and immunological deficits because of protein and lymphocyte depletion.
Methods. Data from 208 consecutive LLDN performed at two institutions, between April 2000 and September 2010, were reviewed to identify the anatomical basis behind CL along with its diagnostic and therapeutic options.
Results. CL developed in eight donors (3.8%), as determined by high-volume drainage (range 540–800 mL/24 hr) of triglyceride-rich fluid. All donors were managed conservatively. Seven were put on total parenteral nutrition plus octreotide. One received low-fat diet, medium-chain triglyceride supplementation, and octreotide. Chylous fistulas resolved in 5 to 16 days (mean time 12.3 days). Drains were removed before hospital discharge, and no donor was readmitted and/or needed outpatient care.
Conclusions. CL is a potentially insidious and perhaps misdiagnosed complication after LLDN. It occurs in nearly 4% of LLDN and it seems to be uniquely associated to left-sided kidney recovery because of distinctive lymphatics distribution around the periaortic area of dissection. Conservative therapy is effective in most donors and should be initially attempted. Surgical ligatures or fibrin sealants may be indicated in case of refractory CL before the arising of malnutrition and/or relevant immunodeficiency.
Transplantation 01/2012; 93(1):82-86. · 4.00 Impact Factor
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Transplantation 06/2011; 91(11):e79. · 4.00 Impact Factor
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ABSTRACT: A kidney from a 56-year-old mother was transplanted to her 37-year-old daughter laparoscopically using the daVinci HDSi surgical system. The kidney was introduced into the abdomen through a 7-cm suprapubic incision used also for the uretero-vescical anastomosis. Vascular anastomoses were carried out through a total of three additional ports. Surgery lasted 154 min, including 51 min of warm ischemia of the graft. Urine production started immediately after graft reperfusion. Renal function remains optimal at the longest follow-up of 3 months. The technique employed in this case is discussed in comparison with the only other two contemporary experiences, both from the USA. Furthermore, possible advantages and disadvantages of robotics in kidney transplantation are discussed extensively. We conclude that the daVinci surgical system allows the performance of kidney transplantation under optimal operative conditions. Further experience is needed, but it is likely that solid organ transplantation will not remain immune to robotics.
Transplant International 02/2011; 24(2):213-8. · 2.92 Impact Factor
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Ugo Boggi,
Stefano Signori,
Fabio Vistoli, Gabriella Amorese,
Giovanni Consani,
Nelide De Lio,
Vittorio Perrone,
Chiara Croce,
Piero Marchetti,
Diego Cantarovich,
Franco Mosca
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ABSTRACT: Pancreas transplant recipients continue to suffer high surgical morbidity. Current robotic technology provides a unique opportunity to test whether laparoscopy can improve the post-operative course of pancreas transplantation (PT). Current knowledge on robotic pancreas and renal transplantation was reviewed to determine feasibility and safety of robotic PT. Information available from literature was included in this review, together with personal experience including three PT, and two renal allotransplants. As of April 2011, the relevant literature provides two case reports on robotic renal transplantation. The author's experience consists of one further renal allotransplantation, two solitary PT, and one simultaneous pancreas-kidney transplantation. Information obtained at international conferences include several other renal allotransplants, but no additional PT. Preliminary data show that PT is feasible laparoscopically under robotic assistance, but raises concerns regarding the effects of increased warm ischemia time on graft viability. Indeed, during construction of vascular anastomoses, graft temperature progressively increases, since maintenance of a stable graft temperature is difficult to achieve laparoscopically. There is no proof that progressive graft warming produces actual damage to transplanted organs, unless exceedingly long. However, this important question is likely to elicit a vibrant discussion in the transplant community.
The Review of Diabetic Studies 01/2011; 8(1):28-34.
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Ugo Boggi,
Fabio Vistoli, Gabriella Amorese,
Rosa Giannarelli,
Alberto Coppelli,
Rita Mariotti,
Lorenzo Rondinini,
Massimiliamo Barsotti,
Alberto Piaggesi,
Anna Tedeschi,
Stefano Signori,
Nelide De Lio,
Margherita Occhipinti,
Emanuela Mangione,
Diego Cantarovich,
Stefano Del Prato,
Franco Mosca,
Piero Marchetti
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ABSTRACT: We report on our single-center experience with pancreas transplantation alone (PTA) in 71 patients with type 1 diabetes, and a 4-year follow-up. Portal insulin delivery was used in 73.2% of cases and enteric drainage of exocrine secretion in 100%. Immunosuppression consisted of basiliximab (76%), or thymoglobulin (24%), followed by mycophenolate mofetil, tacrolimus, and low-dose steroids. Actuarial patient and pancreas survival at 4 years were 98.4% and 76.7%, respectively. Relaparatomy was needed in 18.3% of patients. Restored endogenous insulin secretion resulted in sustained normalization of fasting plasma glucose levels and HbA1c concentration in all technically successful transplantations. Protenuria (24-hour) improved significantly after PTA. Renal function declined only in recipients with pretransplant glomerular filtration rate (GFR) greater than 90 ml/min, possibly as a result of correction of hyperfiltration following normalization of glucose metabolism. Further improvements were recorded in several cardiovascular risk factors, retinopathy, and neuropathy. We conclude that PTA was an effective and reasonably safe procedure in this single-center experience.
The Review of Diabetic Studies 01/2011; 8(2):259-67.
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ABSTRACT: We herein review and comment rationale, outcomes, and current recommendations for live donor (LD) pancreas transplantation (PTx). Segmental (spleen-preserving) pancreas donation is associated with a relatively small risk of complications. The risk of death, presumably not lower than that of LD nephrectomy, cannot be estimated yet because of the lack of reported donor fatalities. The prevalence of type 2 diabetes, in non-obese donors, is expected not to exceed 3%. The risk of type 1 diabetes does not seem to increase. Segmental LD PTx, when compared to cadaver PTx, continues to carry a slightly higher risk of technical failure, but the rate of immunologic failure is consistently lower. Overall, LD PTx should be considered in all patients with a live kidney donor (owing to the shortage of cadaver kidneys, the superlative outcome of LD kidney transplantation, and the immunologic advantages of simultaneous pancreas-kidney transplantation from the same donor). The immunologic advantages of LD PTx are emphasized in highly sensitized recipients of solitary PTx who, with cadaver donation, wait the longest time and face the poorest outcome. Furthermore, LD allows recipient pre-conditioning and/or pair donor exchange. In conclusion, LD PTx may offer significant advantages to well-selected diabetic recipients. LDs are exposed to relatively small risks.
Clinical Transplantation 01/2011; 25(1):4-12. · 1.67 Impact Factor
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ABSTRACT: Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function.
Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion.
Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.
Current opinion in organ transplantation 12/2009; 15(1):102-11. · 1.22 Impact Factor
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Ugo Boggi,
Marco Del Chiaro,
Chiara Croce,
Fabio Vistoli,
Stefano Signori,
Carlo Moretto, Gabriella Amorese,
Salvatore Mazzeo,
Carla Cappelli,
Daniela Campani,
Franco Mosca
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ABSTRACT: The purpose of this study was to evaluate the operative risk and the prognostic implications of pancreatectomy plus resection and reconstruction of peripancreatic vessels (PPV) in patients with pancreatic adenocarcinoma.
One hundred ten patients who underwent pancreatectomy with PPV resection and reconstruction (Study Group; SG) were retrospectively compared with 62 patients without distant metastasis who were palliated, (Control Group 1; CG-1), as well as 197 patients who underwent "conventional"pancreatectomy (Control Group 2; CG-2).
Postoperative morbidity and mortality were similar in SG (33% and 3%), in CG-1 (26% and 3%), and in CG-2 (40% and 6%) patients. Median survival time (MST) of SG patients (15 months) was longer than that of CG-1 patients (6 months; P < .0001) and similar to that of CG-2 patients (18 months). Patients undergoing isolated venous resection (n = 84) had the best outcome (MST: 15 months) ( P < .0001 vs CG-1 patients), while patients undergoing resection of multiple PPV (n = 14) had the worst outcome (MST: 8 months). PPV infiltration, histologically proven in 64 patients (65%), was associated with decreased MST only if the tunica intima was infiltrated (26%) (11 months; P < .001). Multivariate analysis showed that no adjuvant therapy, intimal invasion, and poorly differentiated histology were associated with a higher hazard of death by 2.2, 2.2, and 2.5-fold, respectively.
In properly selected patients, pancreatectomy plus resection and reconstruction of PPV was performed as safely as palliation or "conventional" pancreatectomy and was associated with better survival when compared to palliation.
Surgery 07/2009; 146(5):869-81. · 3.10 Impact Factor
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Ugo Boggi,
Marco Del Chiaro,
Chiara Croce, Gabriella Amorese,
Stefano Signori,
Fabio Vistoli,
Giulio Di Candio,
Alessandro Campatelli,
Luca Morelli,
Simone D'Imporzano,
Francesco Antonio Sgambelluri,
Irene Mosca,
Franco Mosca
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ABSTRACT: Despite decreased postoperative mortality, pancreatic resections continue to be associated with high morbidity rates. Vascular complications and, in particular, erosive bleeding from the large retroperitoneal vasculature are particularly difficult to treat and account for a large percentage of the residual postoperative mortality of pancreatic resections. We herein analyze the pathogenesis, diagnosis, preventive measures and possible remedies of either hemorrhagic or occlusive complications of pancreatic resections through a review of the literature and of our institutional experience consisting of 818 pancreatectomies.
JOP: Journal of the pancreas 02/2007; 8(1 Suppl):102-13.
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Transplantation 05/2006; 81(7):1067-8. · 4.00 Impact Factor
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Ugo Boggi,
Fabio Vistoli,
Stefano Signori,
Marco Del Chiaro,
Alessandro Campatelli, Gabriella Amorese,
Emanuele Marciano,
Alberto Coppelli,
Carla Tregnaghi,
Gaetano Rizzo,
Piero Marchetti,
Franco Mosca
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ABSTRACT: Pancreas transplantation (PTx) with portal-enteric drainage (PED) has been associated with difficulties in respect to arterial anastomosis and graft accessibility for percutaneous biopsy. We describe a new technique that circumvents these difficulties.
Between April 2001 and April 2004, a total of 113 recipients were scheduled for PTx with PED. The superior mesenteric vein was approached from the right retroperitoneal aspect instead of from the anterior transmesenteric route. The pancreas graft was eventually placed in the right retroperitoneal space, being covered by the ascending colon and its mesentery.
One hundred ten (97.3%) PTx were performed as planned. Systemic venous effluent was preferred in three patients because of incidental diagnosis of liver cirrhosis during surgery (n=1) and severe obesity (body mass index>35 kg/m2) (n=2). The Y iliac artery graft was kept as short as possible, and arterial anastomosis was always performed with ease. After a mean follow-up period of 21.2+/-19.9 months, the relaparotomy rate was 13.6%. No patient died after repeat surgery, and none required multiple relaparotomies. Overall, 10 grafts were lost because of acute rejection (n=3), chronic rejection (n=2), venous thrombosis (n=2), recipient death (n=2), and late (6-month) arterial thrombosis (n=1). One-year patient and graft survival were 98.1% and 90.7%, respectively.
Our data confirm that PTx with PED is not associated with an increased risk. The technique described has distinctive technical advantages and should be included in the repertoire of PTx.
Transplantation 06/2005; 79(9):1137-42. · 4.00 Impact Factor
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Ugo Boggi,
Fabio Vistoli,
Stefano Signori,
Marco Del Chiaro, Gabriella Amorese,
Massimiliano Barsotti,
Gaetano Rizzo,
Piero Marchetti,
Romano Danesi,
Mario Del Tacca,
Franco Mosca
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ABSTRACT: The efficacy and safety of basiliximab, in combination with different maintenance regimens, are extensively addressed in the available literature. Basiliximab reduces the incidence of acute rejection, allows a safe reduction of steroid dosage, and is associated with economic savings, although there is substantially no proof that basiliximab prolongs either patient or graft survival. Initial basiliximab administration entails a low-risk and is associated with fewer adverse events than T cell depleting agents. However, life-threatening reactions were reported following re-exposure to basiliximab in recipients who lost graft function early after transplantation and, therefore, discontinued all immunosuppressive agents.
Expert Opinion on Drug Safety 06/2005; 4(3):473-90. · 3.02 Impact Factor
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ABSTRACT: Purpose of review: From the beginning, pancreas transplantation proved to be effective but was associated with high rates of surgical complications and technical failure. Duct management and venous drainage were soon identified as major issues. The purpose of this review is to examine recent surgical advances with special reference to their possible metabolic and immunologic implications.
Recent findings: The new surgical techniques described in the period reviewed mainly address the issue of difficult vascular reconstruction possibly encountered with grafts from small pediatric donors or in patients with limited access to possible anastomotic sites. Portal-enteric drainage with retroperitoneal pancreas placement was also described. This technique facilitates arterial anastomosis using short Y grafts and improves graft accessibility for percutaneous biopsy.
Systemic venous drainage (vs. portal) is associated with hyperinsulinemia, but the relevance of increased insulin concentrations on the metabolic pathways of transplanted patients is still unclear.
The immunologic advantage of portal pancreas drainage on kidney rejection was not confirmed in a large UNOS survey. Other small studies, although not specifically designed to address this issue, do not highlight a clear immunologic benefit.
Summary: Pancreas transplantation remains an unfinished procedure. Enteric drainage is currently predominant in simultaneous pancreas-kidney transplantation but bladder drainage remains largely used in solitary transplants. Portal drainage is as safe as systemic drainage, but there is still no convincing evidence that it is immunologically or metabolically convenient. Future research should better address these issues in the setting of standardized, prospective, randomized studies, possibly enrolling patients without irreversible diabetic complications.
Current Opinion in Organ Transplantation 05/2005; 10(2):155-168. · 2.97 Impact Factor
