Background Information:

What are the other Names for the Procedure?

• Transplantation of Pancreas

What is the Pancreas Transplantation surgical procedure?

Pancreas Transplantation is a procedure to surgically remove a damaged or diseased pancreas and replace with a healthy pancreas, from a compatible donor (a donor who has immunological equivalent characteristics).

Pancreas Transplantation procedure is classified into four types:

• Pancreas Transplant Alone (PTA) procedure: PTA is performed in individuals who have type 1 insulin-dependent diabetes with frequent hypoglycemic (low blood sugar) attacks. In such individuals, the kidneys function quite normally
• Simultaneous Pancreas-Kidney Transplant (SPK) procedure: In this type of transplantation procedure an individual receives both the pancreas and kidney together, from the same donor (a deceased donor)
• Pancreas After Kidney Transplant (PAK) procedure: In this procedure, the Pancreas Transplantation (where the pancreas is obtained from a deceased donor) is performed in an individual, who has undergone a kidney transplant from a different donor. In other words, both the kidney and pancreas are from different donors. The kidney may have been from a donor who is alive or deceased
• Pancreas Transplant (pancreas obtained from a deceased donor) along with a Kidney Transplant (kidney obtained from a living donor): With this procedure type, there are advantages of performing both the deceased donor Pancreas Transplant and ‘live’ donor kidney transplant, because studies have shown lower graft rejection rates, decreased waiting times for transplant, and improved/successful long-term outcomes.

The following are certain conditions when Pancreas-Kidney Transplant (SPK) is not performed:

• Advanced stage of cancer
• HIV infection
• Severe heart failure
• Longstanding and constant drug abuse
• Advanced liver fibrosis and liver failure

What part of the Body does the Procedure involve?

The Pancreas Transplantation procedure involves the damaged or diseased pancreas and duodenum of the patient.

Why is the Pancreas Transplantation surgical procedure Performed?

Pancreas Transplantation procedure is performed for the following reasons:

• Preventing complications associated with severe diabetes, such as kidney failure (diabetic nephropathy) and injury to the retinas (diabetic retinopathy)
• The procedure is typically performed in individuals who have insulin-dependent diabetes i.e., mostly in those who have type 1 diabetes with end-stage kidney disease. In such cases, the Pancreas Transplantation procedure is usually performed along with a kidney transplant

Note: Not all diabetic patients are candidates for the Pancreas Transplantation surgical procedure.

What are some Alternative Choices for the Procedure?

Islet cell transplant is a procedure that involves transferring specialized insulin-producing cells into the diseased pancreas.

What are the Recent Advances in the Procedure?

Islet cell transplant is a procedure that involves transferring specialized insulin producing cells into the diseased pancreas.

What is the Cost of performing the Pancreas Transplantation surgical procedure?

The cost of Pancreas transplantation procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused by the information regarding Pancreas Transplantation surgical procedure on what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist and also recommend another physician, if required
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5^th Edition, New York, 2006

http://www.surgeryencyclopedia.com/La-Pa/Pancreas-Transplantation.html (accessed on 11/10/2014)

http://www.mayoclinic.org/tests-procedures/pancreas-transplant/ (accessed on 11/10/2014)

Prior to Pancreas Transplantation surgical procedure:

How is the Pancreas Transplantation surgical procedure Performed?

The Pancreas Transplantation procedure is performed under general anesthesia.

• The pancreas and a portion of the small intestine (duodenum) are removed from a suitable donor
• The surgeon makes an incision on the abdomen of the patient
• Leaving the original pancreas intact, the donor pancreas and small intestine are placed in the abdomen of the recipient
• The small intestine may be connected either to the intestine or to the bladder of the recipient
• The blood vessels are connected to the transplanted organs
• Sometimes, the patient may simultaneously undergo a kidney transplant
• The abdomen is then closed in layers

Where is the Procedure Performed?

A Pancreas Transplantation surgical procedure is performed in a hospital.

Who Performs the Procedure?

A surgeon with experience, training and specialized in Pancreas Transplantation surgery performs the procedure.

How long will the Procedure take?

A Pancreas Transplantation procedure may take up to 3 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Pancreas Transplantation procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Pancreas Transplantation procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Pancreas Transplantation surgical procedure?

Before a Pancreas Transplantation procedure, the patient has to undergo certain tests, such as:

• Immune system and pancreas matching procedures
• Body system studies

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is Pancreas Transplantation surgical procedure?
• Why is this procedure necessary?  How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Pancreas Transplantation surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia by injection and inhalation is administered for the Pancreas Transplantation procedure.

How much Blood will you lose, during the Procedure?

The blood loss during an uncomplicated Pancreas Transplantation surgery is not significantly high.

What are the possible Risks and Complications during the Pancreas Transplantation surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Pancreas Transplantation surgery are:

• Excessive bleeding
• Thrombosis of blood vessels
• Infection in the surgical wound
• Anesthetic complications
• Donor pancreas rejects its new host
• Failure of new donor pancreas to function normally at first
• Acute pancreatitis

What Post-Operative Care is needed at the Healthcare Facility after the Pancreas Transplantation surgical procedure?

• After the Pancreas Transplantation surgical procedure, the patients are sent to an area of the hospital called postoperative recovery area (or PACU)
• The patient’s blood pressure, heart rate, and respiration cycle, shall be closely monitored. Any additional pain associated with the procedure will be treated
• Individuals are usually discharged from the hospital, 3 weeks after the surgery is performed

After the Pancreas Transplantation surgical procedure:

What are the possible Risks and Complications after the Pancreas Transplantation surgical procedure?

Post Pancreas Transplantation procedure, the following complications may arise:

• Excessive bleeding
• Infection in the surgical wound
• Donor liver rejects its new host
• Bowel leakage
• Pancreatic fistula

What is the Prognosis after the Surgery?

The prognosis after a Pancreas Transplant procedure is usually good. More than half the patients have a functional transplant five years after the procedure.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Pain that worsens and swelling around the surgical wound
• Bleeding or fluid drainage from the surgical wound
• The occurrence of any symptom that causes uneasiness, such as nausea, vomiting, abnormal swelling, or prolonged constipation
• Signs of an infection
• Having to urinate more frequently
• Increased thirst
• Muscle aches, headache
• Dizziness
• Fever, feeling sick
• Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Pancreas Transplantation surgical procedure?

At home, the following post-operative care is recommended, after a Pancreas Transplantation procedure:

• Slowly resume regular/daily activities as early as possible, which aids in faster recovery
• Use a heat pad or warm compress to relieve pain due to the incision
• Resume showering and keep the wound clean and dry. Avoid taking baths until the surgical wound is completely healed. Gently wash the surgical wound with unscented soap and re-bandage the wound again
• Elevate legs while resting to prevent the formation of blood clots and reduce the possibility of swelling
• Take stool softeners to prevent constipation (under advice of the physician)
• Take antibiotic medication to help combat or prevent infection (per the physician’s advice)
• Complete the course of prescribed medication under advice of the physician
• Per physician’s advice, take immunosuppressant medications to reduce the possibility of rejection
• Avoid taking nonprescription medications, such as aspirin. However, individuals may take acetaminophen to relieve pain, per the physician’s advise
• Avoid all activities that are physically strenuous for about 6 months, or for a period as advised by your physician

How long does it normally take to fully recover, from the Procedure?

Recovery from a Pancreas Transplant procedure usually takes a few months, sometimes even up to six months.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later disposed as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Pancreas Transplantation surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital
• An anesthesiologist (if anesthesia was administered)
• A pathologist
• A general surgeon with experience in a Pancreas Transplantation procedure

The patient is advised to inquire and confirm the type of billing, before the Pancreas Transplantation procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA