G Amorese

Robotic renal transplantation: first European case

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.

Surgical techniques for pancreas transplantation.

Purpose of reviewFrom 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 findingsThe 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. SummaryPancreas 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.

Laparoscopic Robot-Assisted Pancreas Transplantation: First World Experience

Background. 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. Methods. 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. Results. 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. Conclusions. 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.

The Learning Curve in Robotic Pancreaticoduodenectomy

Background/Purpose: Few data are available on the learning curve (LC) in robot-assisted pancreaticoduodenectomy (RAPD) and no study specifically addresses the LC of a single surgeon. Methods: The LC of a single surgeon in RAPD was determined using the cumulative sum method, based on operative time (OT). Data were extracted from a prospectively maintained database and analyzed retrospectively considering all events occurring within 90 days of index operation. Results: Seventy RAPD were analyzed. One operation was converted to open surgery (1.4%). One patient died within 30 days (1.4%) and one within 90 days (2.8%). Postoperative complications occurred in 53 patients (75.7%) and exceeded Clavien-Dindo grade IIIb in 7 patients (10%). OT dropped after 33 operations from a mean of 564 ± 101.7 min to a mean of 484.1 ± 77.9 min (p = 0.0005) and was associated to reduced incidence of delayed gastric emptying (72.7 vs. 48.7%; p = 0.039). The rate of hospital readmission improved after 40 operations from 20.0 (8 of 40) to 3.3% (1 of 30) (p = 0.04). Conclusions: RAPD was safely feasible in selected patients. OT dropped after the first 33 operations and was associated with reduced rate of delayed gastric emptying. Readmission rate improved after 40 operations.

Laparoscopic robot-assisted major hepatectomy

We herein present a systematic review of English literature on robot‐assisted major hepatectomy (MH).

Segmental live donor pancreas transplantation: review and critique of rationale, outcomes, and current recommendations

Boggi U, Amorese G, Marchetti P, Mosca F. Segmental live donor pancreas transplantation: review and critique of rationale, outcomes, and current recommendations.
Clin Transplant 2011: 25: 4–12.

Incidence, Diagnosis, and Treatment of Chylous Leakage After Laparoscopic Live Donor Nephrectomy

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.

Contribution of Contrast‐Enhanced Ultrasonography to Nonoperative Management of Segmental Ischemia of the Head of a Pancreas Graft

A 32‐year‐old recipient of a pancreas transplant (PTx) alone was diagnosed with segmental graft ischemia, involving the head of the pancreas graft (HPG), based on color Doppler ultrasonography (CDU) and computed tomography (CT) angiography. For investigational purposes, graft supply was further checked by contrast‐enhanced ultrasonography (CEU). Surprisingly, CEU showed collateral blood supply to the HPG starting from 40 s after contrast injection and resulting in homogenous parenchymography at 90 s. Full‐dose heparin infusion, followed by long‐term oral anticoagulation, allowed graft salvage without reoperation. At the longest follow‐up of 18 months, the patient is insulin independent. This case report shows that CEU may be employed in PTx recipients suspected to harbor vascular complications. To the best of our knowledge, this is the first description of the use of CEU in PTx and the first description of graft salvage, without partial pancreatectomy after CDU and CT diagnosis of segmental graft ischemia.

Total Duodenectomy with Enteric Duct Drainage: A Rescue Operation for Duodenal Complications Occurring after Pancreas Transplantation

Duodenal graft complications (DGC) occur frequently after pancreas transplantation but rarely cause graft loss. Graft pancreatectomy, however, may be required when DGC compromise recipients safety. We herein report on two patients with otherwise untreatable DGC in whom the entire pancreas was salvaged by means of total duodenectomy with enteric drainage of both pancreatic ducts. The first patient developed recurrent episodes of enteric bleeding, requiring hospitalization and blood transfusions, starting 21 months after transplantation. The disease causing hemorrhage could not be defined, despite extensive investigations, but the donor duodenum was eventually identified as the site of bleeding. The second patient was referred to us with a duodenal stump leak, 5 months after transplantation. Two previous surgeries had failed to seal the leak, despite opening a diverting stoma above the duodenal graft. Thirty‐nine and 16 months after total duodenectomy with dual duct drainage, respectively, both patients are insulin‐independent and free from abdominal complaints. Magnetic resonance pancreatography shows normal ducts both basal and after intravenous injection of secretin. The two cases presented herein show that when DGC jeopardize pancreas function or recipient safety, total duodenectomy with enteric duct drainage may become an option.

Efficacy and safety of basiliximab in kidney transplantation

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, discontin-ued all immunosuppressive agents.