Trailblazer in transplant surgery

Anuradhapura Hospital performs Lanka’s first simultaneous pancreas and kidney transplant :

By Carol Aloysius

Diabetes mellitus is a common disease condition in Sri Lanka. However, if this condition is not properly controlled, over long term it can result in complications in other organs; namely kidneys, eyes, blood vessels, nerves, among others.

“When kidneys fail, the urine production and excretion of waste material with it reduces. This results in toxic materials, acid and water accumulating in the body resulting in oedema (swelling),shortness of breath, lack of appetite, body aches, bone diseases, anaemia and high blood pressure, among other complications”, Vascular and Transplant Surgeon, Dr Joel Arudchelvam who led the surgery, told the Sunday Observer as he unveiled the news of another first for Sri Lankan surgeons : the first ever combined (simultaneous ) pancreas and kidney transplantation (SPK) performed in the country. The trailblazing surgery was performed at the Anuradhapura Teaching Hospital.

The surgery was done by a seven member team led by Dr. Joel Arudchelvam and Dr. Amanthana Marasinghe (vascular and transplant surgeons). Others in the transplant team were Dr.Rajeewa Dassanayake (consultant nephrologist), Dr.Anver Sadath (consultant nephrologist) and Dr.Premil Rajakrishna (nephrologist).

The Sunday Observer spoke to Dr Arudchelvam to find out more about his path breaking surgery.

Excerpts…

Q:What does Simultaneous Pancreas and Kidney Transplant (SPK) mean?

A. When a patient with diabetes mellitus develops end stage renal failure he will need kidney transplantation. If this patient’s blood sugar control is also difficult even with insulin, a pancreas can be transplanted at the same time as the kidney transplantation. This is called Simultaneous Pancreas and Kidney transplantation (SPK)

Q: What was the need for both transplants to be done at the same time? Couldn’t patients with diabetes mellitus undergo just one, namely pancreas transplant?

A. In some patients with diabetes mellitus which was complicated and difficult to control with insulin, as well as in patients who already had kidney transplant a ‘pancreas alone transplantation’ is possible. However, a few patients with advanced complications need to undergo a combined pancreas and kidney transplantation (SPK). Up to now, such patients had to go abroad for these operations. Now, finally, we have made this facility available here.

Q: What are the benefits of such a surgery to these diabetic patients?

A. Their diabetes mellitus is cured, and the new kidney, when it starts functioning well, will improve the quality of the life of the patient. It was to enhance the quality of life of one such patient that the operating team at the Anuradhapura Teaching Hospital came together to perform their path breaking surgery. The patient was a 47 year old male who had diabetes mellitus and renal failure, and whose blood sugar was difficult to control. The pancreas and kidney were retrieved from a forty one year old Brain Dead donor. It took ten hours for both operations. We began operating at 5.pm on July 20 and finished at 3.30 p.m. the next day.

Q:Tell us something about the procedure involved in this never before performed surgery in Sri Lanka.

A. After taking these organs out from the donor they are kept in cold preservative solution. Then, the recipient surgery began. The recipient’s abdomen was opened through midline incision and the vessels which run from abdomen to the legs (Iliac vessels) – refer the diagram) were prepared on both sides for the transplantation of organs. First the pancreatic vessels were sutured to the right iliac vessels (anastomosis) and the duodenum of the donor which comes with the pancreas was joined to the patient’s small bowel.

That completes the pancreatic transplantation. This was followed by kidney transplantation. The kidney was attached to the left iliac vessels and the ureter (tube running from kidney carrying urine) was joined to the patient’s bladder. The abdomen was then closed and the patient sent to intensive care unit (ICU)

Q:What are the precautions needed after such an operation?

A. After transplantation the transplanted organs (pancreas and kidney) may be rejected by the patient’s immune system. To prevent this, the patient needs to be on regular lifelong anti-rejection medications. To detect rejection they have to do some blood tests regularly as instructed by doctors.

Q: What happens if they do reject the organs despite these precautions?

A. When that happens, the functions of both, kidney and pancreas get affected. When the pancreas is affected, the blood glucose level rises. In addition, the pancreas inflames (transplant pancreatitis) and the patient develops abdominal pain. When the kidney is rejected the amount of urine produced is reduced and the serum creatinine rises, causing body swelling. Generally, the pancreas and kidneys are rejected together. When the patient develops rejection he needs to get admitted for further anti rejection medications.

Q: Do all patients with diabetes mellitus need a pancreatic transplantation?

A. No. as I mentioned earlier only patients who have high blood sugar despite being on a high dose of insulin and other organ complications need a pancreatic transplantation. Others can be managed with oral drugs or a small dose of insulin.

Q: For the benefit of our readers, could you explain the types of diabetes mellitus.

A. Diabetes mellitus is divided into two types, namely, Type I and Type II. In type I, the beta cells in the pancreas which secrete insulin is destroyed by antibodies produced by the patient’s own body (auto antibodies).

This usually happens in young patients and since they are going to have diabetes mellitus for a long time, the chances of getting other organ complications are high.

Pancreatic transplantation is often done for type I diabetes mellitus. In type II, there is lack of insulin or lack of action of insulin (insulin resistance). This type of diabetes mellitus occurs in late middle age and in older people, and the chance of undergoing a pancreatic transplantation is low in their lifetime.”

Q: What are the precautions that a patient needs to take after simultaneous pancreatic and kidney transplantation?

A. After transplantation the transplanted organs (pancreas and kidney) may be rejected by the patient’s immune system.

To prevent this, the patient needs to be on regular lifelong anti-rejection medications. To detect rejection they have to do some blood tests regularly as instructed by doctors. However, some patients can still develop rejections. When this happens the functions of both kidney and pancreas get affected. When the pancreas is affected, the blood glucose level rises.

In addition, the pancreas inflames (transplant pancreatitis) and patient develops abdominal pain. When the kidney is rejected the amount of urine produced is reduced and the serum creatinine rises, thereby causing body swelling. Generally, the pancreas and kidneys are rejected together. When this happens the patient needs to get admitted and undergo further anti rejection medications.

Q: Other complications that can happen after simultaneous pancreatic and kidney transplantation?

A. During and after surgery the patient can develop bleeding (haemorrhage / haematoma), or a clot can develop inside the blood vessels (vascular thrombosis). When this happens it is a disaster and the organs have to be taken out.

Also, the bowel anastomosis of the pancreas can leak. In transplanted kidneys the ureter can either get blocked (obstruction) or it can leak (anastomotic leak). Besides, long term patients can develop complications due to anti rejection medications (e.g. Infections). When these things happen the function of the organs reduce.

Q: What are the main obstacles to simultaneous pancreatic and kidney transplantation?

A. There are several obstacles to transplantation in this country. Firstly, there are only a few surgeons in the country who are trained to do pancreatic and kidney transplantation (e.g. vascular and transplant surgeons).

So, there is a need to train more doctors and other staff in this field. Also, the infrastructure needs to be developed (operation theatres, instruments, transport and investigations, etc.) The other main obstacle is the lack of donors.

The pancreas and other organs are taken mainly from brain dead donors. But, lack of knowledge about brain dead donation (both among public and health care professionals) results in the loss of a lot of potential donors. More awareness raising programs are necessary at national level.

Q: Your message to patients and the public?

A. There are many patients with diabetes mellitus in Sri Lanka. But, by following medical instructions carefully and by controlling blood sugar, they can avoid many complications and avoid undergoing a complicated surgery like simultaneous pancreatic and kidney transplantation.

Also, there must be more awareness among the public about organ donation which will save and improve the quality of many lives.