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?

Dr. Joel Arudchelvam (2nd from right), Dr. Amanthana
Marasinghe (vascular and transplant surgeons). Dr.Rajeewa
Dassanayake (consultant nephrologist), Dr.Anver Sadath
(consultant nephrologist) and Dr.Premil Rajakrishna (nephrologist). |
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. |