For 2 weeks in August 2018, I was in Warsaw, Poland for the Gap Medics Internship. The experience was fascinating, allowing me to observe surgeries from the same vantage point as the operating doctor while also giving me the opportunity to learn so much more about medicine. My first week in Poland was spent in the gastroenterology and transplantation department while my second week was spent in the orthopedics and traumatology department. Both weeks proved especially insightful and just showed how life-changing, and hard, medicine truly is. In this post, I will be discussing some gastrointestinal surgeries like a simultaneous pancreas and kidney transplant, a jejunostomy, and an abdominoperineal resection with a right hemicolectomy.
A simultaneous pancreas and kidney transplant (SPK) is one of the rarest and most technically challenging types of surgeries there is with fewer than 1000 done in the US each year. I was, fortunately, able to see this operation on my first night, coming into the hospital at 1 AM and staying until the surgery’s terminus at 5 AM. An SPK is used to cure a patient with Type 1 Diabetes as the pancreas is responsible for the creation of insulin, and in Type 1 Diabetes, the patient’s own pancreas is not making sufficient, or any, insulin. An SPK is the most common type of pancreas transplant; however, a pancreas transplant alone (PTA) and a pancreas after kidney transplant (PAK) can also be done. As this procedure is very invasive and carries the risk of many complications, SPK is generally only offered to those with life-threatening complications from T1D (like hypoglycemic unawareness) and with severe kidney disease (like end-stage renal disease). With a new pancreas and kidney, the patient can now produce their own insulin and manage damage to other structures like their eyes or nervous system, but they have to take immunosuppressants for the rest of their life to prevent immune attacks to their new pancreas and kidney.
After being transported from the brain-dead donor, the kidney was in ice when I walked into the OR as the surgeons sat around it, preparing the kidney by ligating various vessels and making sure that the renal artery, renal vein, and ureter were ready for their anastomosis to the recipient’s vessels. For the pancreas, which would be transplanted along with a section of the duodenum, the surgeons were constructing the portal vein, the superior mesenteric artery, the superior mesenteric vein, the splenic artery, and the splenic vein. The surgeon connected the donor’s splenic artery and the donor’s superior mesenteric artery to a Y graft made of the donor’s common iliac artery bifurcation into the internal iliac artery and the external iliac artery.
After preparing both organs, the kidney was the first to be transplanted after the surgeons created a pocket for it to lie in the iliac fossa. The kidney receives oxygenated blood via the renal artery, gets rid of deoxygenated blood via the renal vein, and disposes of waste products via the ureter. All three of these need to be reattached to the recipient’s vascular and urinary system. The recipient’s external iliac vein was clamped and cut before the donor’s renal vein was anastomosed to the external iliac vein in an end-to-side fashion. Following the kidney’s venous attachment, the surgeon created another opening in the recipient’s external iliac artery before “parachuting” the donor’s renal artery to it in a similar end-to-side anastomosis. He then went on to anastomose the ureter to the bladder, making sure the connection was tight. Soon after, the kidney became a light pink as it was reperfused with oxygenated blood.
The pancreas was then transplanted with the splenic artery and superior mesenteric artery being connected from the donor’s pancreas to the recipient’s external iliac artery via the Y graft described earlier. This gave the pancreas its arterial blood supply. Afterward, the superior mesenteric vein and the splenic vein were connected to the recipient’s common iliac vein via the donor’s portal vein. This reconstructed the pancreas’ venous blood supply. The donor’s duodenum attached to the pancreas was also anastomosed to the recipient’s duodenum in a side-to-side fashion so that the exocrine material (digestive enzymes) from the pancreas could drain through the pancreatic ducts into the donor’s duodenum and, from there, into the recipient’s duodenum.