GDT Vs ST for Pancreas Transplant Surgery

A Pancreas Transplant is the accepted treatment in patients with Insulin Dependent Diabetes Mellitus (IDDM) and end-organ failure. Simultaneous Pancreas and Kidney (SPK) Transplant is done in over 90% of cases. At present there is a 5- 8% 30-day mortality with over 80% graft survival at 1 year. At Manchester Royal Infirmary (MRI) approximately 40 cases are done per year.

Goal-Directed Therapy (GDT) involves fluid resuscitation intra-operatively and early in the post-operative period, guided by cardiac output monitoring. The mechanism of therapeutic benefit is thought to be related to improved tissue oxygenation and oxygen delivery. There are a number of studies showing significantly improved biochemical markers of inflammation in animal models and in studies on septic patients (patients with an overwhelming infection) following GDT. Studies have also shown that GDT improves clinical outcome in post-operative patients and in serum inflammatory mediators. These studies have looked at "major abdominal surgery" but none have investigated transplant patients. Given the nature of surgery we feel that our patients would benefit with reduced Intensive Care Unit stay, reduced length of hospital stays and reduced rates of post-operative complications.

The study will be conducted on all adult patients undergoing pancreas transplant at MRI. It will last for 2 years and we hope to recruit 60 patients

Patients will be randomised into Standard Therapy (ST) or GDT groups, with ST being current practice. Each intervention will last for six hours post-operatively before continuing with normal care thereafter. Omental fat biopsies will be taken from patients intra-operatively and blood samples will be taken from patients at regular intervals for 72 hours intra- and post- operatively. Patients will be followed up daily while an in-patient and at three-monthly intervals in out-patients for 1 year.

• Procedure: Goal-Directed Therapy
  Peri-operative optimisation of fluid status, based on Oxygen Delivery
• Procedure: Standard Therapy
  Following standard protocol during peri-operative period

• Experimental: Goal-Directed Therapy
  Intervention: Procedure: Goal-Directed Therapy
• Active Comparator: Standard Therapy
  Intervention: Procedure: Standard Therapy

Inclusion Criteria:

• All adult pancreas transplant recipients between November 2011- November 2013

Exclusion Criteria:

• Those unable to consent
• Paediatric recipients
• Patients unable to meet follow-up protocol
• Patients with a contra-indication to central venous catheterisation
• Patients with advanced directives, restricting the implementation of the study protocol