Purpose: Technical complications requiring early relaparotomy (relap) and allograft pancreatectomy (AP) have long been the Achilles heel of simultaneous kidney-pancreas transplantation (SKPT).

Methods: Single center retrospective review of all SKPTs from 11/1/01 – 8/12/20 managed with T-cell depleting antibody, tacrolimus, MMF, steroids, and enteric exocrine drainage.  Early relap was defined as occurring within 3 months of SKPT. Patients (pts) were stratified into 2 sequential eras: Era 1 (E1): 11/1/01 – 5/30/13; Era 2 (E2) 6/1/13 – 8/12/20.

Results: During the period of study, 255 SKPTs were performed (E1, n=165; E2, n=90) with an overall mean follow-up of 8.1±5 years. Recipient age and donor and recipient ethnicity, gender, and BMI were comparable between eras. E1 pts received organs from older donors (E1 27 vs. E2 23 years, P<0.001) with longer pancreas graft cold ischemic times (CIT) (E1 16 vs. E2 13 hours, P=0.04). E2 pts received more imported organs (E1 16% vs. E2 27%, P=0.04). E1 pts had a higher early relap rate (E1 43% vs. E2 14%, P<0.001) and were more likely to require AP (E1 10.3% vs E2 2.2%, P=0.019). E2 pts underwent systemic venous drainage more frequently (E1 8% vs. E2 29%, P<0.001). The most common indications for early relap in E1 were pancreas thrombosis (12%), abscess/infection (12%), bleeding (4%), and leak (4%) whereas in E2 were for abscess/infection (3%), small bowel obstruction (3%), and thrombosis (2%), P=0.001. Pancreas venous drainage technique did not affect either early relap or AP rates. Mean transplant volume was 14/year for E1 and 13/year for E2; mean transplant volume in the past 3 years of E2 was 18/year.

Conclusions: Maximizing donor quality (younger donors) and minimizing CIT are paramount for reducing complications requiring either early relap or AP and for optimizing long-term pancreas graft survival following SKPT.