Pancreas Transplant
4855450360wRVU: 38.88 — Simultaneous kidney transplant (SPK)48556wRVU: 18.98 — Pancreas transplant, living donor (rare)
Type 1 diabetes mellitus with [ESRD / prior kidney transplant / brittle diabetes / hypoglycemia unawareness]: [SPK / PAK / PTA]
Same
Deceased donor pancreas transplant [with simultaneous kidney transplant (SPK)], enteric [/ bladder] drainage
[Attending name], MD
[Fellow/Resident name]
General endotracheal
Patient is a [Type 1 diabetic] with [ESRD / prior kidney transplant / hypoglycemia unawareness / brittle diabetes] presenting for [SPK / PAK / PTA]. MELD equivalent [X], HbA1c [X], C-peptide [X]. ABO compatible. Cross-match negative. CMV D/R [+/-]. Cold ischemia time [X] hours. Risks including thrombosis (most common cause of early graft loss), pancreatitis, enteric leak, rejection, infection, and death discussed. Consent obtained.
Pancreas graft [appeared viable, soft, and pink / mild edema / excellent perfusion on back table]. Donor duodenal segment [adequate length, viable]. On reperfusion: [immediate softening and improved texture / initial congestion resolved after flushing]. [Portal glucose monitoring showed rapid normalization.]
The patient was positioned supine. A midline laparotomy was performed from xiphoid to pubis. The retroperitoneal space was developed.
[For SPK: kidney implanted first via right iliac fossa; see concurrent kidney transplant note. Pancreas placed in left iliac fossa.]
The pancreas was placed intraperitoneally [/ retroperitoneally]. The donor iliac Y-graft (reconstructed on back table) was anastomosed end-to-side to the [right / left] external or common iliac artery with running [5-0 / 6-0 Prolene]. The donor portal vein was anastomosed end-to-side to the [right iliac vein / superior mesenteric vein (systemic / portal drainage)] with running [5-0 Prolene].
Clamps released; [immediate reperfusion with color change]. [Blood glucose checked; trending down within minutes of reperfusion.]
EXOCRINE DRAINAGE (ENTERIC): A [side-to-side / Roux-en-Y] duodenojejunostomy was performed using [3-0 Vicryl / GIA stapler] with [hand-sewn / stapled] technique, creating enteric drainage of the donor duodenal segment.
Hemostasis confirmed. [Closed-suction drains placed near pancreatic hilum.] Midline fascia closed with running [looped PDS]. Skin closed with staples. Patient tolerated the procedure well.
None
None
[X] mL
[Jackson-Pratt drain near pancreatic hilum / None]
Patient taken to transplant ICU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Type 1 diabetes mellitus with [ESRD / prior kidney transplant / hypoglycemia unawareness]: [SPK / PAK / PTA]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Deceased donor pancreas transplant [with simultaneous kidney (SPK)], enteric drainage
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX Type 1 diabetic with [ESRD / prior kidney transplant / brittle diabetes] presenting for [SPK / PAK / PTA]. ABO compatible. Cross-match negative. CMV D/R: ***. Cold ischemia time: *** hours. Risks including graft thrombosis, pancreatitis, enteric leak, rejection, and death discussed. Informed consent obtained.
FINDINGS: Pancreas graft viable, pink, soft on back table. Donor duodenal segment adequate. Reperfusion: immediate color change. [Blood glucose trending down intraoperatively.]
DESCRIPTION OF PROCEDURE:
Patient supine. Midline laparotomy xiphoid to pubis. [SPK: kidney placed in right iliac fossa first.] Pancreas placed [intraperitoneally / retroperitoneally] in left iliac fossa. Donor iliac Y-graft anastomosed end-to-side to [right / left] iliac artery with 5-0 Prolene. Donor portal vein anastomosed end-to-side to [iliac vein / SMV] with 5-0 Prolene. Clamps released; immediate reperfusion. Exocrine drainage: [duodeno-jejunostomy / Roux-en-Y] created with [hand-sewn / stapled] technique. Hemostasis confirmed. [JP drain placed.] Fascia closed with looped PDS; skin with staples. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [JP drain near hilum / None]
DISPOSITION: Patient to transplant ICU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Bladder drainage (less common, selected cases)
Duodenocystostomy instead of enteric anastomosis. Allows urinary amylase monitoring for rejection. Associated with urologic complications (hematuria, urethritis, metabolic acidosis). Document rationale for bladder vs. enteric drainage.
Portal venous drainage (vs. systemic)
SMV anastomosis (portal drainage) vs. iliac vein (systemic drainage). Portal drainage is more physiologic but technically more demanding. Document approach and anastomotic site explicitly.
Charting Tips
- Document cold ischemia time and warm ischemia time
- {'State vascular anastomotic technique': 'arterial (Y-graft) and venous (systemic vs. portal)'}
- {'Note exocrine drainage technique': 'enteric (duodenojejunostomy) vs. bladder'}
- Document intraoperative glucose trend after reperfusion as a functional marker
- Record drain placement (near pancreatic hilum is standard)
- Note Y-graft reconstruction on back table (iliac artery bifurcation to splenic and SMA)
Billing Tips
- Bill 48554 for pancreas transplant, deceased donor (38.53 wRVU, 90-day global). For simultaneous pancreas-kidney (SPK), bill 48554 for the pancreas and 50360 for the kidney. These are separately reportable and each carries its own wRVU. Document both procedures.
- The duodenal segment management (enteric vs. bladder drainage) is included in 48554. Do not separately bill anastomosis codes. Document drainage technique used, as this affects postoperative management and complication coding.
- Exocrine drainage via enteric anastomosis (Roux-en-Y or duodeno-jejunostomy) is standard and included in 48554. Bladder drainage (now less common) is also included. Document which technique was used and rationale.
- Pancreas transplant alone (PTA) and pancreas after kidney (PAK) use the same code 48554. The clinical indication and timing relative to kidney transplant are documented in the note but do not change the CPT.
- 90-day global: rejection workup, Doppler surveillance, cystoscopy (bladder drainage), and wound management are bundled in the surgical fee. Endoscopy for enteric leak or ERCP is a separate procedure fee but the surgical consultation component is included.