Surgical intervention and techniques
hypocoagulative, CIA
HYPERCOAGULABLE STATE, THROMBOEMBOLISM
In this study, we clamped the superior mesenteric vein (SMV) to the root of the mesentery and after SMV venotomy, created an end-to-side portal vein to SMV anastomosis with the standard vessel anastomosis technique. For arterial reconstruction the patients were randomized to two groups: we used either the Y-graft technique (the classical technique commonly used in our center) or the Y-graft and extension technique (the new technique to be investigated here). The arterial reconstruction in the Y-graft technique is yielded by the anastomosis of the Y-graft to the common iliac artery (CIA) (Fig. In the new technique of Y-graft and extension, the Y-graft is created with short limbs and one extension graft is prepared, using the carotid to be anastomosed to the CIA (Fig. 
The schematic depiction of the Y-graft technique (A) and the Y-graft and extension technique (B)In the study, we created portal venous drainage for outflow of the pancreas. Patients were randomly selected for either of the arterial anastomosis method. For the first group, the Y-graft was directly anastomosed to the right iliac artery and for the second group an extension artery was prepared using the carotid artery. The extension was then, crossed through the mesentery and anastomosed to the right iliac artery, close to SMV. For all patients, pancreas was transplanted prior to the kidney. According to our center guidelines, the kidney is transplanted via the same abdominal incision, in the retroperitoneum and on the left side.During the surgery we did not close the fascia and leave it to be done in the following one year. Patients underwent simultaneous appendectomy and they were transferred to the post-transplantation intensive care unit with 2 drainage tubes, one inserted near the kidney and one near the pancreas. All the patients were transferred to the organ transplantation intensive care unit after the operation. Methylprednisolone (1 g/day till 3 doses) and ATG (1.5 g/day till 4 days) were used as induction immunosuppression and then anti metabolites, CNIs and prednisolone were used as maintenance therapy. The desired Tacrolimus blood level is 8–12 ng/dL which was first checked on the 3rd day. Patients were then extubated as soon as possible.The procedure of SPK transplantation, similar to any major surgeries, carries a high risk of thromboembolism. The rotational thromboelastometry (ROTEM) test was requested for the patients, if the result showed a hypercoagulable state, anticoagulation with heparin was started during hospitalization and patients were discharged with Aspirin. But if it shows hypocoagulative or normal state, we do not give any anti-coagulants either during hospitalization or after discharge.