JOURNAL

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RESEARCH

20,

Porcine

451-460 (1976)

Pancreatic

I. Autotransplantation

Transplantation

of Duct Ligated

Segments

GEORGE K. KYRIAKIDES, M.D., VIJENDER K. ARORA, M.D., JUDITH LIFTON, B.S., FRANK Q. NUTTALL, M.D., AND JOSHUA MILLER, M.D. Departments of Surgery and Medicine, Veterans Administration Hospital and University of Minnesota, Minneapolis, Minnesota 55417 Submitted for publication December 31, 1975

Transplantation of a segment of the pancreas with ligation of the duct has been attempted both experimentally and clinically [31, 33, 161, but has been unsuccessful because of either (a) early inflammation of the graft leading to severe pancreatitis, thrombosis, autolysis, accumulation of amylaserich peripancreatic fluid with secondary infection [31, 16, 6, 111or (b) later extensive fibrosis of exocrine pancreatic tissue, chronic inflammation and decrease in insulin production by thegraft [31, 15, 181. The purpose of this investigation was to develop a reproducible technique of segmental duct ligated pancreatic autotransplantation in the pig so as to evaluate methods to prevent both the early and late complications. The present study was limited to heterotopic autotransplants to the neck in order to evaluate the degenerative pathophysiologic effect of duct ligated pancreatic grafts, while avoiding the effects of rejection. Several protocols are described which profoundly inhibit autodigestion, fluid accumulation and fibrosis of the graft. A second study [19] has been performed on segmental duct ligated pancreatic allografts. MATERIALS

AND METHODS

Animals

Female pigs were used, weighing between 55 and 70 lb. Routine vascular anastomosis could be performed with pigs of this size and postoperative management was less difficult than with larger pigs. In conducting the research in this report, the investigators ad-

hered to the Guide for Laboratory Animal Facilities and Care of the Institute of Laboratory Animal Resources, National Academy of Sciences-National Research Council. Operative Technique

General anesthesia with endotracheal halothane supplemented by nitrous oxide and oxygen was used. During the procedure the animals received 2 liters of Ringer’s lactate solution containing 1 million units of penicillin and 250 mg of Solu-Medrol/liter. Using a midline incision, the tail and distal body of the pancreas were mobilized to the junction of the splenic, superior mesenteric and portal veins. At this point the porcine pancreas divides into two narrow strips, one crossing the superior mesenteric vein anteriorly and one posteriorly (Fig. 1). These two strips were divided between ligatures, and the distal portion of the gland was used as the graft after dividing the short gastric and left gastric vessels and isolating the gland on a vascular stalk of the celiac artery and splenic vein at its entrance into the portal trunk. The hepatic artery was divided distal to the celiac trunk. The splenic artery in the hilus of the spleen was cannulated and the spleen was removed after ligation of the splenic vessels distal to the cannula. The celiac artery was temporarily proximally occluded and then divided. Then the splenic vein was divided at its junction with the portal vein and the venous stump on the portal vein was ligated. The graft was then perfused ex vivo with 250 ml of Ringer’s

4.51 Copyright o 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.

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plasma for the perfusion was prepared according to the methods of Belzer et al. [3]. The plasma was frozen, thawed and filtered, and MgSO, (8 mEq/liter), regular insulin (80 units/liter), Solu-Medrol (800 mg/liter), dexamethasone (8 mg/liter), PSP indicator (2 ml) and aqueous penicillin G (1 million units) were added. The system was primed with 500 cc of perfusate. The pancreas was placed in the circuit after an initial wash out with 250 cc of Ringer’s lactate containing sodium bicarbonate, procaine (1 g/liter), SoluMedrol (500 mg/liter) and heparin (10,000 units/liter), at 4°C. Perfusion was at 7°C with gas Bows adjusted for a pH of 7.4. The pulse rate was set at 30/min and pressure was adjusted as needed to prevent excessive FIG. I. The anatomy of the porcine pancreas is pressure rise on the system, usually varying shown diagrammatically. The pancreatic graft is shown in the insert; this is the distal portion of the pancreas to between 30 and 50 mm Hg. the left of the mesenteric vein.

lactate containing 2 ml of sodium bicarbonate, 500 mg Solu-Medrol and 10,000units of heparin/liter at 4°C through the cannulated splenic artery with the celiac artery stump of the graft being temporarily occluded. The hepatic and left gastric arterial stumps in the graft were ligated. The graft was then transplanted to the right side of the neck, using end-to-end anastomoses between the celiac and common carotid arteries and the splenic and external jugular veins. The celiac artery stump in the abdomen was anastomosed endto-end to the distal hepatic artery, reestablishing arterial blood flow to the stomach, duodenum and liver. The gallbladder was removed in order to avoid necrosis in case of compromised blood supply. Postoperatively the animals were given penicillin, streptomycin and subcutaneous heparin (10,000 units) daily for 5 days. They were allowed water on the first postoperative day and food on the second postoperative day. Preservation

Radiation

Radiation was administered to the grafts ex vivo while on the portable preservation machine using a 220 kV machine (15 mA) with a 1.2 mm aluminum filter at a distance of 15 cm and a rate of 100 R/min. Functional and Morphologic

Studies

Fasting blood sugar was determined before operation and at sacrifice. Graft arterial (carotid) and venous (jugular) insulin levels were determined by radioimmunoassay both at the time of transplantation as well as at sacrifice. Insulin production by the graft was expressed as the difference between the arterial and venous insulin levels (V-A difference). Serum amylase determinations were made before operation and at sacrifice. The amount and amylase concentration of the peripancreatic fluid was measured. At sacrifice tissue was taken from both the graft and the pancreatic remnant in the abdomen for histologic study. Sections were stained with both hematoxylin and eosin and aldehyde-fuchsin.

Pancreas grafts were preserved by Experimental Groups A total of 69 animals were heterotopically pulsatile hypothermic perfusion using the “MOX” 100 kidney preservation machine autotransplanted and divided into the follow(Waters Co., Rochester, Minn.). Pooled pig ing groups:

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Group 1. Control animals (n = 24). No treatment was given to these animals other than antibiotics and heparin. Group 2. Solu-Medrol treatment (n = 17). After transplantation these animals were treated with daily intramuscular injections of Solu-Medrol, 500 mg/day. Group 3. Pancreas preservation (n = 3). Grafts were autotransplanted after pulsatile preservation for 4 hr. Group 4. Irradiated grafts (n = 6). 5000 R was administered to each graft while on perfusion. Group 5. Irradiation and postoperative Solu-Medrol (N = 6). Grafts were irradiated as in group 4 and in addition the animals were treated with daily injections of 500 mg SoluMedrol as in group 2. Group 6. Trasylol (Aprotinin) treatment (n = 7). The grafts were perfused with lOO,000 units of Trasylol mixed in 250 cc of perfusate. After transplantation daily Trasylol injections were given, 100,000 units IM. Group 7. Glucagon treatment (n = 5). Glucagon (4 mg) was administered IM twice daily after 1 mg was given iv preoperatively. Group 8. Glucagon and steroid treatment (n = 6). Postoperative treatment with SoluMedrol as in group 2, and glucagon as in group 7.

Morphologic

I. 2. 3. 4. 5.

Control Solu-Medrol Preservation Radiation Radiation + Solu-Medrol 6. Trasylol 7. Glucagon 8. Glucagon + Solu-Medrol

Animals were sacrificed at 1 to 2 week intervals and morphologic as well as functional studies were done whenever possible. RESULTS Survival and Graft Morphology

Survival and morphological results of all the groups are summarized in Table 1 and are the findings 2 weeks after implantation. Contributory causes of occasional deaths in all groups were pneumonia, peripancreatic abscess, ischemic necrosis of the stomach and peritonitis. Group 1. By 14 days postoperatively 5 of the 24 animals in this group died. Of the 19 surviving animals 5 had necrotic grafts, and no further study was done. Of the 14 remaining grafts, 12 showed severe macroscopic changes, including edema, thick fibrous capsules, multiple cysts filled with fluid, areas of hemorrhage, necrosis and interlobular fibrosis. Histologically there was intense interstitial edema, architectural distortion of the acini, dilatation of ducts, arteriolar and venous thrombosis, necrosis of pancreatic parenchyma and severe fibrosis (Fig. 2). The number of islets was reduced compared to the normal pancreatic remnant in the abdomen. Group 2. Two of 17 animals died by 14 days postoperatively. Of the 15 survivors there were two necrotic grafts. The others

TABLE I and Viability of the Duct Ligated Pancreas 2 Weeks after Autotransplantation

Characteristics

Group

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Total No. animals

No. surviving animals

Viable grafts

24 I7 3 6 6

I9 I5 3 4 4

I4 I3 2 3 3

7 5 6

6 5 6

3 2 6

Severe morphologic changes (fibrosis, inflammation, necrosis, cyst formation, duct dilatation) 12114 o/13

Peripancreatic fluid volume (range) (m 1)

l/3 O/3

250-750 750~1700 500- 1000 500~1000 500- 1000

313

250-750

012

212 O/5

IO-35

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FIG. 2. Photomicrograph of control autograft 2 weeks following transplantation. There is complete disorganization of pancreatic architecture, inflammation, duct dilatation and fibrosis; the findings are compatible with severe pancreatitis (hematoxylin-eosin stain).

were remarkably free of the degenerative or inflammatory changes which occurred in the controls. These grafts were covered with a thin, filmy capsule with a normal macroscopic appearance. Histologically these grafts were characterized by very minimal inflammation and edema. Fibrosis was virtually absent (Fig. 3). Islets of Langerhans were abundant. Group 3. Perfusion characteristics were remarkably stable in this group as well as group 4. After 4 hr of preservation by pulsatile hypothermic perfusion the pancreas had only minimal edema. All 3 animals survived, but one had thrombosed vessels at sacrifice. In the other two animals, the grafts were fairly well preserved, with moderate gross inflammatory changes and mild fibrosis and inflammation histologically. Group 4. Four of six animals survived. One had a necrotic graft. In the remaining three grafts there were moderate gross and microscopic degenerative changes.

Group 5. Four of six animals survived. Three had patent vessels. All three of the grafts were very well preserved, similar to grafts in group 2. Group 6. Six of seven animals survived. In three the grafts were necrotic. The other three grafts had severe inflammatory changes comparable to the control group. Group 7. All five animals survived. However, only two grafts were viable and both had undergone severe morphologic changes comparable to group 1 (Fig. 4). Group 8. All six animals in this group survived. There were no instances of thrombosis and all the grafts exhibited the same virtually unaltered macroscopic and histologic changes (Fig. 5) which characterized group 2. Peripancreatic

Fluid

In untreated animals (group 1) with viable grafts, there was a variable amount of peripancreatic fluid, ranging from 250 to 500

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FIG. 3. Autograft of Solu-Medrol treated animal 2 weeks post-transplantation. The graft is very well preserved with minimal evidence of inflammation or fibrosis. Note the presence of islets (hematoxylineosin stain).

FIG. 4. Autograft of glucagon treated animal 2 weeks after transplantation. exhibit severe inflammation, duct dilatation and fibrosis (hematoxylin-eosin).

Grafts in this group, as in the control,

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FIG. 5. Solu-Medrol and glucagon treated autograft 2 weeks after transplantation. and chronic inflammation. These grafts are similar to the ones in group 2.

ml (Table 1). In noninfected animals this was clear, straw colored, but in most animals it was purulent. The amylase content always exceeded 10,000 units/ml, and often was greater than 100,000 units/ml. Most of this fluid accumulated early in the postoperative period, the rate of accumulation decreasing as the pancreas was replaced by fibrosis. In group 2 (Solu-Medrol treatment) the amount of peripancreatic fluid was much larger than in group 1, ranging from 750 to 1700 ml, exceeding 1000 ml in 8 of the 13 animals with viable grafts. In animals with viable grafts in groups 3, 4, 5 and 6 the amount of peripancreatic fluid was comparable to groups 1 and 2, radiation and Trasylol both failing to inhibit exocrine pancreatic secretion. By contrast, in group 7 (glucagon) the amount of peripancreatic fluid was dramatically reduced, not exceeding 35 ml in any of the six animals in the group, but necrosis and fibrosis still occurred. In group 8 (glucagon and Solu-Medrol), however, the grafts were preserved in the absence of pancreatic fluid.

1976

There is absence of fibrosis

Insulin Production Despite the heterotopic location of the grafts, in no animal was there evidence of hyperinsulinism. Fasting blood sugars both preoperatively and at sacrifice were within normal limits. The insulin V-A difference in the several groups is summarized in Table 2. In group 1 (control) there was a decline in insulin production at the time of sacrifice compared to that immediately after transplantation. This difference was statistically significant (P < 0.05). In groups 2 and 8 the production of insulin remained unchanged between operation and sacrifice 2 weeks later (P >0.2 and >OS, respectively) reflecting the structural integrity exhibited by these grafts. In groups 3-7 no statistical comparison could be made between insulin levels at sacrifice and at surgery due to the small number of animals surviving. Nevertheless, only group 5 (3 animals) maintained normal V-A insulin values 2 weeks after grafting while the others all showed decline postoperatively.

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TABLE 2 Insulin Production by the Grafts At sacrifice; V-A Insulin diff. (&J/ml)

At surgery; V-A insulin diff. (rU/ml) Group

No. of animals 11

17 3 6 6 1

5 6

Range

Mean f SE

79-310 92-306 135-311 1688308 221-305 57-310 80-300 21-302

209 + 25 239 + 19 283 zt 23 283 zt 13 220 f 42 261 zt 25 188 i 48

No. of animals

Range

Mean * SE

P*

6 13 2 3 3 2 2 6

5-174 54-300 151-221 50-280 270-302 21~100 18-75 36-270

108 + 31 204*20

0.2

155 *40

>0.5

*P value between insulin levels at surgery and sacrifice within each group.

DISCUSSION A variety of methods of pancreatic transplantation have been attempted in the past. All have been associated with such prohibitively high rates of complications and mortality, however, that their clinical use has been limited. As of October 1975, only 36 clinical pancreatic transplants have been performed since the first attempt by Kelly et al. [16] 8 yr ago. There are two basic models of vascularized pancreatic grafts. In the first the pancreatic duct is drained either externally or internally, preserving the exocrine function of the gland. Most of these are pancreatoduodenal [14, 341,using the duodenum as a conduit for drainage of the pancreatic juice. In both experimental and clinical transplants of this type, complications arose from the transplanted duodenum, involving rejection, ulceration, perforation and bleeding [16, 21, 231. However, it was demonstrated that successful grafts of this type continued to produce adequate insulin over a long period of time. In the second model the pancreatic duct is ligated. These grafts are usually segmental and have been associated with several complications. In the early stage as a result of duct ligation severe pancreatitis, thrombosis, and pancreatic necrosis occurred [ 18, 3 11. Because of continuing exocrine activity in nonthrombosed grafts amylase-rich peripancreatic fluid accumulated, probably draining through divided cap-

sular lymphatics becoming secondarily infected. Those grafts that survived the initial inflammation gradually underwent extensive fibrosis of the exocrine gland with few islets of Langerhans dispersed in the dense fibrous tissue [15, 18, 311.As a result, insulin production by the graft diminished. The same difficulties were encountered in clinical trials using this model [ 11, 161. Attempts have been made to modify both models in an effort to prevent these complications. Preoperative irradiation of the pancreas was reported to selectively suppress the pancreatic exocrine function, with prevention of edema, infection, hemorrhage and thrombosis of duct ligated grafts [22]. This method, however, failed in a clinical trial [16]. Others have excluded the duodenum except for a small cuff around the duct for anastomosis to the jejunum [2] or have used a pancreatico-ureteral anastomosis for drainage of the exocrine secretion [ 11, 121.The successof these techniques was at best limited. The concept of a duct ligated segmental graft without duodenum is attractive because of the simplicity of the operative procedure. In rats Orloff et al. [28] have recently demonstrated provocative results with this model. Two conditions ought to be fulfilled, however, for reproducible success. First, the exocrine function of the graft should be suppressed in order to avoid pancreatitis and peripancreatic fluid accumulation leading to

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peripancreatic abscess, and second, fibrosis of the graft should be prevented in order to preserve long-term endocrine function. In the untreated group in our study, the grafts were destroyed and extensively fibrotic by 2 weeks after transplant. There was a high incidence of thrombosis and hemorrhage and significant accumulation of peripancreatic fluid with abscess formation. Insulin production at 1 to 2 weeks following transplantation was significantly decreased. The findings are similar to those previously reported by other investigators who used duct ligated models [ 15,3 l] By contrast, steroids had a marked antiinflammatory effect on the grafts, preventing fibrosis and architectural distortion. The anti-inflammatory properties of steroids are well established [5, 131.In addition, steroids have a lysosomal membrane stabilizing effect [35, 361 and this may be important in preventing parenchymal autodestruction by pancreatic enzymes. The maintenance of normal graft insulin production by the steroid treated animals may simply be a reflection of their structural integrity and absence of fibrosis. However, steroids also have been demonstrated to cause hyperplasia of the beta cells and increased insulin extraction from the pancreas [20]. Although less likely, the autoimmune state induced by initial nonspecific damage with subsequent tissue destruction observed in other organs [24, 321 might also have been prevented by the use of high dose steroids. The clinical effect of steroids on the pancreas has been controversial. They have been incriminated as a cause of pancreatitis [8, 261, but have also been demonstrated to have a beneficial effect [4, lo]. This latter effect in experimental pancreatitis reported by Anderson et al. [l] resembles our own findings. Because of structural preservation of the grafts by steroids, continuing exocrine pancreatic activity resulted in accumulation of large amounts of peripancreatic fluid. This became infected in a large number of animals forming a peripancreatic abscess. The preliminary findings of this study in

regard to preservation indicate that pancreas can be very well preserved up to 4 hr by pulsatile hypothermic perfusion. Preservation for longer periods was not attempted because the animals could not be kept safely anesthetized, but longer preservation certainly seemsfeasible. Radiation has been reported to selectively inhibit the exocrine function of the pancreas, preventing many of the complications in duct ligated grafts [22]. This was not our experience to date using 5000 R. However, in our experiments radiation was administered to the pancreas preserved with hypothermic perfusion and, therefore, might not have been as effective. Our findings, nevertheless, are in agreement with reports of only a small and transient inhibition of exocrine pancreas function by radiation [30]. By contrast, the inhibitory effect of glucagon on the exocrine pancreas has been previously reported in both clinical and experimental studies [7, 9, 17, 251. Glucagon decreases both the volume and protein content of the pancreatic fluid [9, 371. The mechanism of action has not been clarified, but activation of cyclic 3’, 5’-AMP [9,27,29] has been postulated. The profound effect of glucagon in suppressing the exocrine pancreas in the present experiments was very dramatic. When used concomitantly with steroids the amount of peripancreatic fluid was negligible in contrast to the massive fluid accumulation when steroids were used alone. Glucagon is a short acting agent and it should optimumly be given by continuous iv infusion. This has not been technically feasible as yet in these experiments, however, and twice daily was im administration remarkably effective. SUMMARY A method of autotransplantation of duct ligated pancreatic segments has been described. In untreated animals autotransplants underwent significant destruction within 2 weeks after transplantation due to inflammation following ligation of the duct. Insulin production by these grafts was signi-

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ficantly decreased. Radiation and Trasylol failed to prevent these inflammatory and fibrotic changes. Steroids had a protective effect on these grafts, preserving both their morphology and function. Insulin production was preserved and continued exocrine function resulted in accumulation of large volumes of peripancreatic fluid. When glucagon was added to the steroid treatment there was virtually total inhibition of the exocrine function and negligible peripancreatic fluid accumulation, but insulin production continued and the grafts appeared normal morphologically. The implications of the use of high dose steroid therapy and glucagon to prevent the acute damage to duct ligated pancreatic autografts are that major obstacles to the use of this method in allografts can now be removed. REFERENCES I. Anderson, M. C., Booher, D. L., and Lim, T. B. Treatment of acute pancreatitis with adrenocorticosteroids. Surgery 55:55 1, 1964. 2. Aquino, C., Ruiz, J. O., Schultz, L. S., and Lillehei, R. C. Pancreatic transplantation without duodenum in the dog. Amer. J. Surg. 125:240, 1973. 3. Belzer, F. O., Ashby, B. S., and Dunphy, J. E. Twenty-four-hour and 72-hour preservation of canine kidneys. Lancer 2:536, 1967. 4. Brockis, J. G., and Jones, E. T. Treatment of acute pancreatitis with cortisone. bit. Med. J. 5008:1524, 1956. 5. Boggs, D. R., Athens, J. W., Cartwright, G. E., and Wintrobe, M. M. The effect of adrenal corticosteroids upon the cellular composition of inflammatory exudates. Amer. J. Pothol. 44:763, 1964, 6. Brooks, J. R., and Gifford, G. H. Pancreatic homotransplantation. Transplunr. Bull. 6:100, 1959. 7. Condon, J. R., Knight, M. J., and Day, J. L. Glucagon therapy in acute pancreatitis. Brit. J. Surg. 60:509, 1973. 8. Carone, F. A., and Liebow, A. A. Acute pancreatic lesion in patients treated with ACTH and adrenal corticoids. N. Engl. J. Med. 257:690, 1957. 9. Dyck, W. P., Texter, E. C., Lasater, J. M., and Hightower, N. C., Jr. Influence of glucagon on pancreatic exocrine secretion in man. Gasrroenterology 58:532, 1970. 10. Eskwith, I. S., Cacace, V. A., and Sallosy, A. Acute hemorrhagic pancreatitis treatment with cortisone. N. Engl. J. Med. 252~494, 1955. 11. Gliedman, M. L., Gold, M., Whittaker, J., Rifkin, H., Soberman, R., Freed, S., Tellis, V., and Veith,

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F. J. Pancreatic duct to ureter anastomosis for exocrine drainage of pancreatic transplantation. Amer. J. Surg. 125:245,1973. 12,Gliedman, M. L., Gold, M., Whittaker, J., Rifkin, H., Soberman, R., Freed, S., Tellis, V., and Veith, F. J. Clinical segmental pancreatic transplantation with ureter-pancreatic duct anastomosis for exocrine drainage.Surgery74:171, 1973. Howes, E. L., Plotz, C. M., Blunt, J. W., andTagan, 13’C. Retardation of wound healing by cortisone. Surgery 28:177,1950. 14. Idezuki, Y., Feemster, J. A., Dietzman, R. H., and Lillehei, R. C. Experimental pancreatico-duodenal preservation and transplantation. Surg. Gynecol. Obstet. 126:1002, 1968. t5, Idezuki, Y., Goetz, F. C., and Lillehei, R. C. Late effects of pancreatic duct ligation on beta cell function. Amer. J. Surg. 117:33, 1969. 16. Kelly, W. D., Lillehei, R. C., Merkel, F. K., Idezuki, Y., and Goetz, F. C. Allotransplantation of pancreas and duodenum along with kidney in diabetic neuropathy. Surgery 61:827, 1967. 17. Knight, M. J., Condon, J. R., and Smith, R. Possible use of glucagon in the treatment of pancreatitis. Brit. Med. J. 2:440, 197 I. 18. Kyriakides, G., Miller, J., Lifton, J., and Najarian, J. S. Effect of steroids on the structure and endocrine function of the duct ligated porcine pancreatic autografts. Surg. Forum 15:384, 1974. 19. Kyriakides, G. K., Arora, V. K., Lifton, J. Nuttall, F. Q., and Miller, J. Porcine pancreatic transplantation. II. Allotransplantation of duct ligated pancreatic segments. J. Surg. Rex 20:461, 1976. 20. Like, A. A., and Chick, W. L. Pancreatic beta cell replication induced by glucocorticoids in subhuman primates. Amer. J. Pathol. 75~329, 1974. 21. Lillehei, R. C., Simmons, R. L., Najarian, J. S., Weil, R., Uchida, H., Ruiz, J. O., Kjellstrand, C. M., and Goetz, F. C. Pancreaticoduodenal allotransplantation: Experimental and clinical experience. Ann. Surg. 172:405, 1970. 22. Merkel, F. K., Kelly, W. D., Goetz, F. C., and Maney, J. Irradiated heterotopic segmental canine pancreatic allografts. Surgery 63:291, 1968. 23. Merkel, F. K. ACS/NIH Organ Transplant Registry: First scientific report. J. Amer. Med. Assoc. 217:1520, 1971. 24. Merrill, J. P. Glomerulonephritis in renal transplants. Transplant. Proc. 1~994, 1969. 25. Necheles, H. Effect of glucagon on external secretion of the pancreas. Amer. J. Physiol. 191:595, 1957. 26. Nelp, W. B. Acute pancreatitis associated with steroid therapy. Arch. Intern. Med. 108:702, 1961. 27. Orloff, J., and Handler, J. S. The role of adenosine 3’, 5’-phosphate in the action of antidiuretic hormone. Amer. J. Med. 42~757, 1967. 28. Orloff, M. J., Lee, S., Charters, A. C. III, Gram-

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bort, D. E., Storck, L. G., and Knox, D. Long term studies of pancreas transplantation in experimental diabetes mellitus. Ann. Surg. 182:198, 1975. 29. Pryor, J., and Berthet, J. The action of adenosine3’, 5’-monophosphate on the incorporation of leucine into liver proteins. Biochim. Biophys. Acta 43:556, 1960. 30. Rauch, R. F., and Stenstrom, K. W. Effects of Xray radiation on the pancreatic function in dogs. Gastroenterology 20:595, 1952. 31. Rausis, C., Choudhury, A., and Ogata, Y. Influence of pancreatic duct anastomosis on function of autotransplanted canine pancreatic segments. J. Surg. Rex lo:55 1, 1970. 32. Roitt, I. M., Doniach, D., Campbell, P. N., and Hudson, R. V. Autoantibodies in Hashimoto’s disease.Lancet 2:820, 1956.

33. Teixeira, E. D., and Bergan, J. J. Auxiliary pancreas allografting. Arch. Surg. 95:65, 1967. 34. Uchida, H., Ruiz, J. O., Castelfranchi, P. L., Schultz, L. S., and Lillehei, R. C. New technique of one stage heterotopic pancreaticoduodenal autotransplantation in the dog. Surgery 70:604, 1971. 35. Weissman, G., and Thomas, L. Studies on lysosomes. I. The effect of endotoxin tolerance and cortisone on the release of acid lydrolases from a granular function of rabbit liver. 1. Exp. Med. 116:433,1962. 36. Weissman, G., and Dingle, J. R. Release of lysosomal protease by ultraviolet irradiation and inhibition by hydrocortisone. Exp. Cell Res. 25:207, 1961. 37. Zajtchuk, R., Amato, J. T., Paloyan, E., and Baker, R. J. Inhibition of pancreatic exocrine secretion by glucagon. Surg. Forum 18:410, 1967.