TABLE 4.

Expert panel recommendations on activity volume and innovation in pancreas transplantation

Query	Recommendation	GRADE	Quality score	Agreement	Proposed action
1.1 – “What is the minimally acceptable annual volume of pancreas transplants per center?”	The outcome of pancreas transplantation is multifactorial. Higher annual volume is expected to be among the factors contributing to better outcome, but available data do not allow for a clear definition of a minimum annual volume, as this could also be influenced by several geographical variables as well as donor and recipient selection.	NG	83%	97.3%	Investigate the impact of annual volume of pancreas transplants per center. Estimates should take into account the possible impact of concurrent volume of renal and hepatic transplantation.
1.2 – “What is the minimally acceptable annual volume of pancreas transplants per surgeon?”	Pancreas transplantation should not be performed occasionally by the individual surgeon. Younger surgeons who are starting their practice are expected to have completed a formal training program in pancreas transplantation and/or act under the supervision of a proficient pancreas transplant surgeon.	NG	96%	97.3%	Investigate volume‐outcome relationship for individual surgeon. Investigate volume‐outcome relationship based on overall surgeon experience vs. current annual volume.
1.3 – “Is there a role for segmental live donor pancreas transplantation in non‐immunized recipients?”	Live donor segmental pancreas transplantation could be an option even in nonimmunized patients in extremely well‐selected pairs provided that the center is able to ensure quality of the procedure and careful lifelong follow‐up of the donor.	NG	68%	88.4%	None.
1.4 – “Is there a role for segmental live donor pancreas transplantation in immunized recipients?”	Live donor segmental pancreas transplantation is an option in immunized patients in extremely well‐selected pairs provided that the center is able to ensure quality of the procedure and careful lifelong follow‐up of the donor.	NG	70%	93.4%	None.
1.5 – “What are the anticipated risks for the live donor?”	There is no enough specific evidence (i.e., direct evidence from live donors) to address this question, especially concerning the risks of simultaneous distal pancreatectomy and nephrectomy. There is a risk of early technical complications and a risk for delayed metabolic complications demanding for careful selection of donors and lifelong follow‐up.	NG	83%	88.4%	None.
1.6 – “Is there evidence that minimally invasive pancreas transplantation increases the risk of the transplant procedure versus open pancreas transplantation?”	Robotic pancreas transplantation is feasible. Available data do not allow to draw a conclusion on safety, although there may be a potential benefit in obese recipients.	NG	82%	94.1%	Establish a training path for safe implementation and diffusion of robotic pancreas transplantation. Report on additional cases.
1.7 – “Is there evidence that minimally invasive pancreas transplantation is associated with worse long‐term results versus open pancreas transplantation?”	Due to lack of data, this query cannot be answered at the present time.	NG	97%	100%	Establish a training path for safe implementation and diffusion of robotic pancreas transplantation. Report on additional cases.
1.8 – “Is there evidence of benefits from minimally invasive pancreas transplantation?”	Due to lack of data, this query cannot be answered at the present time.	NG	79%	97.3%	Establish a training path for safe implementation and diffusion of robotic pancreas transplantation. Report on additional cases.
1.9 – “Is there evidence that minimally invasive pancreas transplantation is more beneficial in obese versus lean pancreas transplant recipients”	Due to lack of data, this query cannot be answered at the present time.	NG	93%	97.3%	Establish a training path for safe implementation and diffusion of robotic pancreas transplantation. Report on additional cases.

Abbreviation: NG, not graded.