*Purpose: Portal drainage (PD) of pancreas grafts has been associated with improved metabolic profile and fewer rejection episodes than systemic drainage (SD). These advantages would be especially useful in pancreas transplant alone (PTA) recipients due to their higher risk of rejection and their metabolic disarrangements. We compare our experience with PD and SD in PTA.

*Methods: Between December 2000 and May 2017 the venous effluent of 101 PTA was managed by PD (n=65) or SD (n=36). Exocrine secretions were drained enterically in all but two recipient. The groups were well matched for all baseline characteristics and were managed with equivalent maintenance immunosuppression. Basiliximab (41 PD vs 14 SD) or thymoglobuline (24 PD vs 22 SD) were alternatively used as induction therapy. The comparison of the two drainage groups was performed applying the Propensity Score Matching (PSM) on a 1(SD):2(PD) basis, in order to obtain greater homogeneity. Data were analyzed in terms of graft survival, complete thrombosis of the graft, acute 6-month rejection rate, overall acute rejection rate and chronic rejection, recorded for the maximum follow-up time for each patient.

*Results: Overall, delayed endocrine pancreas function rate was 0 in the SD group vs 1.5% in the PD group. Six grafts were lost in the early post-PTA course due to vascular thrombosis (2 SD vs 1 PD) and humoral rejection (0 SD vs 3 PD). Relaparotomy rate was 19.4% in SD and 15.4% in PD group. PSM selected 57 PD vs 26 SD. No significant differences between the two types of drainage in terms graft survival (Odds ratio = 0.67 (0.31-1.53), p = 0.33), overall acute rejection (Odds Ratio = 0.40 (0.15-1.09), p = 0.07) and chronic rejection (Odds Ratio = 0.44 (0.14-1.42), p = 0.17) were recorded. Six-month acute rejection rate (Odds Ratio = 5.16 * 10 ^ -9 (na-0.02), p <0.0001) was significantly lower in the portal drainage group. No difference was seen in thrombosis onset (odds ratio = 0.44 (0.05-3.81), p = 0.43). Glycemic control was excellent in both groups, but fasting serum insulin levels were significantly lower in PD. Patient survival at 1 and 5 years was 100% (SD) vs. 98.2% (PD) at either time points. Equivalent figures for insulin independence were 78.9% and 61.3% (SD) vs 87.9% and 80.1% (PD)

*Conclusions: Either routes of venous drainage are suitable for PTA, although more recipients experience rejection with SD as compared with PD in the early post-transplant period. This difference, already statistically relevant, could become even more prominent with larger randomized series.

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