Percutaneous Ultrasound-Guided Pancreas Allograft Biopsy: A Single-Center Experience

Accessibility of Percutaneous Biopsy in Retrocolic-Placed Pancreatic Grafts With a Duodeno-Duodenostomy

Duodeno-duodenostomy (DD) has been proposed as a more physiological alternative to conventional duodeno-jejunostomy (DJ) for pancreas transplantation. Accessibility of percutaneous biopsies in these grafts has not yet been assessed. We conducted a retrospective study including all pancreatic percutaneous graft biopsies requested between November 2009 and July 2021. Whenever possible, biopsies were performed under ultrasound (US) guidance or computed tomography (CT) guidance when the US approach failed. Patients were classified into two groups according to surgical technique (DJ and DD). Accessibility, success for histological diagnosis and complications were compared. Biopsy was performed in 93/136 (68.4%) patients in the DJ group and 116/132 (87.9%) of the DD group (p = 0.0001). The graft was not accessible for biopsy mainly due to intestinal loop interposition (n = 29 DJ, n = 10 DD). Adequate sample for histological diagnosis was obtained in 86/93 (92.5%) of the DJ group and 102/116 (87.9%) of the DD group (p = 0.2777). One minor complication was noted in the DD group. The retrocolic position of the DD pancreatic graft does not limit access to percutaneous biopsy. This is a safe technique with a high histological diagnostic success rate.

An Initial Analysis of the Baseline Levels of Dd-cfDNA After Pancreas Transplantation: A Prospective Study From High-volume Centers in the United States

Pancreas transplantation offers patients with diabetes an opportunity for glucose homeostasis. Current blood tests to surveil for rejection have poor sensitivity and specificity for identifying rejection, and pancreas biopsies are challenging and associated with morbidity and graft loss. Donor-derived cell-free DNA (dd-cfDNA) is shed from transplanted organs and detectable in peripheral blood. Thus, a potential dd-cfDNA blood test assessing rejection would be clinically advantageous.

Methods

One hundred eighty-one dd-cfDNA samples (n) were collected from 77 patients (N) up to 132 mo posttransplant.

Results

The median dd-cfDNA level among all subjects was 0.28% (0.13%, 0.71%). In simultaneous pancreas-kidney (SPK) transplant recipients, the median dd-cfDNA level was 0.29% (0.13%, 0.71%), and it was 0.23% (0.08%, 0.71%) in pancreas transplant alone (PTA) recipients. When isolating for when without infection or rejection, the median dd-cfDNA level was 0.28% (0.13%, 0.64%) for SPK and 0.20% (0.00%, 0.32%) for PTA. Both transplant types approached 1.0% ≤1 mo posttransplant followed by a decrease in median dd-cfDNA. During episodes of rejection or infection, median dd-cfDNA levels were greater among all transplant types.

Conclusions

The mean dd-cfDNA level for all pancreas transplant recipients is <1.0%, consistent with the published kidney transplant rejection threshold (>1.0%), regardless of SPK or PTA. Early posttransplant dd-cfDNA levels are transiently higher than later measurements. Dd-cfDNA elevation also correlates with rejection and infection and thus is a promising biomarker for surveilling pancreas transplant dysfunction.

Percutaneous biopsy and drainage of the pancreas

Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.

CT fluoroscopy-guided pancreas transplant biopsies: a retrospective evaluation of predictors of complications and success rates

To identify predictors of biopsy success and complications in CT-guided pancreas transplant (PTX) core biopsy. We retrospectively identified all CT fluoroscopy-guided PTX biopsies performed at our institution (2000-2017) and included 187 biopsies in 99 patients. Potential predictors related to patient characteristics (age, gender, body mass index (BMI), PTX age, PTX volume) and procedure characteristics (biopsy depth, needle size, access path, number of samples, interventionalist's experience) were correlated with biopsy success (sufficient tissue for histologic diagnosis) and the occurrence of complications. Biopsy success (72.2%) was more likely to be obtained in men [+25.3% (10.9, 39.7)] and when the intervention was performed by an experienced interventionalist [+27.2% (8.1, 46.2)]. Complications (5.9%) occurred more frequently in patients with higher PTX age [OR: 1.014 (1.002, 1.026)] and when many (3-4) tissue samples were obtained [+8.7% (-2.3, 19.7)]. Multivariable regression analysis confirmed male gender [OR: 3.741 (1.736, 8.059)] and high experience [OR: 2.923 (1.255, 6.808)] (biopsy success) as well as older PTX age [OR: 1.019 (1.002, 1.035)] and obtaining many samples [OR: 4.880 (1.240, 19.203)] (complications) as independent predictors. Our results suggest that CT-guided PTX biopsy should be performed by an experienced interventionalist to achieve higher success rates, and not more than two tissue samples should be obtained to reduce complications. Caution is in order in patients with older transplants because of higher complication rates.

Complication incidence of EUS-guided pancreas biopsy: A systematic review and meta-analysis of 11 thousand population from 78 cohort studies

A systematic review and meta-analysis were performed to estimate the incidence of possible complications following EUS-guided pancreas biopsy. Pancreatic cancer has a very poor prognosis with a high fatality rate. Early diagnosis is important to improve the prognosis of pancreatic cancer. We searched Pubmed, Embase, Web of Science, and Scopus databases for studies published from inception to Augest, 2018. Meta-analysis were conducted with random-effect models and heterogeneity was calculated with the Q, I² and τ² statistics. We enrolled 78 studies from 71 articles in the meta-analysis, comprising 11,652 patients. Pooled data showed that the whole complication incidences were low 0.210 × 10^-4(95%CI -0.648 × 10^-4, 1.068 × 10^-4). And they were in bleeding 0.002 × 10^-4 (95%CI -0.092 × 10^-4, 0.097 × 10^-4), pancreatitis 0.002 (95%CI -0.082 × 10^-4, 0.086 × 10^-4), abdominal pain 0 (95%CI -0.037 × 10^-4, 0.038 × 10^-4), fever 0 (95%CI -0.032 × 10^-4, 0. 032 × 10^-4), infection 0 (95%CI -0.030 × 10^-4, 0.031 × 10^-4), duodenal perforation 0 (95%CI -0.033 × 10^-4, 0.034 × 10^-4), pancreatic fistula 0 (95%CI -0.029 × 10^-4, 0.029 × 10^-4), abscess 0 (95%CI -0.029 × 10^-4, 0.029 × 10^-4) and sepsis 0 (95%CI -0.029 × 10^-4, 0.030 × 10^-4). Subgroup analysis based on the tumor size, site, needle type and tumor style also showed robust results. The pooled data showed EUS-guided pancreas biopsy could be a safe approach for the diagnosis of pancreatic lesions. More large-scale studies will be necessary to confirm the findings across different population.

Ultrasound-Guided Percutaneous Core Needle Biopsy for the Diagnosis of Pancreatic Disease

Few studies have evaluated the performance of percutaneous core needle biopsies of the pancreas. This article is an overview of the advantages, disadvantages, predictive power and complications associated with percutaneous ultrasound-guided core needle biopsies of pancreatic lesions. A comprehensive literature search of Medline (using PubMed as the search engine) and EMBASE was done to identify suitable studies up to March 2017. A study of quantitative pre-operative pancreatic biopsy data was reported. Lesion location, mean or median number of passes, inadequate tissue or technical failures and complications were assessed for all cases by reviewing clinical notes and post-procedural imaging. The analysis included 13 studies, mostly of a retrospective nature. The sensitivity (mean: 94.42%, range: 90%-100%) and specificity (mean: 97.94%, range: 94.7%-100%) of the procedure were high, and the mean accuracy of diagnosis was 95.76 (range: 91-100). Furthermore, the procedure had a high negative predictive value of approximately 76.26%. Of the 13 reported studies, 7.3% were inadequate or technical failure cases. The mean rate of complications was 2.08%, which seemed similar to the lower limit of this rate for endoscopic ultrasound-guided fine-needle aspirations. The risk of tumor seeding with ultrasound-guided core needle biopsies was not reported in the included articles. With the development of technology, ultrasound-guided percutaneous core needle biopsy for pancreatic lesions is increasingly available and has optimal diagnostic power in pancreatic neoplasms.

A Single-center Experience on the Value of Pancreas Graft Biopsies and HLA Antibody Monitoring After Simultaneous Pancreas-Kidney Transplantation

BACKGROUND

In simultaneous pancreas-kidney transplantation (SPKT), monitoring of the pancreas allograft is more complex than the kidney allograft due to difficulties in obtaining pancreas histology and weak clinical evidence supporting the role of donor-specific antibodies (DSA).

METHODS

We performed a single-center retrospective analysis of all 17 SPKT recipients who underwent a total of 22 pancreas allograft indication biopsies from October 2009 to September 2012. Fifteen patients had at least 2 DSA measurements: pretransplantation and at the time of biopsy.

RESULTS

All 7 patients (100%) with post-transplantation DSA-positivity (de novo: n = 6; persistent: n = 1) at biopsy had at least 1 rejection episode either of the pancreas (n = 4) or the kidney (n = 3), with 3 antibody-mediated rejections (AMR). In contrast, only 4 of 8 patients (50%) without post-transplantation DSA had evidence of rejection, with 1 AMR. Findings during pancreas allograft biopsy procedures led to a change of immunosuppressive therapy in 11 of 15 (73%) patients. Patient survival, graft survival, and function were not adversely affected by the presence of post-transplantation DSA. One major and 2 minor procedure-related complications occurred during the pancreas biopsies.

CONCLUSIONS

In this small retrospective analysis, pancreas allograft histology provided the most therapeutically relevant information, rather than the kidney histology or DSA monitoring.

The efficacy of on-site evaluation for identification of transplant pancreas

OBJECTIVE

Pancreatic transplantation has been relatively uncommon until the last 2 decades, but is now an accepted therapeutic intervention for type I diabetes. Core biopsies of pancreas transplants are frequently performed to rule out rejection, which is a leading cause of graft failure. Often, it is difficult to localize the graft for biopsy by imaging. Our objective was to determine whether on-site assessment by cytopathology can assist in procedure protocols for biopsy of pancreas transplants.

STUDY DESIGN

We reviewed cytology and surgical pathology reports from 68 instances of pancreas transplant biopsy at our institution and evaluated the correlation between cytology (fine needle aspiration, touch preparation or both) and the final core biopsy.

RESULTS

Pancreatic tissue was identified by on-site assessment in 56/68 cases and was present on core biopsy in 53/68 cases. There were 3 cases where fine needle aspiration/touch preparation results were not concordant with final core biopsy results. The positive predictive value of a positive on-site assessment was 96.4%. More importantly, the negative predictive value of on-site assessment was 100%.

CONCLUSIONS

On-site evaluation by cytopathology is highly effective for the identification of transplant pancreas. In cases where no pancreatic tissue is identified by on-site assessment, relocalization of the biopsy needle is recommended.

Sonographically guided puncture of the pancreas: incidence of complications, and risk factors

PURPOSE

Data yielded by transabdominal ultrasound-guided puncture techniques are valuable for determining the malignancy of inoperable mass lesions of the pancreas. In this study we analyzed the incidence of complications and the risk factors.

METHODS

A total of 430 punctures of the pancreas were performed for 281 patients. Risk factors were prospectively assessed and complications were recorded. All punctures were sonographically guided.

RESULTS

The 281 patients underwent a total of 351 puncture procedures including 430 punctures and 901 passes. The maximum diameter of the pancreatic mass lesion was documented; the mean diameter was 48.3 ± 29.1 mm. 75.8 % of punctures were performed with a needle diameter of 0.7-0.95 mm, and 23.0 % of punctures were performed as cutting biopsies producing a tissue sample 1.2 or 1.6 mm in diameter. In 77.8 % of punctures, one puncture was performed, and in 21.9 %, two punctures were performed. Three punctures were performed for one patient (0.3 %) only. The incidence of major complications was 0.3 %. None of the assessed risk factors was associated with an elevated incidence of complications.

CONCLUSION

Our findings demonstrate the safety of transabdominal percutaneous puncture of the pancreas but do not enable conclusions to be drawn with regard to individual risk factors.

Evaluation of pancreatic allografts with sonography

OBJECTIVES

The purposes of this study were to develop a protocol for evaluating pancreas allografts, to describe a method for successfully studying pancreatic transplants, and to determine whether the resistive index (RI) of the splenic artery is a useful differentiator between complications.

METHODS

We retrospectively analyzed clinical, surgical, procedural, and radiologic reports in 51 consecutive patients undergoing 182 sonographic examinations during a 4.5-year period. Complications included splenic vein thrombosis, rejection, and pancreatitis. We obtained RIs in normal and complication groups and performed mixed model regression methods and receiver operating characteristic analysis.

RESULTS

The mean RI ± SD for normal transplants was 0.65 ± 0.09; for splenic vein thrombosis, 0.76 ± 0.09; after resolution of splenic vein thrombosis, 0.73 ± 0.09; during rejection, 0.94 ± 0.09; after successful treatment of rejection, 0.74 ± 0.09; for pancreatitis, 0.83 ± 0.09; and for fluid collections, 0.66 ± 0.09. There was a statistically significant difference (P < .05) between normal transplants and splenic vein thrombosis (P = .0003), rejection (P < .0001), and pancreatitis (P = .04). A significant difference was also seen between rejection and successful treatment thereof (P < .0001).

CONCLUSIONS

We developed a protocol that allowed us to successfully evaluate 96% of the pancreatic allografts studied. Furthermore, our data show that the RI can be used as a therapeutic guide. When the RI is less than 0.65, the risk of vascular abnormalities is very low; however, fluid collections may be present. When greater than 0.75, splenic vein thrombosis, pancreatitis, or rejection should be suspected. When greater than 0.9, rejection must be seriously considered.

Duodenoduodenostomy in pancreas transplantation

Enteric drainage (ED) using duodenojejunostomy (DJ) is an established technique in pancreatic transplantation. Duodenoduodenostomy (DD), an alternative ED technique, may provide unique advantages over DJ. We compared our experience with these two types of ED through a retrospective review of all pancreas transplants performed at our institution from November 2007 to November 2009. The allograft duodenum was anastomosed to the recipient jejunum or duodenum. Duodenal drainage was performed by a stapled or hand-sewn technique. Patient demographics, operative times, major post-operative complications, and graft survival data were analyzed. Of 57 pancreas transplants, DJ was performed in 36 patients, stapled DD in 14 patients, and hand-sewn DD in seven patients. Two DD grafts (9.5%) thrombosed compared with no DJ grafts (p = NS). Enteric leak and small-bowel obstruction occurred in 3 of 36 DJ patients and in two DD patients (p = NS). Gastrointestinal bleeding occurred more frequently in stapled DD compared with DJ (4 vs. 0, p < 0.015). In conclusion, DD is technically feasible with no increase in operative time or enteric complications. GI bleeding rates appear to be higher following DD (stapled) technique. Potential complications of DD should be balanced against the benefits conferred by this technique.

Exocrine drainage into the duodenum: a novel technique for pancreas transplantation

Simultaneous pancreas-kidney transplantation is the treatment of choice for patients suffering from type 1 diabetes mellitus and end-stage renal failure secondary to diabetic nephropathy. Until 1995, about 90% of pancreas transplantations were performed with exocrine drainage into the bladder. Since then the proportion of pancreas transplants with enteric drainage increased steadily because of frequency of complications and long-term disadvantages of bladder drainage. However, the use of enteric drainage removes the opportunity to monitor pancreatic allograft function either by measuring urinary amylase or by carrying out biopsy via cystoscopy. We report a new technique of exocrine pancreatic drainage into the recipient duodenum. This modification places the pancreas graft including the duodenal anastomosis in a retroperitoneal location and, importantly, allows easy graft monitoring via gastroscopy.