Surgical complications after conversion from bladder to enteric drainage in pancreaticoduodenal transplantation

Enteric conversion after bladder-drained pancreas transplantation is not associated with worse allograft survival

In the early experience of pancreas transplantation, bladder drainage was favored, but it often caused urologic, metabolic, and infectious complications that necessitated conversion to enteric drainage. Long-term graft survival after enteric conversion and the impact of time interval from transplantation to enteric conversion on graft survival is poorly understood. We studied all bladder-drained first-time pancreas transplantations performed at the University of Wisconsin from 1985 to 2000. Time to conversion was estimated with the Kaplan-Meier technique, whereas risk factors associated with conversion were estimated via a time-varying Cox proportional hazards model. Of 386 bladder-drained pancreata, 162 (41.9%) eventually required enteric conversion, 29 (17.9%) within the first year. Median time to conversion varied by indication: 0.68 years for surgical, 3.1 years for urologic, and 2.7 years for metabolic disorders. In a time-varying Cox model adjusting for donor and recipient factors, enteric conversion did not affect the risk of pancreas graft loss (hazard ratio [HR] 0.86, P = .26). Kidney survival was not associated with enteric conversion. When necessary due to symptoms or complications, enteric conversion of bladder-drained pancreata is safe and does not affect overall graft survival. This relationship appears to be true no matter when the conversion is performed.

Enterovesical Fistula After Enteric Conversion of a Bladder-Drained Pancreatic Allograft: A Case Report

Since the inception of pancreas transplant as a treatment for type 1 diabetes mellitus, there has been considerable debate about the best way to manage exocrine secretions and monitor patients for graft rejection. For patients who undergo bladder exocrine drainage of a pancreatic allograft, a bladder-to-enteric drainage conversion can serve as a rescue procedure in case of anastomotic leaks or other complications. However, this procedure is associated with its own complications, including a rarely described enterovesical fistula. Here we report on a 45-year-old man who underwent a simultaneous kidney and pancreas transplant with bladder drainage to the latter. He developed a pancreatic allograft duodenal leak (duodenal-vesical anastomosis) requiring a bladder-to-enteric drainage conversion. The patient returned 2 weeks after discharge with an enterovesical fistula. He was treated nonsurgically with intravenous antibiotics, bowel rest, and parenteral nutrition, and the fistula successfully closed in approximately 2 weeks. Overall, enterovesical fistula formation is a rare but treatable complication that can occur after a bladder-to-enteric drainage conversion of a pancreatic transplant allograft. It can be managed nonsurgically, which is preferable in these immunocompromised patients.

Transplantation of the pancreas

Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.

Surgical techniques for pancreas transplantation

PURPOSE OF REVIEW

Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function.

RECENT FINDINGS

Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion.

SUMMARY

Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.

Perioperative treatment with octreotide minimizes technical complications after enteric conversion of bladder-drained pancreas transplants

We review our experience with enteric conversion of previously bladder-drained pancreas transplants (PTx) using a short perioperative course of octreotide (OCT). Between July 1994 and December 2001, 45 consecutive primary bladder-drained PTx were performed. Immunosuppression consisted of a combination of tacrolimus, mycophenolate mofetil and steroids after induction with monoclonal or polyclonal antibodies. A total of 16 patients underwent enteric conversion at an average of 3 months after the initial transplant. Each patient received OCT perioperatively. We report no technical complications with the exception of one superficial wound infection and good early and late PTx survival rates. Perioperative treatment with octreotide is well tolerated and may reduce technical complications while performing enteric conversion of previously bladder-drained PTx.

Pancreatic transplantation and subsequent graft surveillance by pancreatic portal-enteric anastomosis and temporary venting jejunostomy

OBJECTIVE

To evaluate portal-enteric (PE) pancreas and kidney transplantation with venting jejunostomy (VJ) for its efficacy, safety, and reproducibility.

SUMMARY BACKGROUND DATA

Simultaneous pancreas and kidney transplantation for patients with long-standing insulin-dependent diabetes mellitus that progresses to renal failure has revolutionized their treatment and quality of life. A current clinical focus is to refine the technical aspects of this procedure. Simultaneous pancreas and kidney transplantation with PE anastomosis with VJ appears to offer several advantages over bladder drainage. VJ allows initial decompression of the enteric anastomosis, monitoring of pancreatic function by ostomy amylase, and simple access for endoscopic evaluation and biopsy of the allograft.

METHODS

Simultaneous pancreas and kidney transplantation with VJ was performed in 21 patients from December 1996 to October 2000 at Willis Knighton/LSU Regional Transplant Center. All patients had long-standing insulin-dependent diabetes mellitus and subsequent renal failure. They were evaluated at the time of surgery by a multidisciplinary transplant team and monitored for numerous factors, including length of hospital stay, immunosuppressive regimen, and ischemia times. All patients had intermittent visual and biochemical evaluation of pancreatic secretions monitored by means of the VJ.

RESULTS

Of the 21 patients, 10 were women and 11 were men. Four patients were black and 17 were white. The mean age at transplantation was 38 years; average human leukocyte antigen (HLA) match was one; and average cold ischemia time was 12 hours. The median hospital stay was 16 days. Four episodes of postoperative bleeding requiring exploration occurred in four patients. Postoperative wound infections developed in four patients. There were 12 episodes of rejection in nine patients. All patients with suspected acute pancreatic rejection underwent endoscopy by means of the VJ and duodenal biopsy for evaluation. Two patients lost pancreatic function subsequent to kidney failure, one secondary to noncompliance and the other as a result of hemolytic-uremic syndrome. Patient, kidney, and pancreatic survival rates were 100%, 90%, and 90%, respectively. The mean follow-up period was 25 (range 2-48) months.

CONCLUSION

The authors believe that PE pancreatic drainage with VJ is a more physiologic method to perform pancreatic transplantation than bladder drainage. PE drainage allows rapid diagnosis of acute rejection and anastomotic leak and provides a simple way to monitor ostomy amylase and transplant duodenal bleeding. This technique is safe and has minimal associated complications.

Roux-en-Y venting jejunostomy in pancreatic transplantation: a novel approach to monitor rejection and prevent anastomotic leak

INTRODUCTION

Pancreatic transplantation (PTx) with portal venous delivery of insulin and enteric drainage of the exocrine secretion is more physiologic than bladder-systemic (BS) drainage. With portal-enteric (PE) PTx, the diagnosis of acute rejection (AR) requires a percutaneous biopsy. The roux-en-y (RNY) venting jejunostomy in patients with PEPTx offers a novel approach to monitor rejection and prevent anastomatic leaks.

METHODS

From January 1996 to December 1998, we performed 17 simultaneous kidney/pancreas transplants (SKPTx). The initial 4 patients underwent BS drainage and the subsequent 13 patients underwent RNY venting jejunostomy with PE drainage. All patients were treated with quadruple therapy. There were 9 males, 14 patients were Caucasian with a mean age of 32 yr (range 30-54 yr), and a mean pre-transplantation duration of diabetes of 25 yr. Six patients underwent endoscopic donor duodenal biopsy through the jejunostomy to rule out clinically suspected AR. Gastrograffin was inserted into the jejunostomy to examine the integrity of anastamosis when indicated. In 9 out of 13 patients, the venting jejunostomy was taken down 9-12 months post-transplantation after allograft function was stable.

RESULTS

Actual patient, kidney, and pancreas graft survival rates were 100, 100 and 94%, respectively, after a mean follow-up of 16 months. Renal allografts functioned immediately in 89% of patients. The mean length of hospital stay was 19 d. Four (23%) patients (2 with BS drainage and 2 with PE drainage) suffered an AR episode in the first month, and 4 (23%) patients had five AR from 3-36 months post-transplantation. Other complications were post-operative bleeding in 3 patients, wound infection in 2 patients and a proximal duodenal stump leak in 1 patient. In patients with clinical rejection, endoscopy through the venting jejunostomy showed inflamed, friable doudenal mucosa and doudenal biopsy findings were compatible with AR.

CONCLUSION

These preliminary results suggest that RNY venting jejunostomy with PE drainage can be used safely to diagnose and monitor pancreas AR and to diagnose and prevent anastamotic leaks. This technique will be even more useful to visualize transplanted duodenal mucosa, collect pancreatic secretions (amylase) for analysis and perform endoscopic retrograde cholangiopancreatography if needed to obtain pancreatic biopsies.

Vascularized pancreas allotransplantation--clinical indications and outcome

AIMS

This review examines the status of vascularized pancreas transplantation as a treatment for Type 1 diabetes mellitus (DM).

METHODS

The world literature, with a particular emphasis on data from the International Pancreas Transplant Registry (IPTR), is reviewed and interpreted particularly for clinical indications and outcome.

RESULTS

Over 9000 cases of vascularized pancreas transplant (VPT) have been registered, with insulin dependence approaching 82% at 1 year with 94% patient survival. The majority of transplants are simultaneous pancreas and kidney (SPK) transplants, with far fewer pancreas after kidney (PAK) or pancreas transplants alone (PTA). The success rates differ between the procedures but are generally improving as technical advances, improvements in immunosupression and greater experience are gained. The most obvious advantage is an improved quality of life (QoL) but there are risks associated with the procedure and with the immunosuppression. There is some evidence coming to light of a very slow beneficial effect on microvascular complications.

CONCLUSIONS

VPT is an attractive option to offer Type 1 DM patients who need or already have a renal allograft. Patients have to decide between the increased surgical risk and the risks of long-term immunosuppression and the benefits of improved QoL. In the absense of end-stage renal failure (ESRF) there is no justification for PTA, except where the diabetes itself poses a greater risk to life than the transplantation procedure.