Feasibility of Visualization and Biopsy of Donor Duodenum by Double-balloon Enteroscopy Technique in a Recipient of Simultaneous Enteric-drained Pancreas-kidney Transplant: Case Report

Endoscopic visualization of graft status in patients with pancreas transplantation

BACKGROUND

Enteric drainage into the recipient duodenum in pancreas transplantation (PT) can identify the graft duodenum by endoscopy. This study aimed to identify the characteristic endoscopic findings associated with graft failure or acute rejection in patients with PT.

METHODS

We reviewed the medical records of patients who underwent PT with duodenoduodenostomy (DD) between January 2015 and August 2019. During this period, there were 44 PTs with DD in 42 patients; 122 endoscopies were performed and analyzed.

RESULTS

Overall, pancreatic graft survival was 82% at a mean follow-up of 27 months (range 6-55 months). There were 8 graft failures and 10 acute rejections. In all 8 graft failures, a deep ulcer covered with fibrinous exudates of the graft duodenum was confirmed on endoscopy. Diffuse erythema inside the graft duodenum was observed in 8 of 10 acute rejections. The factors associated with acute rejection were elevated serum lipase level (OR 8.5, p = 0.02) and diffuse erythema inside the graft duodenum on endoscopy (OR 20.5, p < 0.01) in multivariate analysis.

CONCLUSIONS

In PT with DD patients, graft failure can be visualized by endoscopy, and diffuse erythema inside the graft duodenum may be a finding of acute rejection.

In vivo endomicroscopy of donor duodenum improves early detection of pancreas rejection in a recipient of simultaneous duodenum-drained pancreas-kidney transplantation: a case report

Confocal laser endomicroscopy (CLE) is a new technique, which allows subsurface histological diagnosis at a cellular and subcellular level in vivo and could provide histological diagnosis during endoscopic examination. Up to now histological examination of the tissue sample is the only definitive way of diagnosis and monitoring organ rejection after transplantation. In case of pancreas transplantation percutaneous pancreas biopsy under imaging control is still the method of choice for obtaining tissue samples. However in 73–89% of biopsy attempts, it was shown that the duodenal histology predicts the initial diagnosis of rejection of the pancreas, usefulness of transplanted duodenum biopsies for graft rejection monitoring was also described. The histology technique is time consuming, and the therapeutic decision could not be made quickly, in spite of clinical necessity. In this paper we described feasibility of visualization and biopsy of donor duodenum and detection of microscopic changes in 2 cases of transplanted duodenum, expressed as destruction of the villi and dispersed goblet cells in comparison to a microscopic view of their own healthy duodenum No or only small, endoscopically non-significant macroscopic changes in transplanted duodenum in those patients were observed. In both cases, the histological examination confirmed acute organ rejection. We demonstrated for the first time that CLE is promising and effective method to detect acute phase of organ rejection and also for follow up in those patients.

Endoscopic retrograde pancreatography using single balloon enteroscopy in a patient with smoldering pancreatitis in a distal jejunal pancreas transplant

Portal-enteric drainage of graft secretions is currently the preferred method of pancreatic transplantation and usually created between the donor duodenum and recipient jejunum; however, this anatomy does not allow for easy access to the donor pancreas. We report here the first case of a single balloon assisted-endoscopic retrograde pancreatography in a patient with progressively increasing amylase and lipase in portal-enteric-drained pancreas-kidney transplantation.

Enteroscopic biopsies in the management of pancreas transplants: a proof of concept study for a novel monitoring tool

BACKGROUND

Although percutaneous biopsies are considered to be the gold standard in diagnosing pancreas graft rejection, they are not performed routinely because of their association with severe complications. On the other hand, correct diagnosis of rejection is essential but may be difficult in cases of enteric drainage, particularly in patients with a pancreas transplant alone or a pancreas after kidney transplant.

METHODS

Pancreas recipients who underwent enteroscopy between May 2005 and September 2009 were included in this retrospective analysis. Biopsies were graded 0 to 4 for interstitial and vascular changes.

RESULTS

During the study period a total of 65 simultaneous pancreas-kidney transplants, 13 pancreas after kidney transplants and 4 pancreas transplants alone were performed. Sixty-three patients underwent a single enteroscopy, 10 had two, and 6 had three or more. Indications were protocol graft monitoring (n=73), graft dysfunction (n=17), enteric hemorrhage (n=9), or other (n=3). The duodenal segment was accessed in 76 instances (75%) with abnormal findings in 23. A total of 69 biopsies were obtained and revealed normal mucosa in 49 cases (71%). Histology showed signs of acute rejection in 11 cases. The upper gastrointestinal tract was also assessed, and, in 13 cases, additional pathologies were identified including gastroduodenitis (n=10), gastric/duodenal ulcer (n=2), and hemorrhagic esophagitis (n=1). No procedure-related complication occurred.

CONCLUSIONS

This series of enteroscopies demonstrates that the duodenal segment of a pancreatic graft is accessible using our implant technique, and thus permitting biopsies to be obtained and endoscopic interventions to be performed.

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.