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Duodenal segment complications in vascularized pancreas transplantation

  • Original Articles
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Journal of Gastrointestinal Surgery

Abstract

Bladder drainage by the duodenal segment (DS) technique is currently the preferred method of pancreas transplantation (PTX) but is associated with unique complications. Over a 7-year period, 191 diabetic patients underwent 201 whole-organ PTXs with bladder drainage using a 6 to 8 cm length of DS as an exocrine conduit. A retrospective chart review was performed to document all DS morbidity. DS complications occurred in 38 cases (19%). Twelve patients developed DS leaks and required operative repair. DS bleeding was documented in 26 cases, necessitating cystoscopy in 22 patients and open repair in eight patients for significant hematuria. Cytomegalovirus (CMV) duodenitis was diagnosed in seven cases, with four presenting as DS leaks and three with hematuria. Five patients experienced ampullary obstruction early after PTX. Rejection of the DS was confirmed by biopsy in 13 patients, including eight cases of acute and five cases of chronic rejection. Two patients had stone formation from the DS staple line. Enteric conversion was performed in five patients for DS abnormalities (leaks in 2 cases, bleeding in 2, and CMV duodenitis in 1). Among patients with DS complications, patient survival is 84% and pancreas graft survival is 68% after a mean follow-up of 44±12 months. Complications related to the DS remain an important source of morbidity but rarely cause death after PTX. In spite of unique side effects, transplantation of the DS remains an acceptable alternative for exocrine drainage after PTX.

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References

  1. Sutherland DER, Gruessner A. Pancreas transplantation in the United States of America (USA) as reported to the United Network for Organ Sharing (UNOS) and analyzed by the International Pancreas Transplant Registry. In Terasaki PI, Cecka JM, eds. Clinical Transplants 1995. Los Angeles: UCLA Tissue Typing Laboratory, 1996, pp 49–67.

    Google Scholar 

  2. Stratta RJ, Taylor RJ, Larsen JL, Cushing KA. Pancreas transplantation: State of the art. Int J Pancreatol 1995;17:1–13.

    PubMed  CAS  Google Scholar 

  3. Stratta RJ, Taylor RJ, Gill IS. Pancreas transplantation: A managed cure approach to diabetes. In Wells SA, ed. Current Problems in Surgery, vol 33. St. Louis: Mosby, 1996, pp 711–808.

    Google Scholar 

  4. Lillehei RC, Simmons RL, Najarian JS. Pancreatico-duodenal allotransplantation: Experimental and clinical experience. Ann Surg 1970;172:405–436.

    Article  PubMed  CAS  Google Scholar 

  5. Cook K, Sollinger HW, Warner T, Kamps D, Belzer FO. Pancreaticocystostomy: An alternative method for exocrine drainage of segmental pancreatic allografts. Transplantation 1983;35:634–636.

    Article  PubMed  CAS  Google Scholar 

  6. Nghiem DD, Corry RJ. Technique of simultaneous renal pancreaticuduodenal transplantation with urinary drainage of pancreatic secretion. Am J Surg 1987;153:405–406.

    Article  PubMed  CAS  Google Scholar 

  7. Sollinger HW, Pirsch JD, D’Alessandro AM, Kalayoglu M, Belzer FO. Advantages of bladder drainage in pancreas transplantation: A personal view. Clin Transpl 1990;4:32–36.

    Google Scholar 

  8. Schang T, Timmermann W, Thiede A, Najarian JS, Sutherland DER. Detrimental effects of fluid and electrolyte loss from duodenum in bladder-drained pancreas transplants. Transplant Proc 1991;23:1617–1618.

    PubMed  CAS  Google Scholar 

  9. Munda R, Tom WW, First MR, Alexander JW. Pancreatic allograft exocrine urinary tract diversion: Pathophysiology. Transplantation 1987;43:95–97.

    Article  PubMed  CAS  Google Scholar 

  10. Nghiem DD, Gonwa TA, Corry RJ. Metabolic effects of urinary diversion of exocrine secretions in pancreatic transplantation. Transplantation 1987;43:70–73.

    Article  PubMed  CAS  Google Scholar 

  11. Sollinger HW, Messing EM, Eckhoff DE, Pirsch JD, D’Alessandro AM, Kalayoglu M, Knechtle SJ, Hickey D, Belzer FO. Urological complications in 210 consecutive simultaneous pancreas-kidney transplants with bladder drainage. Ann Surg 1993;218:561–570.

    Article  PubMed  CAS  Google Scholar 

  12. Smith JL, See WA, Ames SA, Piper JB, Corry RJ. Lower urinary tract complications in patients with duodenocystostomies for exocrine drainage of the transplanted pancreas. Transplant Proc 1991;23:1611–1612.

    PubMed  CAS  Google Scholar 

  13. Marsh CL, Forg P. The diagnosis and management of urologic complications in non-renal transplant recipients. Semin Urol 1994;12:233–250.

    PubMed  CAS  Google Scholar 

  14. Sindhi R, Stratta RJ, Lowell JA, Sudan D, Cushing KA, Castaldo P, Jerius JT. Experience with enteric conversion after pancreas transplantation with bladder drainage. J Am Coll Surg 1997;184:281–289.

    PubMed  CAS  Google Scholar 

  15. Burke GW, Sutherland DER, Najarian JS. Intra-abdominal fluid collections in pancreas transplant recipients: Bladder versus enteric drainage. Transplant Proc 1988;20:887–888.

    Google Scholar 

  16. Gruessner RWG, Dunn DL, Tzardis PJ, Nakhleh RI, Najarian JS, Sutherland DER. Complications occurring after whole organ duodenopancreatic transplantation: Relation to the allograft duodenal segment. Transplant Proc 1990;22:578–579.

    PubMed  CAS  Google Scholar 

  17. Elkhammas EA, Henry ML, Tesi RJ, Ferguson RM. Duodenal segment-associated complications following combined kidney/pancreas transplantation. Transplant Proc 1993;25:2230–2231.

    PubMed  CAS  Google Scholar 

  18. D’Alessandro AM, Sollinger HW, Stratta RJ, Kalayoglu M, Pirsch JD, Belzer FO. Comparison between duodenal button and duodenal segment in pancreas transplantation. Transplantation 1989;47:120–122.

    Article  PubMed  CAS  Google Scholar 

  19. Stratta RJ, Taylor RJ, Wahl TO, Duckworth WC, Gallagher TF, Knight TF, Fischer JL, Neumann TV, Miller S, Langnas AN, Ozaki CF, Bynon JS, Larsen JL, Weide LG, Cassling RS, Taylor AJ, Shaw BW Jr. Recipient selection and evaluation for vascularized pancreas transplantation. Transplantation 1993;55:1090–1096.

    Article  PubMed  CAS  Google Scholar 

  20. Stratta RJ, Taylor RJ, Spees EC, Langnas AN, Marujo WC, Li S, Ozaki C, Ranjan D, Duckworth RM, Shaw BW Jr. Refinements in cadaveric pancreas-kidney procurement and preservation. Transplant Proc 1991;23:2320–2322.

    PubMed  CAS  Google Scholar 

  21. Stratta RJ, Taylor RJ, Lowell JA, Sindhi R, Sudan D, Castaldo P, Weide LG, Frisbie K, Cushing DA, Larsen JL, Grune M, Radio SJ. Pancreas transplantation: The Nebraska experience. In Terasaki PI, Cecka JM, eds. Clinical Transplants 1994. Los Angles: UCLA Tissue Typing Laboratory, 1995, pp 265–281.

    Google Scholar 

  22. Stratta RJ, Taylor RJ. Kidney allocation in the 1990s: Progress and problems. Transplant Proc 1993;25:3065–3066.

    PubMed  CAS  Google Scholar 

  23. Stratta RJ, Taylor RJ, Bynon JS, Lowell JA, Cattral MS, Frisbie K, Miller S, Radio SJ, Brennan DC. Viral prophylaxis in combined pancreas-kidney transplantation recipients. Transplantation 1994;57:506–512.

    Article  PubMed  CAS  Google Scholar 

  24. Stratta RJ, Taylor RJ, Weide IG, Sindhi R, Sudan D, Castaldo P, Cushing KA, Frisbie K, Radio SJ. A prospective randomized trial of OKT3 versus ATGAM induction therapy in pancreas transplant recipients. Transplant Proc 1996;28:927–928.

    Google Scholar 

  25. Stratta RJ, Sollinger HW, Perlman SB, D’Alessandro AM, Groshek M, Kalayoglu M, Pirsch JD, Belzer FO. Early diagnosis and treatment of pancreas allograft rejection. Transpl Int 1988;1:6–12.

    Article  PubMed  CAS  Google Scholar 

  26. Radio SJ, Stratta RJ, Taylor RJ, Linder J. The utility of urine cytology in the diagnosis of allograft rejection after combined pancreas-kidney transplantation. Transplantation 1993;55: 509–516.

    Article  PubMed  CAS  Google Scholar 

  27. Stratta RJ, Taylor RJ. Prevention and management of hematuria in combined pancreas-kidney transplant recipients with pancreaticoduodenocystostomy. Transplant Proc 1992;24: 788–790.

    PubMed  CAS  Google Scholar 

  28. Lowell JA, Bynon JS, Nelson N, Hapke MR, Morton JJ, Brennan DC, Stratta RJ, Taylor RJ. Improved technique of transduodenal pancreas transplant biopsy. Transplantation 1994;57:752–753.

    Article  PubMed  CAS  Google Scholar 

  29. Nakhleh RE, Gruessner RWG, Tzardis PJ, Dunn DL, Sutherland DER. Pathology of transplanted human duodenal tissue: A histologic study, with comparison to pancreatic pathology, in resected pancreaticoduodenal transplants. Clin Transplant 1991;5:241–247.

    Google Scholar 

  30. Nakhleh RE, Benedetti E, Gruessner A, Troppmann C, Goswitz JJ, Sutherland DER, Gruessner RWG. Cystoscopic biopsies in pancreaticoduodenal transplantation: Are duodenal biopsies indicative of pancreas dysfunction? Transplantation 1995;60:541–546.

    Article  PubMed  CAS  Google Scholar 

  31. Wengrovitz M, Jarowenko MV, Gifford RRR, Sechtan AG, Mandell MJ, Yang HC. Stone formation as a cause of allograft pancreatitis in the recipient of a combined kidney and pancreas transplant. Clin Transpl 1990;4:117–119.

    Google Scholar 

  32. Starzl TE, Iwatsuki S, Shaw BW, Greene DA, Van Thiel DH, Nalesnik MS, Nusbacher J, Diliz-Perez H, Hakala TR. Pancreaticoduodenal transplantation in humans. Surg Gynecol Obstet 1984;159:265–272.

    PubMed  CAS  Google Scholar 

  33. Stratta RJ, Taylor RJ, Bynon JS, Lowell JA, Sindhi R, Wahl TO, Knight TF, Weide LG, Duckworth WC. Surgical treatment of diabetes mellitus with pancreas transplantation. Ann Surg 1994;220:809–817.

    Article  PubMed  CAS  Google Scholar 

  34. Ozaki CF, Stratta RJ, Taylor RJ, Langnas AN, Bynon JS, Shaw BW Jr. Surgical complications in solitary pancreas and combined pancreas-kidney transplantation. Am J Surg 1992; 164:546–551.

    Article  PubMed  CAS  Google Scholar 

  35. Castoldi R, Staudacher C, Ferrari G, Cristallo M, Carlucci M, La Rocca E, Secchi A, Pozza G, Di Carlo V. Early postoperative surgical complications: Comparison of segmental duct-injected versus whole bladder-drained pancreas transplantation. Transplant Proc 1992;24:817–820.

    PubMed  CAS  Google Scholar 

  36. Eckhoff DE, Sollinger HW. Surgical complications after simultaneous pancreas-kidney transplant with bladder drainage. In Terasaki PA, Cecka JM, eds. Clinical Transplants 1993. Los Angeles: UCLA Tissue Typing Laboratory, 1994, pp 185–191.

    Google Scholar 

  37. Douzdjian V, Abecassis MM, Cooper JL, Smith JL, Corry RJ. Incidence, management, and significance of surgical complications after pancreatic transplantation. Surg Gynecol Obstet 1993;177:451–456.

    PubMed  CAS  Google Scholar 

  38. Troppmann C, Gruessner AC, Benedetti E, Papalois BE, Dunn DL, Najarian JS, Sutherland DER, Gruessner RWG. Vascular graft thrombosis after pancreatic transplantation: Univariate and multivariate operative and nonoperative risk factor analysis. J Am Coll Surg 1996;182:285–316.

    PubMed  CAS  Google Scholar 

  39. Sutherland DER, Dunn DL, Goetz FC, Kennedy W, Ramsay RC, Steffes NW, Mauer SM, Gruessner R, Moudry-Munns MC, Morel P, Viste A, Robertson RP, Najarian JS. A ten-year experience with 290 pancreas transplants at a single institution. Ann Surg 1989;210:274–288.

    Article  PubMed  CAS  Google Scholar 

  40. Hakim NS, Benedetti E, Sutherland DER, Gruessner R. Duodenal complications after whole organ pancreas transplantation. HPB Surg 1996;9(Suppl 2):40.

    Google Scholar 

  41. Schleibner S, Theodorakis J, Illner WD, Leitl F, Abendroth D, Land W. Ulcer perforation in the grafted duodenal segment following pancreatic transplantation: A case report. Transplant Proc 1992;24:827.

    PubMed  CAS  Google Scholar 

  42. Esterl RM, Stratta RJ, Taylor RJ, Radio SJ. Rejection with duodenal rupture after solitary pancreas transplantation: An unusual cause of severe hematuria. Clin Transplant 1995;9:155–159.

    PubMed  CAS  Google Scholar 

  43. Sollinger HW, Sasaki TM, D’Alessandro AM, Knechtle SJ, Pirsch JD, Kalayoglu M, Belzer FO. Indications for enteric conversion after pancreas transplantation with bladder drainage. Surgery 1992;112:842–846.

    PubMed  CAS  Google Scholar 

  44. Stephanian E, Gruessner RWG, Brayman KL, Gores P, Dunn DL, Najarian JS, Sutherland DER. Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants. Ann Surg 1992; 216:663–672.

    Article  PubMed  CAS  Google Scholar 

  45. Elkhammas EA, Henry ML, Tesi RJ, Davies EA, Ferguson RM. Late urine leaks after combined kidney-pancreas transplantation. Transplant Proc 1994;26:453.

    PubMed  CAS  Google Scholar 

  46. Ploeg RJ, Eckhoff DE, D’Alessandro AM, Stegall MD, Knechtle SJ, Pirsch JD, Sollinger HW, Belzer FO. Urological complications and enteric conversion after pancreas transplantation with bladder drainage. Transplant Proc 1994; 26:458–459.

    PubMed  CAS  Google Scholar 

  47. Gruessner RWG, Stephanian E, Dunn DL, Gruessner AC, Najarian JS, Sutherland DER. Cystoenteric conversion after whole pancreaticoduodenal transplantation: Indications, risk factors, and outcome. Transplant Proc 1993;25:1179–1181.

    PubMed  CAS  Google Scholar 

  48. See WA, Smith JL. Activated proteolytic enzymes in the urine of whole organ pancreas transplantation patients with duodenocystostomy. Transplant Proc 1991;23:1615–1616.

    PubMed  CAS  Google Scholar 

  49. Taylor RJ, Bynon JS, Stratta RJ. Kidney/pancreas transplantation: A review of the current status. Urol Clin North Am 1994;21:343–354.

    PubMed  CAS  Google Scholar 

  50. Eckhoff DE, Ploeg RJ, Wilson MA, D’Alessandro AM, Knechtle SJ, Pirsch JD, Belzer FO, Sollinger HW. Efficacy of 99MTc voiding cystourethrogram for detection of duodenal leaks after pancreas transplantation. Transplant Proc 1994; 26:462–463.

    PubMed  CAS  Google Scholar 

  51. Rayhill SC, Odorico JS, Heisey DM, Wilson MA, Pirsch JD, D’Alessandro AM, Knechtle SJ, Eckhoff DE, Belzer FO, Sollinger HW. Clinical and laboratory features of pancreatic transplant bladder leaks. Transplant Proc 1995;27:3141–3142.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Division of Transplantation, University of Tennessee-Memphis, 956 Court Ave., Suite A202, 38163-2116, Memphis, TN

    Robert J. Stratta M.D.

  2. Department of Pathology and Microbiology, University of Tennessee-Memphis, 956 Court Ave., Suite A202, 38163-2116, Memphis, TN

    Robert J. Stratta M.D.

  3. University of Nebraska Medical Center and Clarkson Hospital, Omaha, Neb

    Rakesh Sindhi M.D., Debra Sudan M.D., John T. Jerius M.D. & Stanley J. Radio M.D.

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  1. Robert J. Stratta M.D.
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Stratta, R.J., Sindhi, R., Sudan, D. et al. Duodenal segment complications in vascularized pancreas transplantation. J Gastrointest Surg 1, 534–544 (1997). https://doi.org/10.1016/S1091-255X(97)80070-4

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