Are there still roles for exocrine bladder drainage and portal venous drainage for pancreatic allografts?

Abstract

Given the advent of newer immunosuppressive agents and overall lower acute rejection rates, the perceived benefit of bladder drainage as a means to measure urinary amylase as an early marker of rejection has not been substantiated. However, there may be a selective role for bladder drainage in 'high risk' pancreases. Also, without a clear-cut metabolic benefit to PVD over SVD, it remains the surgeon's choice as to which method to use.

Exocrine drainage in vascularized pancreas transplantation in the new millennium

“…In more recent series, however, the incidence of and outcomes associated with surgical complications following enteric diversion are similar to those following bladder drainage and the rates of early graft loss with either technique are comparable [1][2][3]52,[62][63][64] . The incidence of surgical complications is also similar by type of transplant (SPK compared to solitary pancreas transplantation) [1][2][3] .…”

“…A number of centers have reported excellent longterm outcomes in pancreas transplantation with the systemic-bladder technique [9,52,69,70,74,80,89] . For a period of time, the bladder drainage technique was also associated with lower incidences of thrombosis, early technical complications, and graft loss in IPTR reports compared to enteric drainage [12,13,15] .…”

“…The incidence of surgical complications is also similar by type of transplant (SPK compared to solitary pancreas transplantation) [1][2][3] . Leaks from the allograft duodenum have been reported to occur in 5%-20% of bladder-drained and 5%-8% of bowel-drained pancreas transplants [9,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][67][68][69][70][71][72][73]80,[91][92][93][94][95] . Increasing experience with enteric exocrine drainage is likewise associated with a decreased rate of technical complications [9,38,80,[96][97][98][99][100][101][102][103] .…”

“…However, in most cases, "portal venous" drainage usually infers that the allograft has a vertical orientation with the body and tail directed towards the pelvis, the head and duodenum directed cephalad, and the recipient SMV as the site for the venous anastomosis [18][19][20][21][22] (Figure 4). The bowel anastomosis is most commonly performed to a bowel loop that is not excluded from the transit of intestinal contents [4,16,17,33,[39][40][41][42][44][45][46][49][50][51][52][53][112][113][114][115][116][117][118][119][120][121] . Alternatively, the allograft duodenum can be connected directly into the native stomach or duodenum, to a diverting Roux limb without or with a venting jejunostomy, or to an omega loop [23][24][25][26][27][28][29][30][31][32]122] (Table 7).…”

“…Although one of the three described techniques is deployed in nearly all pancreas transplants at present, the prevailing viewpoint is that the most appropriate procedure to be used is best determined both by recipient and donor anatomy as well as the practicing surgeon's comfort level and experience. A number of previous excellent reviews have emphasized technical aspects of pancreas transplantation but few have been published in the past 6 years [52,[56][57][58][59][60][61][62][63][64] . The purpose of this review is to examine the prevailing literature on exocrine drainage in the past 20 years (the purported "enteric drainage" era) with special attention to surgical techniques that have been introduced over time and with experience in pancreas transplantation.…”