Arterio-Enteric Fistula in Failed Enteric-Drained Pancreas Transplants: An Impending Danger

Abstract

).Pancreas transplantation allows for a euglycemic state in the absence of exogenous insulin. Exocrine pancreatic drainage can be achieved via the gastrointestinal or urinary tracts. Arterio-enteric fistulas constitute an infrequently encountered but potentially fatal complication associated with failed enteric-drained pancreas transplants. Case ReportOur patient is a 58-year-old woman who is presented with hematemesis. Work up inclusive of esophagogastroduodenoscopy (EGD), colonoscopy, and capsule endoscopy did not identify any site of hemorrhage. After a 48-hour observation period with no further bleeding, the patient was discharged home. Twenty days later, she was presented to an outside hospital with a severe recurrent gastrointestinal bleed, prompting an emergent transfer to our institution for further diagnosis and treatment.Her past medical and surgical histories were significant for type 1 diabetes mellitus and renal failure, for which she had undergone an isolated living donor-related kidney transplant 5 years before presentation. She underwent a cadaveric pancreas after kidney transplant, 2 years later. The methods of pancreas transplantation utilized were enteric exocrine drainage and systemic venous drainage. The pancreatic allograft functioned well initially, and the patient maintained euglycemia for 2 years. At that point, 1 year before presentation, the pancreatic allograft had failed because of chronic rejection. Her kidney allograft was still functioning normally. Her immunosuppressive regimen consisted of the following: mycophenolate mofetil 250 mg oral, twice a day; tacrolimus 3 mg oral, twice a day; and prednisone 5 mg oral, once a day.The patient was admitted to our intensive care unit and transfused 6 units of packed red blood cells and 2 units of fresh-frozen plasma with an adequate hemodynamic response. A bedside EGD showed large amounts of blood in the stomach and duodenum with no apparent source. On the basis of these findings, it was decided to proceed with an emergency angiogram to identify the source of bleeding and control it, possibly by endovascular approach. While in the radiology department, as the procedure was about to be Keywords ► arterio-enteric fistula ► enteric-drained pancreas transplant ► gastrointestinal bleeding ► endovascular stenting ► allograft pancreatectomy AbstractEnteric drainage is the preferred method of exocrine diversion in simultaneous kidneypancreas transplantation. Because of improvements in immunosuppression, enteric drainage has become the preferred method of pancreas transplantation in general.Although associated with less potential complications than bladder-drained pancreas, potentially lethal arterio-enteric fistulas in the setting of nonfunctioning allografts represent a constant threat. We herein present a case report, a review of the literature, and a call for caution.

Arterio-colonic Fistula as a Complication of Failed Pancreatic Transplant

“…Furthermore, the proximity of the colonic wall, and the pulsatile pressure over it may have aided the creation of the arterio-colonic fistula. This type of complication typically presents as massive and abrupt gastrointestinal bleeding from pseudoaneurysm rupture [4,5]. In our case, the subtle presentation with an absence of gastrointestinal bleeding easily could have led to a different, fatal outcome.…”

“…In cases of massive bleeding, resuscitation remains the essential initial step. A recent review of the literature by Villa, et al found 11 cases of iliac-enteric fistulas in failed enteric-drained pancreas transplant [5]. Sixty-four percent of the patients presented with upper gastrointestinal bleed, and mortality was 27%.…”

Allograft Pancreatectomy: Indications and Outcomes

“…Vascular issues may be the most challenging clinically. It is often difficult to detect formation of pseudoaneurysm and/or arterioenteric fistula before developing significant hemorrhage . Endovascular interventions such as covered stent placement and microcoils are useful to control bleeding temporarily or permanently, which stabilizes the hemodynamic state and provides complete vascular control during the allograft pancreatectomy procedure .…”

Beta-cell replacement therapy

“…Islet cell transplantation compares favorably with pancreas transplantation in terms of mortality risk; islet allograft recipients bear 0-2.6 and 5% risk of death at 1 and 5 years posttransplant, whereas even modern era solitary pancreas transplant recipients continue to experience 3 and 10% risk of death at 1 and 5 years [6,15 && ,44 && ]. It should not be minimized, however, that transplantation of the pancreas is plagued by complications related to the exocrine pancreas (pancr eatitis, leak, pain, bowel obstruction, and arterioenteric fistula) which are not relevant risks of islet cell transplantation [45,90]. Adverse events have decreased significantly between earlier and recent eras in allotransplantation (from 53 to 38%) and are certainly lower than those associated with clinical experience in pancreas transplantation [6,69 && ,77,91].…”