Duodenal leaks after pancreas transplantation with enteric drainage - characteristics and risk factors

Abstract

SummaryPancreas-kidney transplantation with enteric drainage has become a standard treatment in diabetic patients with renal failure. Leaks of the graft duodenum (DL) remain a significant complication after transplantation. We studied incidence and predisposing factors of DLs in both simultaneous pancreas-kidney (SPK) and pancreas after kidney (PAK) transplantation. Between January 2002 and April 2013, 284 pancreas transplantations were performed including 191 SPK (67.3%) and 93 PAK (32.7%). Patient data were analyzed for occurrence of DLs, risk factors, leak etiology, and graft survival. Of 18 DLs (incidence 6.3%), 12 (67%) occurred within the first 100 days after transplantation. Six grafts (33%) were rescued by duodenal segment resection. Risk factors for a DL were PAK transplantation sequence (odds ratio 3.526, P = 0.008) and preoperative immunosuppression (odds ratio 3.328, P = 0.012). In the SPK subgroup, postoperative peak amylase as marker of preservation/reperfusion injury and recipient pretransplantation cardiovascular interventions as marker of atherosclerosis severity were associated with an increased incidence of DLs. CMV-mismatch constellations showed an increased incidence in the SPK subgroup, however without significance probability. Long-term immunosuppression in PAK transplantation is a major risk factor for DLs. Early surgical revision offers the chance of graft rescue.

Management of Graft Duodenal Leak in Simultaneous Pancreas Kidney Transplant—a Case Report from India and Review of Literature

“…Graft duodenal leaks are among the most common surgical complications after pancreas transplant with an incidence of 4-10 % and can result in graft loss in some cases [17]. Typically, early duodenal leaks are anastomotic leaks, either at the duodenovesical (in bladder drained pancreas transplant) or duodenoenteric (in enteric drained pancreas transplant) anastomosis.…”

“…Typically, early duodenal leaks are anastomotic leaks, either at the duodenovesical (in bladder drained pancreas transplant) or duodenoenteric (in enteric drained pancreas transplant) anastomosis. Late leaks (after 4 weeks post transplant) arise more frequently from the oversewn or stapled duodenal stumps [17,18]. In a study involving 284 pancreas transplants, the incidence of duodenal leak was 6.3 % of which 94 % cases had duodenal stump leaks [17].…”

“…Late leaks (after 4 weeks post transplant) arise more frequently from the oversewn or stapled duodenal stumps [17,18]. In a study involving 284 pancreas transplants, the incidence of duodenal leak was 6.3 % of which 94 % cases had duodenal stump leaks [17]. In the early period after transplantation, duodenal leaks are often related to graft preservation injury, technical reasons, and recipient's atherosclerosis [17][18][19].…”

“…In a study involving 284 pancreas transplants, the incidence of duodenal leak was 6.3 % of which 94 % cases had duodenal stump leaks [17]. In the early period after transplantation, duodenal leaks are often related to graft preservation injury, technical reasons, and recipient's atherosclerosis [17][18][19]. Long-term immunosuppression in PAK transplant is a risk factor for duodenal leaks.…”

“…If the graft duodenum is not compromised, the leak is well circumscribed and there is no peritonitis then a primary repair can be attempted [17][18][19]. Before attempting for graft salvage, one need to ensure that there is no evidence of distal obstruction, undrained infection, or bowel ischemia as the cause of the leak.…”