Outcomes in Pancreas Transplantation With Exocrine Drainage Through a Duodenoduodenostomy Versus Duodenojejunostomy

Abstract

Until recently, pancreas transplantation has mostly been performed with exocrine drainage via duodenojejunostomy (DJ). Since 2012, DJ was substituted with duodenoduodenostomy (DD) in our hospital, allowing endoscopic access for biopsies. This study assessed safety profiles with DD versus DJ procedures and clinical outcomes with the DD technique in pancreas transplantation. DD patients (n = 117; 62 simultaneous pancreas-kidney [SPK ] and 55 pancreas transplantation alone [PTA ] with median follow-up 2.2 years) were compared with DJ patients (n = 179; 167 SPK and 12 PTA ) transplanted in the period 1998-2012 (pre-DD era). Postoperative bleeding and pancreas graft vein thrombosis requiring relaparotomy occurred in 17% and 9% of DD patients versus 10% (p = 0.077) and 6% (p = 0.21) in DJ patients, respectively. Pancreas graft rejection rates were still higher in PTA patients versus SPK patients (p = 0.003). Hazard ratio (HR) for graft loss was 2.25 (95% CI 1.00, 5.05; p = 0.049) in PTA versus SPK recipients. In conclusion, compared with the DJ procedure, the DD procedure did not reduce postoperative surgical complications requiring relaparatomy or improve clinical outcomes after pancreas transplantation despite serial pancreatic biopsies for rejection surveillance. It remains to be seen whether better rejection monitoring in DD patients translates into improved long-term pancreas graft survival.

Retrospective study on detection, treatment, and clinical outcome of graft thrombosis following pancreas transplantation

“…The two cases of arterial thrombosis are believed to be secondary to the venous thrombosis. The percentage of graft thrombosis in our series is similar to that reported in literature although some centers report even lower thrombosis rates [15]. The thrombosis rate, however, is likely related to intrinsic risks of the pancreatic graft, reflecting in for example the PDRI.…”

“…Whether this is the optimal treatment remains up for debate. Clearly, there are as many possibilities as there are pancreas transplant centers: intravenous heparin, LWMH, acetylsalicylic acid, and a combination of either of them [2,8,15,[17][18][19][20]. We did not find an association between single or double dose LMWH prescription and thrombosis.…”

Pancreas transplant rejection episodes are not revealed by biopsies of the donor duodenum in a prospective study with paired biopsies

“…23,24 A shortcoming of the study is that the patient sample is of limited size. The role of protocol biopsies in surveillance of pancreas graft recipients is still not clear.…”

“…Ultimately, the possible advantage of such a program will be evaluated continuously against the procedure-related risks for the patients. 23,24 A shortcoming of the study is that the patient sample is of limited size. However, the substantial discordance between rejection findings in the transplanted duodenum versus the pancreas does not encourage us to continue using the donor duodenum as a reporter organ for pancreas rejection.…”

Microbubble contrast-enhanced ultrasound in the vascular evaluation after pancreas transplantation: a single-center experience

“…Pancreas transplantation (PTx) is a well-established treatment option for patients with complicated type 1 diabetes mellitus with and without concomitant diabetic end-stage renal disease. PTx is associated with surgical complications such as bleeding, thrombosis, and exocrine leakage (1)(2)(3). In particular, arterial or venous thrombosis, partly due to use of oversized ves-sels (celiac trunk, superior mesenteric artery, and splenic/portal vein) in conjunction with the relatively low blood flow through an isolated PTx, is a feared complication.…”