Pancreas Transplantation With Enteroanastomosis to Native Duodenum Poses Technical Challenges—But Offers Improved Endoscopic Access for Scheduled Biopsies and Therapeutic Interventions

Horneland, Rune; Paulsen, Vemund; Lindahl, Jørn Petter; Grzyb, Krzysztof; Eide, T. J.; Lundin, Katrin U.; Aabakken, Lars; Jenssen, Trond; Aandahl, Einar Martin; Foss, Aksel; Øyen, Ole

doi:10.1111/ajt.12953

Cited by 53 publications

(46 citation statements)

References 18 publications

(19 reference statements)

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“…After March 1998, bladder drainage was substituted with enteric drainage through a donor-derived duodenal segment attached to the proximal jejunum [20]. Since September 2012, the duodenal part of the transplant has been anastomosed to the recipient's duodenum rather than the jejunum to obtain endoscopic biopsies from both the duodenum and pancreas allografts [21].…”

Section: Methodsmentioning

confidence: 99%

Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation

et al. 2015

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Aims/hypothesis Mortality due to cardiovascular disease (CVD), particularly coronary artery disease (CAD), is high in type 1 diabetic patients with end-stage renal disease (ESRD). We aimed to determine whether normoglycaemia, as achieved by successful simultaneous pancreas and kidney (SPK) transplantation, could improve long-term outcomes compared with living donor kidney-alone (LDK) transplantation. Methods We studied 486 type 1 diabetic patients with ESRD who underwent a first SPK (n = 256) or LDK (n = 230) transplant between 1983 and 2012 and were followed to the end of 2014. Data were retrieved from the Norwegian Renal Registry and hospital records. Kaplan-Meier plots and multivariate Cox regression, with correction for recipient, donor and transplant factors, were used to examine potential associations between transplant type and all-cause and CVD-and CADrelated mortality. Results Median follow-up time was 7.9 years (interquartile range 4.3, 12.9). The adjusted HR for CVD-related deaths in SPK recipients compared with LDK recipients was 0.63 (95% CI 0.40, 0.99; p = 0.047), while the HRs for all-cause and CAD-related mortality were 0.81 (95% CI 0.57, 1.16; p = 0.25) and 0.63 (95% CI 0.36, 1.12; p = 0.12), respectively. Compared with the LDK group, SPK recipients were younger and received grafts from younger donors. Cardiovascular mortality was higher in patients transplanted between 1983 and 1999 compared with those who received their grafts in subsequent years. Conclusions/interpretation In patients with type 1 diabetes and ESRD, SPK transplantation was associated with reduced long-term cardiovascular mortality compared with LDK transplantation.

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Section: Methodsmentioning

confidence: 99%

Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation

et al. 2015

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“…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). Utilizing the native stomach or duodenum affords straightforward access to the allograft duodenum and pancreas for biopsy and surveillance by endoscopic techniques and also expands the possibilities for exocrine drainage sites, particularly in cases of pancreas retransplantation (Table 8) [ [25][26][27][28][29][30]…”

Section: Bowel Drainage Of the Pancreatic Ductal Secretions (Portal-ementioning

confidence: 99%

“…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). Utilizing the native stomach or duodenum affords straightforward access to the allograft duodenum and pancreas for biopsy and surveillance by endoscopic techniques and also expands the possibilities for exocrine drainage sites, particularly in cases of pancreas retransplantation (Table 8) [ [25][26][27][28][29][30][31][32]123] . However, because up to 5%-10% of transplanted pancreata are at risk for early technical failure that may lead to leaks, Duodenal leaks: (n = 11); Acute rejection (n = 6); CMV infection (n = 3); Technical failure (n = 2); Death: (n = 2) as a consequence of sepsis Reoperation for duodenal leak: Roux-en-Y technique: (n = 3) DJ technique: (n = 2) Transplantectomy: (n = 6) ND ND Toronto General Hospital, Spetzler et al [95] , Retrospective [106] , Retrospective 49; SPK; All ED Death: (n = 2) (1 patient died from multi-system organ failure and a second from graft vs host disease); Pancreatic graft failures: (2); renal graft failure: (1) Relaparotomies: (n = 5) bowel obstructions: (2) anastomotic leak: (1) ureteral stricture: (1) 96% Kidney 94%; Pancreas University of Pittsburgh, Corry et al [107] , Retrospective 104 SPK Graft loss in 6 patients, Death in one patient Splenic artery hemorrhage: (1) ND 98% 92%; Kidney 95%, Pancreas 83% University of Maryland, Bartlett et al [108] , Prospective…”

Section: Bowel Drainage Of the Pancreatic Ductal Secretions (Portal-ementioning

confidence: 99%

“…Consequently, > 80% of bowel drained pancreas transplants in the United States are performed without a decompressing Roux limb of small bowel and with systemic (iliac or vena cava) venous delivery of insulin [1] . Although the promise of the portal-enteric technique has not been achieved, it has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] . Previous reports have not shown any main variances in outcomes for bladder-or entericdiverted pancreas transplants regardless of method of venous drainage .…”

Section: Introductionmentioning

confidence: 99%

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Exocrine drainage in vascularized pancreas transplantation in the new millennium

El‐Hennawy¹,

Stratta²,

Smith³

2016

WJT

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The history of vascularized pancreas transplantation largely parallels developments in immunosuppression and technical refinements in transplant surgery. From the late-1980s to 1995, most pancreas transplants were whole organ pancreatic grafts with insulin delivery to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). The advent of bladder drainage revolutionized the safety and improved the success of pancreas transplantation. However, starting in 1995, a seismic change occurred from bladder to bowel exocrine drainage coincident with improvements in immunosuppression, preservation techniques, diagnostic monitoring, general medical care, and the success and frequency of enteric conversion. In the new millennium, pancreas transplants are performed predominantly as pancreatico-duodenal grafts with enteric diversion of the pancreatic ductal secretions coupled with iliac vein provision of insulin (systemic-enteric technique) although the systemic-bladder technique endures as a preferred alternative in selected cases. In the early 1990s, a novel technique of venous drainage into the superior mesenteric vein combined with bowel exocrine diversion (portal-enteric technique) was designed and subsequently refined over the next ≥ 20 years to recreate the natural physiology of the pancreas with firstpass hepatic processing of insulin. Enteric drainage usually refers to jejunal or ileal diversion of the exocrine secretions either with a primary enteric anastomosis or with an additional Roux limb. The portal-enteric technique has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion. Reports in the literature suggest no differences in pancreas transplant outcomes irrespective of type of either venous or exocrine diversion. The purpose of this review is to examine the FIELD OF VISION

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“…Creation of a duodenoduodenostomy to facilitate endoscopy of the grafted duodenum and as drainage for exocrine secretions has been reported [15]. Bleeding could have been stopped endoscopically if our patient had a duodenoduodenostomy, so this should be considered in the future.…”

Section: Discussionmentioning

confidence: 94%

Gastrointestinal Bleeding During Anticoagulant Therapy for Deep Vein Thrombosis after Simultaneous Pancreas and Kidney Transplantation

Sannomiya¹,

Nakajima²,

Ogawa³

et al. 2017

J Clin Case Rep

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A 46-year-old Japanese woman on dialysis for type 1 diabetes and chronic renal failure underwent simultaneous pancreas and kidney transplantation from a brain-dead donor. On postoperative day 3, ilio-femoral deep vein thrombosis on the side of pancreatic transplantation was diagnosed from swelling of the right leg, an increased D-dimer level, and imaging findings. Anticoagulant therapy was initiated to prevent proximal propagation of the thrombosis and pulmonary thromboembolism. However, gastrointestinal bleeding occurred, which was thought to be due to mucosal bleeding from the duodenal graft. Her anticoagulant therapy was adjusted and hemostasis was conducted, controlling the gastrointestinal bleeding without surgical intervention. Blood flow was maintained to both grafts and graft function was good. When gastrointestinal bleeding occurs during anticoagulant therapy for deep vein thrombosis after combined pancreas and kidney transplantation, bleeding can be controlled by adjusting anticoagulant therapy and other appropriate measures.

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Pancreas Transplantation With Enteroanastomosis to Native Duodenum Poses Technical Challenges—But Offers Improved Endoscopic Access for Scheduled Biopsies and Therapeutic Interventions

Cited by 53 publications

References 18 publications

Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation

Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation

Exocrine drainage in vascularized pancreas transplantation in the new millennium

Gastrointestinal Bleeding During Anticoagulant Therapy for Deep Vein Thrombosis after Simultaneous Pancreas and Kidney Transplantation

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