Spontaneous Arterioenteric Fistula After Pancreas Transplantation

Abstract

Chronic pancreas transplant rejection with enteric exocrine drainage can lead to significant longterm complications. We report a case of a 47-year-old male insulin-dependent diabetic who survived the complications of peripancreatic abscess, enterocutaneous fistula, and arterioenteric fistula related to pancreas transplantation. To avoid these long-term complications, we now recommend elective removal of nonfunctioning, enterically drained pancreas allografts.Bladder drainage has become the most common technique for diversion of pancreas transplant exocrine secretions (1,2). Urologic complications develop in over 50% of these patients (3). In an attempt to decrease the morbidity and cost of pancreas transplantation, we utilized enteric exocrine drainage for the most recent simultaneous pancreas kidney transplants (4). The 1-year pancreas graft survival rate using this technique was 87% in a recently reported series (5). The long-term complications of enteric drainage will require further study. We report herein a nearly fatal complication after pancreas transplantation with enteric drainage.The patient was a 47-year-old white man with insulin-dependent diabetes mellitus since the age of 5. When he was 36 years old, he developed chronic renal failure secondary to diabetic glomerulosclerosis. After 9 months on hemodialysis, in December 1982, an uneventful cadaveric renal transplant was performed with anastomosis of the donor vessels to the right external iliac artery and vein of the recipient. Cyclosporine and prednisone immunosuppression were maintained after renal transplantation. In March 1983, he was the recipient of a pancreaticoduodenal transplant with enteric drainage to the recipient jejunum. The donor spleen was initially transplanted with the pancreas allograft; however, the patient developed a hemolytic anemia, and a splenectomy was performed on postoperative day 6. The details of this pancreaticoduodenal transplant were reported previously (6). He remained euglycemic for 14 months until the pancreas suddenly failed, and a left lower quadrant extraperitoneal abscess was identified and surgically drained. In July 1985, the patient received his second pancreas transplant through a midline abdominal incision. The allograft was based on both the celiac axis and the superior mesenteric artery, which were anastomosed to the left common iliac artery in an end-to-side fashion using a common Carrel patch. The portal vein was anastomosed to

Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft

“…Close monitoring with serial imaging in patients with nonfunctioning pancreatic allografts should be considered so as to detect early fistula formation, and to prevent catastrophic bleeding consequences [19]. Preemptive allograft removal may be considered in certain cases [19].…”

“…Preemptive allograft removal may be considered in certain cases [19]. When catastrophic GI bleeding does occur, as detailed in the patient described herein, endovascular embolization and/or endovascular stent placement should be the treatment of choice.…”

Significant arterial complications after pancreas transplantation—A single‐center experience and review of literature

“…Eight of the 13 failed allografts (62%) had failed due to chronic rejection. Enteric drainage has been previously described as a risk factor for future development of pseudoaneurysms and arterial fistulas . In our series, however, the initial exocrine drainage for 9 of 23 patients (39%) was to the bladder, of which 2 had been converted to enteric drainage prior to the complication, leaving 7 patients with bladder drainage at the time of arterial complication.…”

“…The literature reporting arterial complications associated with a pancreatic allograft is sporadic, spanning 1989‐2017. In all, 7 case series and 34 case reports describe 70 patients with arterial complications. As in our series, the majority of complications were in primary pancreatic transplant recipients with enteric drainage.…”

Mycotic aneurysm of arterial conduit presenting as massive upper gastrointestinal hemorrhage after liver transplantation

“…3 AEFs have been reported after pancreas transplantation. 4 The timely diagnosis of a mycotic aneurysm in any setting requires a high index of suspicion. 2 Angiography is the most sensitive means of making the diagnosis, followed by computed tomography (CT) with intravenous contrast.…”