Pancreas Transplant Salvage by Proximal Loop Ileostomy and Distal Ileostotomy Tube for Duodenal Stump Leak after Enteric Conversion

Monroy-Cuadros Mauricio, Rodriguez-Velez Cesar

.

DOI: 10.4236/ss.2011.21001                

Abstract

After pancreas transplantation, some patients with bladder drainage (BD) of the pancreatic duct will need to be converted to enteric drainage (ED) because of reflux pancreatitis, metabolic acidosis, and urological complications. However, ED is associated with higher rates of duodenal stump leak, intra-abdominal abscess, and peritonitis. In some cases of enteric anastomosis leakage, a primary repair can be attempted, but in more severe cases, graft pancreatectomy is indicated. We report one patient who received a combined kidney and pancreas transplant with BD of exocrine secretions, but who required ED conversion 6 years later because of persistent metabolic acidosis and adverse urological symptoms. However, a significant duodenal leak was discovered 4 days post-operatively. To salvage the transplanted pancreas, we performed a diverting loop ileostomy proximal to the entero-entero anastomosis and the distal section was drained retrogradely with an ileostostomy tube, allowing the area of the leak to heal. Three months later, the ileostomy was reversed without complications, the symptoms that led to the ED conversion resolved, and the kidney and pancreas allografts remain functional 48 months later. We suggest that this might be a method by which transplanted pancreas may be salvaged in the case of leakage after ED conversion.

Keywords

Pancreas, Transplant, Conversion leak

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	R. W. Gruessner and D. E. Sutherland, “Transplantation of the Pancreas,” New York, Birkhauser, 2004.
[2]	R. W. Gruessner, D. L. Dunn, P. J. Tzardis, R. I. Nakhleh, J. S. Najarian and D. E. Sutherland, “Complications Occurring after Whole Organ Duodenopancreatic Transplantation: Relation to the Allograft Duodenal Segment,” Transplantation Proceedings 1990, Vol. 22, No. 2, pp. 578-579.
[3]	H. W. Sollinger, T. M. Sasaki, A. M. D’Alessandro, S. J. Knechtle, J. D. Pirsch, M. Kalayoglu, et al, “Indications for Enteric Conversion after Pancreas Transplantation with Bladder Drainage,” Surgery, Vol. 112, No. 4, 1992, pp. 842-846, discussion 845-846.
[4]	M. Prieto, W. Collins, M. H. Scott and R. A. Sells, “Method for Home Monitoring of Urinary Amylase after Pancreas Transplantation,” Diabetes, Vol. 38, Sup. 1, 1989, pp. 68-70.
[5]	H. W. Sollinger, E. M. Messing, D. E. Eckhoff, J.D. Pirsch, A. M. D’Alessandro, M. Kalayoglu et al, “Urological Complications in 210 Consecutive Simultaneous Pancreas- kidney Transplants with Bladder Drainage,” Annals of Surgery, Vol. 218, No. 4, 1993, pp. 561-568; Discussion, pp. 568-570.
[6]	M. West, A. C. Gruessner, P. Metrakos, D. E. Sutherland, R. W. Gruessner, “Conversion from Bladder to Enteric Drainage after Pancreaticoduodenal Transplantations,” Surgery, Vol. 124, No. 5, 1998, pp. 883-893.
[7]	M. Monroy-Cuadros, A. Salazar, S. Yilmaz and K. McLaughlin, “Bladder vs Enteric Drainage in Simultaneous Pancreas-kidney Transplantation,” Nephrol Dial Transplant, Vol. 21, No. 2, 2006, pp. 483-487. doi:10.1093/ndt/gfi252
[8]	S. A. White, J. A. Shaw and D. E. Sutherland, “Pancreas transplantation,” Lancet, Vol. 373, No. 9677, 2009, pp. 1808-1817. doi:10.1016/S0140-6736(09)60609-7
[9]	H. W. Sollinger, J. S. Odorico, S. J. Knechtle, A. M. D’Alessandro, M. Kalayoglu and J. D. Pirsch, “Experience with 500 Simultaneous Pancreas-kidney Transplants,” Annnals of Surgery, Vol. 228, No. 3, 1998, pp. 284-296. doi:10.1097/00000658-199809000-00002
[10]	D. E. Sutherland, R. W. Gruessner, D. L. Dunn, A. J. Matas, A. Humar, R. Kandaswamy, et al. “Lessons Learned from more than 1,000 Pancreas Transplants at a Single Institution,” Annals of Surgery, Vol. 233, No. 4 2001, pp. 463-501. doi:10.1097/00000658-200104000-00003
[11]	C. Jimenez-Romero, A. Manrique, J. M. Morales, R. M. Lopez, E. Morales, F. Cambra et al. “Conversion from Bladder to Enteric Drainage for Complications after Pancreas Transplantation,” Transplantation Proceedings, Vol. 41, No. 6, 2009, pp. 2469-2471. doi:10.1016/j.transproceed.2009.06.077
[12]	S. N. Wang, M. Sturdevant, R. Kandaswamy, R. G. Gruessner, D. E. Sutherland and A. Humar, “Technical Failure of the Pancreas after SPK Transplant: Are These Patients Good Candidates for Later Pancreas Retransplant?” Clinical Transplantation, Vol. 22, No. 1, 2008, pp. 50-54.
[13]	P. van de Linde, P. J. van der Boog, A. G. Baranski, J. W. de Fijter, J. Ringers and A. F. Schaapherder “Pancreas Transplantation: Advantages of Both Enteric and Bladder Drainage Combined in a Two-step Approach,” Clinical Transplantation, Vol. 20, No. 2, 2006, pp. 253-257. doi:10.1111/j.1399-0012.2005.00477.x
[14]	W. Steurer, H. Bonatti, P. Obrist, B. Spechtenhauser, R. Ladurner, W. Mark et al, “Incidence of Intraabdominal Infection in a Consecutive Series of 40 Enteric-drained Pancreas Transplants with FK506 and MMF Immunosuppression,” Transplant Intertional, Vol. 13, Sup. 1: 2000, pp. 195-198.
[15]	E. Orsenigo, M. Cristallo, C. Socci, R. Castoldi, P. Fiorina, L. Invernizzi et al, “Successful Surgical Salvage of Pancreas Allograft,” Transplantation, Vol. 75, No. 2, 2003, pp. 233-236. doi:10.1097/01.TP.0000041784.27763.A9
[16]	E. Ablorsu, S. Mehra, A. Tavakoli, T. Augustine, R. Pararajasingam, “Staged Enteric Conversion after Duodenal Necrosis in Simultaneous Kidney and Pancreas Transplant from a Donor after Cardiac Death: A Case Report,” Transplantation Proceedings, Vol. 41, No. 5, 2009, pp. 1778-1780. doi:10.1016/j.transproceed.2009.02.081
[17]	U. Boggi, F. Vistoli, M. Del Chiaro, C. Moretto, C. Croce, S. Signori et al. “Total Duodenectomy with Enteric Duct Drainage: A Rescue Operation for Duodenal Complications Occurring after Pancreas Transplantation,” American Journal of Transplantation, Vol. 10, No. 3, 2010, pp. 692-697. doi:10.1111/j.1600-6143.2009.02981.x
[18]	D. Feliciano, D. Mattox, E. Moore “Trauma,” 6th edition, New York, McGraw-Hill Professional, 2007.