Portal-Endocrine and Gastric-Exocrine Drainage Technique of Pancreas Transplantation Provides an Easy Access for Evaluation of Pancreatic Allograft Dysfunction: Six-Year Experience at a Single Center
Gazi B. Zibari, MD, FACS; Mohammad Kazem Fallahzadeh, MD; Alireza Hamidian Jahromi, MD; Joseph Zakhary, MD; David Dies, MD; Greg Wellman, MD; Neeraj Singh, MD; Hosein Shokouh-Amiri, MD, FACS
Background : The aim of this study is to report our six-year experience with portal-endocrine and gastric- exocrine drainage technique of pancreatic transplantation, which was first developed and implemented at our center in 2007. Methods : In this study, the outcomes of all patients at our center who had pancreas transplantation with portal-endocrine and gastric-exocrine drainage technique were evaluated. Results : FromOctober 2007 toNovember 2013, 38 patients had pancreas transplantationwith this technique - 31 simultaneous kidney pancreas and seven pancreas alone. Median duration of follow-up was 3.8 years. One-, three-, and five-year patient and graft survival rates were 94%, 87%, 70% and 83%, 65%, 49%, respectively. For pancreas allograft dysfunction evaluation, 51 upper endoscopies were performed in 14 patients; donor duodenal biopsies were successfully obtained in 45 (88%). We detected nine episodes of acute rejection (eight patients) and seven episodes of cytomegalovirus (CMV) duodenitis (six patients). No patient developed any complication due to upper endoscopy. Conclusions : Portal-endocrine and gastric-exocrine drainage technique of pancreas transplantation provides lifelong easy access to the transplanted duodenum for evaluation of pancreatic allograft dysfunction.
INTRODUCTION Several techniques of pancreas transplantation have been tried in the past four decades, each with a different approach to manage exocrine and endocrine drainages of the pancreas, including bladder vs. enteric drainage with or without Roux-en-Y for exocrine drainage and systemic vs. portal for endocrine drainage. 1-4 The advantage of bladder drainage is detection of pancreatic rejection by measuring the urinary levels of the pancreatic enzymes. 1,5 However, due to profuse urinary loss of pancreatic exocrine secretions, this technique could result in metabolic complications such as volume depletion andmetabolic acidosis, as well as urologic complications such as recurrent urinary tract infection and hemorrhagic cystitis. 1,5-8 To manage these complications,
about 15%-20% of these patients have to undergo bladder to enteric conversion. These complications are not observed in the enteric drainage technique of pancreas transplantation; 1,5 however, the main disadvantage of enteric drainage tech- nique is lack of a noninvasive access for detection of pancreas allograft rejection. In order to address this issue, our team, who had previously developed portal enteric technique of pancreas transplantation in 1992 3 and revised it by placing a temporary venting jejunostomy in 2000, 9 for the first time introduced the portal-endocrine and gastric-exocrine tech- nique of pancreas transplantation in 2007. 4 The feasibility and optimal three-year outcomes of the portal-endocrine and gastric-exocrine technique of pancreas transplantation have already been reported by our team. 4 The aim of this studywas to evaluate the six-year outcomes of this technique
J La State Med Soc VOL 166 September/October 2014 207
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