Figure 2: Upper endoscopy of transplanted duodenum in one of the patients with pancreatic dysfunction. Panel A: Site of gastroduodenal anastomosis. Panel B: Transplanted duodenum.
DISCUSSION Our results show that portal-endocrine and gastric- exocrine technique of pancreatic transplantation provides easy access to transplanted duodenum through upper endoscopy. As a result, this technique could lead to timely evaluation andmanagement of different causes of pancreatic dysfunction, such as pancreas allograft rejection and CMV infection, while eliminating the risk of major complications secondary to a more invasive diagnostic procedure. The pancreas graft survival in PTA patients is typically inferior to the graft survival in SKP patients. 10-12 Lack of a proper marker for detection of pancreas allograft rejection is one of the main contributing factors to the lower graft survival in PTA patients. 10 Due to the high capacity of the pancreas for maintaining glucose hemostasis, a large proportion of islet cells should be destroyed before labora- tory markers of insulin production, such as blood glucose, HbA1C, or C-peptide levels, become abnormal. 13,14 Rise of serum enzymes like amylase is neither sensitive nor specific for detection of rejection and could happen due to several factors other than pancreas allograft rejection. 13,14 In SKP patients, a rise in serum creatinine levels may indicate si- multaneous kidney and pancreas rejection and is generally considered amore sensitivemarker for detection of pancreas allograft rejection as comparedwith serum amylase levels. 13 However, even in SKP patients, isolated pancreas allograft rejection could occur in the absence of kidney rejection in 30% to 75% of times. 13,15 Although percutaneous pancreatic biopsy remains the gold standard for diagnosis of pancreatic rejection, its failure rate is high and also could lead to seri- ous complications, such as bowel perforation, hemorrhage, or pancreatic leak. 16 Therefore, development of a pancreas transplant technique that could provide an easy access for detection of rejection is of utmost importance.
patients, median duration of follow-upwas 3.8 years (range: one month to six years). One-, three-, and five-year patient survival rates were 94%, 87%, and 70% for all patients; 92%, 88%, and 67% for SKP patients; and 100%, 83%, and 83% for PTA patients. As demonstrated in Figure 4, one-, three-, and five-year graft survival rates were 83%, 65%, and 49% for all patients; 89%, 79%, and 58% for SKP patients; and 57%, 14%, and 14% for all patients. Seven patients died during follow- up (five due to cardiovascular causes [all SKP], one due to donor duodenal perforation [SKP], and one due to unknown cause [PTA]); all of these patients had functioning graft at the time of death. Another SKP patient also presented with donor duodenal perforation but had emergency operative repair of perforation and recovered well postoperatively. Of the 31 living patients, four (two SKP and two PTA) had pancreas failure due to rejection; three of these rejections (two SKP, one PTA) were due to the non-compliance of the patients. Three more cases (all PTA) had vascular throm- bosis of the transplanted pancreas within eight days post- transplantation. These three patients were later diagnosed to have antithrombin-3 deficiency, protein S deficiency, and high levels of lupus anticoagulant antibodies, respectively. Mean levels of serum c-peptide, Hb-A1C, and eGFR in the patients with functioning grafts at their last follow-up visit were 3.64 ng/ml, 5.7 and 61 ml/min/m 2 , respectively. For the evaluation of the pancreas allograft dysfunction, 51 upper endoscopies were performed in 14 patients; donor duodenal biopsies were successfully obtained on 45 occa- sions (88%). Nine episodes of acute rejection (eight patients), and seven episodes of CMV duodenitis (six patients) were detected by upper endoscopy of the transplanted duodenum and were treated accordingly. Moreover, two patients were found to have peptic ulcer at the site of the duodenogastric anastomosis. No patient developed any complication due to the upper endoscopy.
J La State Med Soc VOL 166 September/October 2014 209
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