Journal of the Louisiana State Medical Society
pancreas transplantation that pro- vides an easy access for endoscopy of the transplanted duodenum. 18,19 However, the major concern about this technique is the troublesome repair of the native duodenum or the duodenoduodenal anastomosis in case of the need for allograft pan- createctomy or duodenoduodenal anastomosis leak, respectively. 1 Our results show that the portal- endocrine and gastric-exocrine technique of pancreatic transplan- tation, by providing an easy access to donor duodenum through up- per endoscopy, could potentially solve the issue of evaluation of pancreas allograft dysfunction. By evaluating the donor duodenumas a surrogate marker for the trans- planted pancreas, our technique could facilitate early detection and differentiation of acute pancreas allograft rejection and CMV infec- tion. Moreover, through upper en- doscopy of the donor duodenum, endoscopic ultrasound-facilitated biopsy of transplanted pancreas could be potentially achieved. The site of anastomosis of enteric drainage is also prone to develop- ment of ulcers and bleeding. 1 Our technique also provides an easy access to the site of enteric drainage anastomosis for early detection and management of ulcer or bleeding.
Figure 3: Panel A: Photomicrograph image of a biopsy from normal transplanted duodenum. Note the normal villous architecture and lack of significant inflammatory changes. Hematoxylin and Eosin stain, 100x original magnification. Panel B: Photomicrograph image of a biopsy from a patient with acute rejection. The biopsy demonstrated areas of neutrophilic inflammation (thin arrows), erosive change, and numerous apoptotic bodies (thick arrows). Hematoxylin and Eosin stain, 400x original magnification. Panel C: Photomicrograph image of a biopsy from a patient with Cytomegalovirus duodenitis involving the transplanted duodenum. Arrow denoted cells with viral cytopathic effect. Hematoxylin and Eosin stain, 400x original magnification. Panel D: Photomicrograph image of a biopsy from a patient with Cytomegalovirus duodenitis involving the transplanted duodenum. Arrow denoted cell with positive reaction with CMV immunohistochemical stain. CMV immunohistochemical stain, 400x original magnification.
In the bladder exocrine drainage technique of pancreas transplantation, measurement of urinary amylase levels could provide an easy assay for detection of rejection. 1,5 However, this technique results in profuse urinary loss of pancreatic exocrine secretions, which could result in metabolic acidosis, hypovolemia, and urinary complication, such as hemorrhagic cystitis. 1,5-8 These complications require bladder to enteric drainage conversion in 15%-25% of pa- tients. The enteric exocrine drainage technique of pancreas transplantation results in physiologic drainage of pancreatic exocrine secretions and prevents complications of bladder drainage technique. 1,5 However, the main disadvantage of this technique is lack of an easy access for evaluation of pancreatic rejection. In order to solve this problem, our team introduced a Roux-en-y venting jejunostomy technique that provides an easy percutaneous access to the transplanted duodenum. 9 The disadvantages of this technique, however, are the decreased quality of life of patients due to having a jejunostomy and its resultant complication and the need to close the jejunostomy 9-12 months after transplantation. 9,17 Duodenoduodenostomy is another interesting technique of
Furthermore, in contrast to the duodenoduodenostomy technique, in our method, if the pancreas allograft needs to be removed, the site of the gastric anastomosis can be repaired without any difficulty or long-term consequence. The duodenum and pancreas have the same embryo- logic origin and MHC background. 20 Previous animal and clinical studies have shown that duodenal and pancreatic allograft biopsies are closely correlated. 20-23 These studies have also shown that duodenal biopsies are very useful in guiding clinical management of the patients when pancreas allograft biopsy was not available. 16,20 However, despite these preliminary data in favor of correlation of duodenal and pancreatic allograft results, large clinical studies are still needed to conclusively confirm this correlation. The portal-endocrine and gastric-exocrine drainage technique of pancreas transplantation, by facilitating the proper diagnosis andmanagement of pancreas allograft re- jection and CMV infection, probably has improved the graft and patient survival rates of our patients. However, our total five-year pancreas allograft survival results are not better than the national average (49% vs. 66%, respectively). 10 In
210 J La State Med Soc VOL 166 September/October 2014
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