Delayed Graft Duodenal Perforation Due to Food Impaction at 5 Years After Simultaneous Pancreas-Kidney Transplantation: A Case Report

Abstract

Introduction: Pancreas transplantation is the best treatment option in selected patients with type 1 diabetes mellitus. Although complications including graft thrombosis, graft pancreatitis, and rejection are well documented, graft duodenal perforation is very rare. Here we report a case of nonmarginal duodenal perforation at five years after a simultaneous pancreas-living donor kidney transplantation (SPLKT). The perforation may have been caused by impacted food and possible underlying chronic rejection. Case report: A 31-year old male who underwent SPLKT five years ago presented with severe abdominal pain. His past surgical history includes SPLKT initially with bladder drainage, then converted to enteric drainage one year later due to recurrent urinary tract infections. At that time, a side-to-side duodenoileostomy was performed and an omega loop created to minimize reflux. He had a marginal duodenal perforation four years later, treated by primary closure and drainage. Biopsy of pancreas and duodenum graft showed chronic rejection in the pancreas and acute inflammation with ulcer in the duodenum. At presentation, computerized tomography scan showed mesenteric pneumatosis with enteric leak and ileal dilatation proximal to the anastomotic site including the omega loop. We performed emergent laparotomy and found a 1.0cm perforation at the nonmarginal, posterior wall of the duodenum. Undigested fiber-rich food was extracted from the site and an omental patch placed over the perforation. An ileostomy was created proximal to the omega loop for decompression and a drain placed nearby. The postoperative course was unremarkable. Discussion: There are only seven previous cases of graft duodenal perforation in the literature. Duodenal graft perforation can occur immediately after transplantation or later on. Fiber-rich food residue passing through the anastomosis with impaction may have led to this perforation. The omega loop may contribute to increased pressure in the graft duodenum by luminal congestion. Patients suspected to have chronic rejection, may need modification of their diet.