Massive Bleeding as a Late Complication of Combined Pancreas-Kidney Transplantation

Abstract

Introduction: Acute complications of combined pancreas-kidney transplantation are well documented in the literature. Since they tend to happen during the patient's stay in the hospital, they are dealt with by highly sensitized specialists. Late complications, however, are often first seen by physicians who have no education in the field of transplant medicine. Method: In our center 359 patients underwent a combined pancreaskidney transplantation from the start of our program until 2008. We retrospectivly searched for patients who suffered a massive bleeding as a late complication related to the transplantation and report on their treatment and outcome. Results: We found three patients who suffered from a massive bleeding. The first patient was transplanted in the year 2000. Four years later the function of the transplanted pancreas declined. Again 8 moths later we observed a massive bleeding from the iliac artery where the pancreas was anastomosed. It was dealt with pancreatectomy and a suture of the artery. After several revisions there was another massive bleeding episode with an arrosion of the sigmoid colon. Finally the iliac artery was excised an reconstruced with a venous transplant. In our second case a pancreatic pseudocyst developped 9 years after pancreas transplantation. Two and a half years later the transplant pancreas had to be removed because of an acute bleeding emergency. The artery in this case was sutured, too. This could not prevent the next bleeding and the arterial stump was then occluded interventionally by coils. Finally, because of a repeated bleeding episode an endovascular reconstruction was used to exclude the affected arterial wall from the circulation. Our last patient started to bleed from the arterial anastomosis of the pancreas 8 months after transplantation. The bleeding was preceeded by a severe pancreatitis with septic complications (MRSA). Despite the emergency removal of the pancreas this patient, too, had several episodes of bleeding until an endovaskular reconstrucion was performed. Conclusions: Primarily, an episode of massive bleeding seems to be a complication of the transplanted pancreas. Presumably, an arrosion by the exocrine secretion is the main reason for this. No trial to treat the problem at the site of origin was successful since the dammage of the arterial wall does not allow for a primary suture or an interventional closure. Thereforte we think that a more extended method of vascular reconstruction should be the first choice.