P.145: Retroperitoneal Pancreas Transplantation With High Duodenojejunal Anastomosis on a Roux-en-Y Loop

Abstract

Introduction: The incidence of infectious complications after pancreas transplantation (PTx) is 7–50%. Some surgeons place the graft retroperitoneally to reduce the severity of them. As usual, in this case the graft’s duodenal stump is used to drain pancreatic juice into the recipient’s duodenum. But when the graft’s removal is required, the risk of intestinal failure with unpredictable consequences seems too high. We present a technique for retroperitoneal PTx with high duodenojejunal anastomosis (DJA) on a Roux-en-Y loop of the recipient’s jejunum. This method retains all the advantages of endoscopic access (via intestinoscopy) and retroperitoneal positioning of the pancreas, but seems not so dramatically in case of complications. Methods: 2 women, 42 and 36 y.o., have been suffering from diabetes mellitus more than 10 years. They both had been getting hemodialysis. In December 2020 SPKT’s were performed from standard criteria donors. The Y-graft reconstruction of the splenic and superior mesenteric arteries of the pancreaticoduodenal transplants was performed. The CIT’s of the pancreas grafts were 9 and 10 hours. Intraoperatively a Roux-en-Y loop was formed at a distance of 40 cm from the Treitz ligament. Then the loop was brought out into the right retroperitoneal space through a puncture in the peritoneum under the ascending colon. The peritoneum was fixed to the intestine with interrupted sutures. Vascular anastomoses were formed between Y-graft and common iliac artery then between portal vein and inferior vena cava. DJA “end-by-side” was formed in the retroperitoneal space using GIA-stapler (Fig. 1) in both recipients. KTx was performed according to the standard technique in the left iliac region. Results: In the postoperative period euglycemia were recorded from the first hours in both cases. Drains were removed on the 2nd day. According to the ultrasound data there were no peripancreatic fluid collections recorded. The first patient was infected with Klebsiella pneumonia, which was successfully treated. She was discharged on the 29th day with functioning grafts. Other patient was discharged on the 10th day because of COVID-19. The patient did not require re-hospitalization after she had been cured of coronavirus disease. Conclusion: Thus, the proposed method retains all the advantages of the retroperitoneal location and endoscopic access, while avoiding the main disadvantage of duodenal drainage. This will prevent the development of severe complications in patients with duodenal wall failure or anastomotic leakage.