Pancreatobiliary Complications After Composite Visceral Transplantation: Incidence, Diagnosis and Management

Abstract

Background: Combined liver-intestinal (L/SB) and multivisceral (MV) transplantation has been increasingly utilized with significant improvement in outcome. This is the first report to address the potential risk and management of pancreatobiliary (PB) complications in this unique population. Aim: Assess incidence, clinical features and management outcome of PB complications after the different types of the composite visceral graft. Methods: Between May 1990 and October 2006, a total of 227 consecutive patients received a composite visceral graft. Of these, 115 (51%) were adults and 112 (49%) were children. The composite visceral grafts were L/SB in 130 (57%) and MV in the remaining 97 (43%). The pancreas was included in 61 (53%) of the L/SB and the liver was excluded in 25 (26%) of the MV. Most donors were ABO identical and HLA matching was random with positive cross match in 23%. Immunosuppression was tacrolimus based and induction was used in 150 patients (66%). With a mean cold ischemia time of 9 ± 2 hours, UW solution was used to preserve the allograft in 82% and HTK in 18%. With ERCP being the gold standard for the diagnosis of biliary complications and pancreatic leak, significant injury of the pancreatic gland was diagnosed according to serum tests and operative findings. Results: A total of 28 PB complications were diagnosed in 20 patients with an overall incidence of 9%. Risk was similar among L/SB and MV recipients with a rate of 8% and 10%, respectively. Of the 28 morbid events, 9 were biliary complications alone, 11 were isolated pancreatic injury and 8 were combined pathology. Biliary complications included bile leak (n = 5), bile cast syndrome (n = 4), ampullary dysfunction (n = 3) and recurrent ascending cholangitis (n = 1). Pancreatic injury was necrotizing pancreatitis in 7, distal duct fistulae in 6 and chronic calcific pancreatitis in 2. ERCP was instrumental in diagnosis and treatment of cases with ampullary dysfunction, bile cast syndrome and non-surgical PB leak. However, surgical intervention was performed in patients with significant pancreatic allograft necrosis and anastomotic biliary leak. With no direct complication related mortality, all morbid events were successfully treated with the exception of a case with persistent pancreatico-cutaneous fistula. With no statistically identifiable risk factors, there was a trend toward more pancreatitis events with HTK use. Conclusions: PB complications are not uncommon after composite visceral transplantation. Early diagnosis and prompt intervention with combined surgical and endoscopic approach is essential for proper management and successful outcome.