Donor Duodenum Research Articles

Endoscopic control after retroperitoneal pancreas transplantation with a Roux-en-Y duodenojejunostomy for exocrine drainage

Background. Simultaneous pancreas and kidney transplantation is a gold standard in the treatment of diabetes mellitus complicated by stage 5 chronic kidney disease as a result of diabetic nephropathy. One of the main problems of clinical pancreas transplantation is the pancreas graft exocrine drainage. In order to preserve the advantages of the retroperitoneal graft location and avoid the main disadvantage of duodenal drainage, namely, fatal complications potentially arising in case of necessary graft removal, we have proposed a modified method of retroperitoneal pancreatic transplantation with exocrine drainage via a modified Roux-en-Y duodenojejunostomy. It reduces the number of severe surgical complications and increases the recipient survival rate. When this method was used in previous years, it was not possible to assess the condition of donor duodenum mucosa and interintestinal anastomoses.Objective. To demonstrate the possibility of endoscopic assessment of interintestinal anastomoses when performing retroperitoneal pancreas transplantation with small intestine drainage of exocrine secretions.Results. The article presents the initial experience of endoscopic assessment of the interintestinal anastomoses and the mucous membrane of the donor duodenum after retroperitoneal pancreas transplantation with exocrine drainage via a Roux-en-Y duodenojejunostomy.Conclusion. The presented case demonstrates the feasibility of diagnostic endoscopic interventions when performing retroperitoneal pancreas transplantation with small intestine drainage of pancreatic secretions.

A Prospective Study of the Effect of Gastroduodenal Artery Reconstruction on Duodenal Oxygenation and Enzyme Content After Pancreas Transplantation

BackgroundWhole pancreas transplantation provides durable glycemic control and can improve survival rate; however, it can carry an increased risk of surgical complications. One devastating complication is a duodenal leak at the site of enteroenteric anastomosis. The gastroduodenal artery (GDA) supplies blood to the donor duodenum and pancreas but is commonly ligated during procurement. Since we have not had expressive changes in pancreatic back table surgical techniques in the recent decades, we hypothesized whether back table GDA reconstruction, improving perfusion of the donor duodenum and head of the pancreas, could lead to fewer surgical complications in simultaneous pancreas-kidney (SPK) transplants.Material and MethodsBetween 2017 and 2021, we evaluated demographic information, postoperative complications, intraoperative donor duodenum, recipient bowel O2 tissue saturation, and patient morbidity through the Comprehensive Complication Index (CCI®).ResultsA total of 26 patients were included: 13 underwent GDA reconstruction (GDA-R), and 13 had GDA ligation (GDA-L). There were no pancreatic leaks in the GR group compared to 38% (5/13) in the GDA-L group (p = 0.03913). Intraoperative tissue oxygen saturation was higher in the GDA-R group than in the GDA-L (95.18 vs.76.88%, p < 0,001). We observed an increase in transfusion rate in GDA-R (p < 0.05), which did not result in a higher rate of exploration (p = 0.38). CCI® patient morbidity was also significantly lower in the GDA-R group (s < 0.05).ConclusionsThis study identified improved intraoperative duodenal tissue oxygen saturation in the GDA-R group with an associated reduction in pancreatic leaks and CCI® morbidity risk. A larger prospective multicenter study comparing the two methods is warranted.

Three Lumens Full of Blood—An Unusual Case of Gastrointestinal Bleeding

Question: A 58-year-old man was initially referred to our gastroenterology outpatient clinic for investigation of iron-deficiency anemia and positive fecal occult blood test (FOBT). His medical history was significant for simultaneous pancreas-kidney transplants 9 years earlier in the context of type 1 diabetes, for which he remained on triple immunosuppressive therapy with prednisolone, mycophenolate, and tacrolimus. His transplants were complicated by biopsy-proven chronic antibody-mediated rejection 4 years earlier, for which he received 6 months of intravenous immunoglobulin. There was no history of chronic liver disease or nonsteroidal medication use. Investigations demonstrated iron-deficiency anemia with a hemoglobin of 88 g/L, ferritin 14 μg/L, transferring saturation 5%, and a positive FOBT (1 of 3 samples). The patient underwent further evaluation with gastroscopy and colonoscopy, which were both unremarkable and did not identify a cause for iron-deficiency anemia. One month later, the patient re-presented to the emergency department with several days of melena and symptomatic anemia with a hemoglobin of 78 g/L. The patient underwent repeated gastroscopy, which did not reveal a cause for his symptoms. He received a blood transfusion and was referred for outpatient capsule endoscopy. Several weeks later, the patient represented with 3 days of melena and symptomatic anemia with a hemoglobin level of 45 g/L. The patient underwent an urgent push enteroscopy. What are the differential diagnoses of gastrointestinal bleeding in this patient? Look on page 335 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. A pediatric colonoscope was inserted 60 cm beyond the pylorus. There was no evidence of esophageal varices, esophagitis, or gastric varices. There was no ulceration or stigmata of recent hemorrhage found in the stomach or duodenum. At 55 cm distal to the pylorus, the anastomosis of the pancreatic transplant was encountered. It demonstrated a side-to-side duodenojejunostomy with 2 short blind duodenal limbs and the native efferent jejunal limb (Figure A). At the anastomosis, multiple varices were noted, of which one vessel was actively bleeding (Figure B). Hemostasis was achieved with the injection of adrenaline (2 mL, 1:10,000) and 2 through-the-scope hemostatic clips (Figure C). The patient then underwent a computed tomographic scan with pancreas protocol to characterize the anatomy and vasculature at the duodenojejunal anastomosis. Multiple venous varices were identified that communicated with a distended transplant pancreatic vein (Figure D). The transplant pancreatic vein anastomoses with the proximal right common iliac vein, and therefore the varices were not due to portal venous hypertension. There was no anastomotic stenosis, no venous thrombosis, and no arteriovenous fistulae. The hemoglobin remained stable after endoscopy and the patient was discharged home 3 days later. At outpatient follow-up 2 months after discharge, there was no evidence of further gastrointestinal bleeding and the hemoglobin level was stable. The patient will continue to be closely observed in the outpatient setting, with a view to endovascular intervention if further gastrointestinal bleeding occurs. Ectopic variceal bleeding from anastomotic varices between the donor duodenum and recipient small bowel are rare, with only 3 cases reported in the literature.1Gopal J.P. Jackson J.E. Palmer A. Taube D. Rathnasamy Muthusamy A.S. Gastrointestinal bleeding in a pancreas transplant recipient: a case to remember.Am J Case Rep. 2020; 21e923197Crossref PubMed Scopus (3) Google Scholar, 2Rostambeigi N. Shrestha P. Dunn T.B. et al.Recurrent ectopic variceal bleed after pancreas transplantation with no portal hypertension: case report and outcomes of endovascular onyx embolization.Vasc Endovasc Surg. 2019; 53: 415-419Crossref PubMed Scopus (5) Google Scholar, 3Fontana I. Bertocchi M. Di Domenico S. et al.Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.Transplant Proc. 2010; 42: 2162-2163Crossref PubMed Scopus (5) Google Scholar The mechanism by which ectopic varices develop after pancreas transplantation are not clear. Potential explanations include portal hypertension secondary to cirrhosis, increased vascular resistance, rejection of pancreatic transplant, and chronic venous obstruction. In our case, the mechanism was not elucidated.

LAMS for Creation of an Anastomosis Between the Native and Donor Duodenum to Bypass a Proximal Jejunal Obstruction in a Pancreas Transplant Recipient.

LAMS for Creation of an Anastomosis Between the Native and Donor Duodenum to Bypass a Proximal Jejunal Obstruction in a Pancreas Transplant Recipient.

Pancreas Transplantation: a retroperitoneal graft placement

Background: Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the “normal” pancreas.We herein present a video with the pancreas placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodeno-duodenostomy. Methods: Back-table preparation was performed prior to transplantation.The donor duodenum was reduced to a length of 8–12 cm.The arterial reconstruction of the graft was created by anastomosis end-to-end between the splenic artery and distal superior mesenteric artery. Results: In the recipient,a median laparotomy was done for surgical access.The right colon was then mobilized and a Kocher manoeuvre was performed to expose the retroperitoneal site along with the vena cava and iliac vessels.The venous anastomosis was performed end-to-side between donor portal vein and recipient vena cava.The arterial supply for the graft was provided by anastomosis end-to-side between the graft superior mesenteric artery with the recipient common right-iliac artery. For enteric drainage a duodeno-duodenostomy was performed side-to-side by means of a hand-sewn, double-layered anastomosis, at the level between the second and third portions of the recipient’s duodenum. A drain was inserted beside the pancreas graft, ending near the duodeno-duodenostomy. Finally, the colon was returned to its original position Conclusion: The retroperitoneal placement of the pancreatic graft imitates the physiological position of the organ.

Novel intussusception technique for surgical control of hemorrhage from donor duodenum after pancreas transplantation

Novel intussusception technique for surgical control of hemorrhage from donor duodenum after pancreas transplantation

Histological study of donor's duodenal mucosa biopsy specimens in the diagnosis of pancreatoduodenal complex rejection: the experience of N.V. Sklifosovsky Research Institute for Emergency Medicine

Background. The verification and identification of the transplanted pancreas rejection type requires a morphological examination of the graft tissue. The pancreas graft transcutaneous biopsy procedure is associated with a high risk of surgical and infectious complications, and with the risk of the graft loss. Relatively safe is the biopsy of the donor duodenum mucosa. Objective: to evaluate the efficacy of morphological examination of the donor duodenum mucosa in early diagnosis of an acute rejection crisis of pancreas graft. Material and methods . The study presents a retrospective analysis of 35 donor duodenum mucosa biopsies performed in 19 recipients. In order to assess the correlation between clinical and morphological signs of rejection, the patients were divided into two groups. The first group included 6 patients with clinical signs of graft dysfunction; the second group included 7 patients without signs of rejection. Statistical processing of the study results was made using the descriptive statistics methods. Results . The signs of immunological complications were identified in 18 donor duodenum mucosa biopsies (51.4%) in 12 recipients (63.2%). In most cases (n = 13; 72.2%), the histological signs of mild rejection were found, the signs of moderate and severe rejection were less frequent (n = 3; 16.6% and n = 2; 11.1%, respectively). Morphological signs of acute rejection were found in all the patients of the 1st group (n = 6), including the signs of mild rejection in 4 cases (66.6%), of medium and severe rejection in 1 case each (16.7%). In the 2nd group, morphological signs of mild rejection were found in 3 patients (42.9%). Differences between the groups in the incidence of immunological complications were statistically significant (p < 0.05). Conclusions: the biopsy of donor duodenum mucosa is an important criterion in the diagnosis of an acute rejection crisis of the pancreatoduodenal complex, and also remains a safe method, even in the earliest postoperative period.

Duodenal Graft Perforation after Simultaneous Pancreas-Kidney Transplantation

A 45-year-old woman with type 1 diabetes and chronic renal failure on dialysis underwent simultaneous pancreas-kidney transplantation from a brain dead donor. On postoperative day 15, acute generalized peritonitis was diagnosed and emergency laparotomy was performed. Perforation of the donor duodenum was found, which had apparently resulted from duodenal compression by the tip of the intestinal fistula tube placed for decompression. The perforation was sutured and the intestinal fistula tube was exchanged. Following this, perforation repeatedly recurred at the same site and open repair at laparotomy was required a total of four times. The fourth operation involved both suturing the perforation and covering it with ileum, after which there was no further recurrence. The patient was discharged on posttransplantation day 219, with the pancreas and kidney grafts both functioning well. This report presents a rare complication of simultaneous pancreas-kidney transplantation.

Extraperitoneal pancreatic transplant

We describe a technique where pancreas transplants are positioned in the pre-peritoneal space with violation of only a few centimeters of the peritoneum necessary for the creation of the duodeno-enteric anastomosis. Retrieval and back-table of the pancreatic graft are performed in the standard fashion. After a Gibson incision is performed, the common and external iliac vessels are isolated and the head of the pancreas is laid in caudal position in the iliac fossa. The graft portal vein is anastomosed end-to-side to the recipient's common or external iliac vein. The arterial inflow is obtained anatomosing the “Y” iliac artery graft to the recipient's common or external iliac artery. After reperfusion, a 3–4 cm peritoneal incision in the medial aspect of the surgical field is performed and a loop of the recipient's small intestine is brought into the retroperitoneal space and anastomosed with a side to side or end to side to the free surface of the donor's duodenum without a Roux-en-Y intestinal loop. After completion of the duodeno-enteric anastomosis, the loop of intestine is repositioned in the peritoneal cavity and the suture line is approximated to the level of the recipient's peritoneal window. The advantages of this technique are several. Among them, the extra-peritoneal location of the pancreatic graft prevents formation of intestinal adhesions, facilitates percutaneous pancreatic graft biopsies and decreases the risk of diffuse peritonitis in patients who develop enteric leaks or peripancreatic infections.

Graft Pseudoaneurysm Hemorrhage in a Patient With a History of an Enteric-Drained Pancreatic Transplant: A Case Report

Graft pseudoaneurysm is a rare but life-threatening complication in patients who have undergone pancreatic transplantation. While most of the reported post-pancreatic transplantation pseudoaneurysms present in the early postoperative period, late-onset pseudoaneurysms do occur, though much more rarely. We report a case of massive lower gastrointestinal hemorrhage in a 58-year-old female with a history of enteric-drained pancreatic transplant and donor duodenum anastomosis to recipient jejunum. This transplant occurred 7 years prior but 1 year prior the pancreatic graft failed as insulin-dependent diabetes mellitus recurred. Around the same time, a small bowel obstruction occurred requiring a small bowel resection with primary anastomosis. The bleeding episode began with the patient initially presenting in hypovolemic shock from hematochezia and an acute hemoglobin drop to 5.5 g/dL. Upper endoscopy was unremarkable, and colonoscopy revealed blood within the colon and the terminal ileum but no source could be identified. An abdominal angiogram and tagged RBC study were also unable to identify a source of gastrointestinal hemorrhage. CT angiogram of the abdomen revealed a mid-right common iliac artery pseudoaneurysm at the failed pancreatic graft site. Deployment of a covered stent across this vascular structure resulted in controlling the active extravasation into the small bowel lumen. Follow-up abdominal CT showed an excluded thrombosed pseudoaneurysm. In summary, we report this case to emphasize the diagnostic challenges associated with identifying this rare but life-threatening and at times late-onset complication of enteric-drained pancreatic transplant.

In vivo endomicroscopy of donor duodenum improves early detection of pancreas rejection in a recipient of simultaneous duodenum-drained pancreas-kidney transplantation: a case report.

Confocal laser endomicroscopy (CLE) is a new technique, which allows subsurface histological diagnosis at a cellular and subcellular level in vivo and could provide histological diagnosis during endoscopic examination. Up to now histological examination of the tissue sample is the only definitive way of diagnosis and monitoring organ rejection after transplantation. In case of pancreas transplantation percutaneous pancreas biopsy under imaging control is still the method of choice for obtaining tissue samples. However in 73–89% of biopsy attempts, it was shown that the duodenal histology predicts the initial diagnosis of rejection of the pancreas, usefulness of transplanted duodenum biopsies for graft rejection monitoring was also described. The histology technique is time consuming, and the therapeutic decision could not be made quickly, in spite of clinical necessity. In this paper we described feasibility of visualization and biopsy of donor duodenum and detection of microscopic changes in 2 cases of transplanted duodenum, expressed as destruction of the villi and dispersed goblet cells in comparison to a microscopic view of their own healthy duodenum No or only small, endoscopically non-significant macroscopic changes in transplanted duodenum in those patients were observed. In both cases, the histological examination confirmed acute organ rejection. We demonstrated for the first time that CLE is promising and effective method to detect acute phase of organ rejection and also for follow up in those patients.

Technical aspects of intestinal transplantation

Intestinal transplantation includes an heterogeneous group of procedures in which different compositions of organs are transplanted. The current classification includes four groups according to the inclusion of the liver and/or the stomach in the graft: isolated intestinal transplantation, liver-intestinal transplantation, multivisceral transplantation, and modified multivisceral transplantation. Variants exist, the technical evolution having been slow, yet constant over years. The most relevant early technical improvements were aimed at achieving better feasibility and safety of the most difficult aspects of the different procedures, such as removal of the recipient's diseased organs, performing of vascular reconstructions and prevention of complications as with retention of the donor's duodenum and pancreas in liver-intestine transplantation. More recently, apart from a clear definition of the classification of the procedures, progress has been more directed in a conservative direction such as the preservation of the native spleen with and without the pancreas in multivisceral transplants. After achieving consistent satisfactory short-term results, the technical interest in intestinal transplantation is now moved to solutions that, in spite of a possible increased difficulty, may offer better opportunities of mid-term and long-term successes, both in terms of survival and quality of life.

Use of Enteroscopy for Treating Pancreatitis in a Pancreas and Kidney Transplantation Patient With Roux-en-Y Portoenteric Derivation—A Case Report

In pancreas and kidney transplantations, the donor duodenum and pancreas are frequently anastomosed to the jejunum to allow exocrine drainage by creation of a Roux-en-Y jejunal loop. In this situation, those organs are relatively inaccessible using standard endoscopes. We present a case of the use of single-balloon enteroscopy in the treatment of cronic pancreatitis in the donor pancreas.

Endoscopic retrograde pancreatography using single balloon enteroscopy in a patient with smoldering pancreatitis in a distal jejunal pancreas transplant

Portal-enteric drainage of graft secretions is currently the preferred method of pancreatic transplantation and usually created between the donor duodenum and recipient jejunum; however, this anatomy does not allow for easy access to the donor pancreas. We report here the first case of a single balloon assisted-endoscopic retrograde pancreatography in a patient with progressively increasing amylase and lipase in portal-enteric-drained pancreas-kidney transplantation.

Sa1603 Accuracy of Endoscopic Based Confocal Laser Endomicroscopy of Donor Duodenum in Early Detection of Pancreas Rejection in a Recipient of Simultaneous Duodenum-Drained Pancreas - Kidney Transplantation

Sa1603 Accuracy of Endoscopic Based Confocal Laser Endomicroscopy of Donor Duodenum in Early Detection of Pancreas Rejection in a Recipient of Simultaneous Duodenum-Drained Pancreas Kidney Transplantation Marek Stobinski*, Janusz Milewski, Aleksandra Poplawska, Marek Durlik, Agnieszka Serwacka, Andrzej Rydzewski, Grazyna Rydzewska Dpt. of Internal Medicine and Gastroenterology, Central Clinical Hospital of Ministry of Internal Affairs and Administration, Warszawa, Poland; Dpt. of Gastroenterological and Transplantation Surgery, Central Clinical Hospital of Ministry of Internal Affairs and Administration, Warszawa, Poland; Dpt. of Internal Medicine and Nefrology, Central Clinical Hospital of Ministry of Internal Affairs and Administration, Warszawa, Poland Background and aims: Confocal laser endomicroscopy (CLE) is a new, powerful technic, allows to get in vivo histology. This technology is widely investigated in different gastrointestinal diseases and becomes an alternative to conventional histology. Percutaneous transplanted pancreas biopsy under imaging control is the method of choice in monitoring of organ rejection, however adequate samples are obtained in 73-89% of biopsy attempts. Recently we described also usefulness of transplanted duodenum biopsies for graft rejection monitoring. However histology technique is time consuming, so the aim of the present study was to investigate usefulness of CLE in monitoring of acute pancreas rejection, and it’s influence on potential clinical decision. Patients and methods: During first 2 weeks after SPK procedure 18 patients were examined with CLE technique and histological biopsies from transplanted and own duodenum were also taken for confirmation of endoscopic changes. No difficulties to reach anastomosis with CLE were observed. Results: In the group of 18 patients after SPK transplantation we found in 2 cases endoscopic changes in transplanted duodenum, expressed as destruction of the villi and dispersed globlet cells in comparison to their own healthy duodenum. No macroscopic changes in transplanted duodenum in those patients were observed. In both cases histological examination confirmed acute organ rejection. Patients were operated and graft was removed. Conclusion: In our pilot study we demonstrated for the first time, that CLE is a promising and effective method to detect acute phase GvHD and also for follow up in those patients group. The procedure is easy acceptable and safe for patients and clinical decision based on the information obtained after examination could be made quickly. Further studies are needed to confirmed clinical usefulness of this technique in monitoring of patients after SPK transplantation. Sa1604 Mucosal Healing in Patients With Ulcerative Colitis Assessed by Confocal Laser Endomicroscopy Cristian Gheorghe, Razvan Iacob*, Bogdan Cotruta, Ion Bancila, Gabriel Becheanu, Mona Dumbrava, Liana Gheorghe Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania; Gastroenterology and Hepatology, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania Background & Aim: The ultimate therapeutic goal in patients with ulcerative colitis (UC) is represented by mucosal healing. Recently, confocal LASER endomicroscopy (CLE) has emerged to allow in vivo histological evaluation during ongoing endoscopy. Considering that histologic remission should be part of sustained deep remission, we have conducted a pilot study to investigate the ability of CLE to differentiate between normal mucosa and residual inflammation. Methods: Rectal CLE has been performed using 5 ml 10% fluorescein iv and targeted biopsies have been analysed by the pathologist. Mucosal inflammation was investigated by CLE assessing crypt architecture and interstitial and cryptal fluorescein leakage. The image processing was performed using ImageJ, a public domain Java software. All images have been captured using the same LASER power setting, at the superficial and medium-depth level. Semiautomatic computer estimation of interstitial and cryptal fluorescein leakage (ICFL) has been performed on stacks of images, by evaluating mean luminosity of pixels corresponding to crypts and interstitium, on a scale ranging from 0-255. ICFL in patients with UC in histological remission has been compared to patients with active ulcerative colitis and to patients with irritable bowel syndrome undergoing screening colonoscopy for colorectal cancer, using Student’s T Test. Results: A total of 184 CLE images have been analysed. Only minor cryptal abnormalities have been noted for patients with ulcerative colitis in remission, whereas for patients with active ulcerative colitis a wide range of cryptal alterations have been registered, from crypt distortion to crypt destruction and crypt abcess. ICFL was 94 21 for patients with ulcerative colitis in histological remission, 106 12.6 for IBS controls (p 0.24 -NS) and 178.6 21.6 for patients with active UC (p 0.0001). Conclusion: CLE is an emerging endoscopic technique for real-time assessment of deep mucosal remission during ongoing endoscopic examination, in patients with UC. The semiautomatic quantification of interstitial and cryptal fluorescein leakage can be objectively used to diagnose in vivo deep mucosal remission in patients with UC. Abstracts

Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center

Complications of pancreas transplantation involving the arterial anastomosis are potentially life threatening. In this report, we review our experience with such vascular catastrophes. Pancreas transplants performed between January 2003 and December 2009 were reviewed. All cases of pseudoaneurysm (PA) or arterioenteric fistula (AEF) were included. Of 346 pancreas transplants, 10 vascular catastrophes in nine recipients were identified. There were five PAs, one involving the pancreas allograft, one involving the donor iliac artery Y-graft stump following allograft pancreatectomy, two involving the kidney allograft, and one involving the bifurcation of the Y-graft. The latter was treated with coil embolization, but subsequently developed into an AEF. There were five AEFs including the recipient mentioned above. Four had a failed allograft and three had discontinued immunosuppression. The final case had a clamp injury to the proximal common iliac artery that fistulized to the donor duodenum. The management, course and outcome of all nine recipients are described in detail. Vascular catastrophes such as PA and AEF are potentially life-threatening complications of pancreas transplantation. Immediate treatment at the time of bleeding is essential and covered stenting of the involved artery may provide immediate vascular control in these situations.

Obscure Gastrointestinal Bleeding in a Pancreas and Kidney Transplant Patient

Purpose: Case: A 48-yr-old female presented with melena and symptomatic anemia. She had been hospitalized multiple times with similar symptoms in the past 5 months, requiring multiple blood transfusions. Two EGDs and 2 colonoscopies during this time period did not reveal a cause of her gastrointestinal (GI) bleeding. Past medical history included type 1 Diabetes, and a combined cadaveric pancreas and kidney transplant 2 yrs ago. A video capsule endoscopy (VCE) performed at this point showed a mucosal polypoid lesion about 1 hr and 25 minutes post pylorus without active bleeding (Figure 1). Patient subsequently underwent an antegrade double balloon enteroscopy (DBE) based on the VCE findings. This exam showed a heaped up, friable area at the anastomosis between the donor duodenum and the recipient jejunum. Hemostasis was achieved with injection of epinephrine and application of one endoclip. Patient has presented on 2 more occasions with similar symptoms since then, and successful hemostatsis has been achieved with antegrade DBE guided therapy with epinephrine, endoclips, and Argon Photo Coagulation (APC) (Figure 2). Discussion: Localizing the source of obscure GI bleeding in pancreatic transplant patients can be challenging. Potential source may include anastomotic ulcerations due to ischemia, opportunistic infections, NSAIDs or post-transplant lymphoproliferative disease. Surgical intervention may carry high morbidity. This case highlights the potential role of VCE and DBE in the management of obscure GI bleeding in pancreas transplant patients.Figure: Video capsule study showing a polypoid lesion at the anastomosis betweeen donor duodenum and recepient jejunum.Figure: Double balloon endoscopy images with heaped up and friable area at anastomosis; hemostasis achieved with epineprine injection, APC, and endoclips.

A Novel Technique of Portal-Endocrine and Gastric-Exocrine Drainage in Pancreatic Transplantation

Pancreas transplant (PT) is an established treatment for patients with diabetes mellitus. Diagnosis of rejection has continued to be problematic. In 2007, a new technique of PT with gastric exocrine (P-G) drainage was first performed at our institution. This technique facilitates access to pancreas allograft. The purpose of this study was to compare our experience with PT using P-G technique and the technique of portal enteric (P-E) with venting jejunostomy. Thirty patients who underwent PT between 2007 and 2009 (G-I) and 30 consecutive patients before this time (G-II) were studied. In both groups arterial and venous anastomosis was similar to standard P-E technique. In G-I, the end of allograft jejunum was anastomosed to the anterior aspect of the stomach. In the G-II, allograft duodenum was anastomosed to the Roux-en-Y and end of Roux-en-Y was brought out as venting jejunostomy. Donor and recipient demographic data, number of antigen matches, and immunosuppressant were similar in both groups. All patients achieved euglycemia. In G-I, 3 patients underwent pancreatectomy, 2 owing to vessel thrombosis and 1 owing to chronic rejection. Two patients died with functioning pancreatic allografts. In G-II, 1 pancreas was removed owing to vessel thrombosis. Seven patients with cytomegalovirus and 4 patients with rejection in G-I were diagnosed with endoscopy of allograft duodenum. One-year patient and graft survivals were similar. This technique has proven to be safe with good patient and allograft survival. Access to donor duodenum and pancreas allograft via endoscopy is unique to this technique and provides the added advantage of life-long easy access to allograft.

Surgical techniques for pancreas transplantation

Pancreas transplantation reproducibly induces insulin independence in beta-cell penic diabetic patients. The difference between full insulin independence, partial graft function, and graft loss, mostly results from technical failure, graft rejection, and patient death with function graft. The purpose of this review is to examine recent surgical advances and discuss their contribution to improved graft function. Few actual surgical innovations were described in the period reviewed. Duodenoduodenostomy is an interesting option for drainage of digestive secretions, when the pancreas is placed behind the right colon and is oriented cephalad. The main advantage of this technique is easy endoscopic assessment of donor duodenum but, when allograft pancreatectomy is necessary, repair of native duodenum may be troublesome. Selective revascularization of the gastroduodenal artery, at the back-table, possibly improves blood supply to the head of the pancreas graft and duodenal segment. There is no proof that this additional maneuver is always beneficial, although it can be graft saving in case of poor segmental graft perfusion. Transplant surgeons should be familiar with all techniques for pancreas transplantation. Long-term graft function is possible only after technically successful pancreas transplantation. There is clearly a need for more objective assessment and standardization of surgical techniques for pancreas transplantation.

Combined En-bloc Liver-Pancreas Transplantation in Patients With Liver Cirrhosis and Insulin-Dependent Type 2 Diabetes Mellitus

We report about our experience with combined en-bloc liver-pancreas transplantation in 14 patients with liver cirrhosis and insulin dependent type 2 diabetes mellitus. Exocrine drainage was achieved by duodeno-duodenostomy. Median posttransplant follow-up is currently 92.5 months. All patients were rendered independent from insulin therapy shortly after transplantation. Levels of glycosylated hemoglobin normalized in all recipients. Mean fasting C-peptide values increased from pretransplant 7.0+/-1.7 ng/mL to 10.5+/-2.9 ng/mL 3 months posttransplantation (P<0.001). One recipient (7.1%) developed recurrent exogenous insulin dependence 7 years after transplantation. Pancreas allograft rejection was confirmed by endoscopic biopsy of donor duodenum mucosa in two patients (14.3%). Calculated 5- and 7-year survival is currently at 64.3% and 64.3%, respectively. Our results indicate that combined en-bloc liver-pancreas transplantation using duodeno-duodenostomy is technically feasible and leads to excellent long-term control of glucose metabolism in patients with liver cirrhosis and insulin-dependent type 2 diabetes.