Enteric Drainage Research Articles

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

Biliary Atresia: Biliary-Enteric Drainage or Primary Liver Transplant?

The paper from LeeVan et al entitled "Biliary-Enteric Drainage vs Primary Liver Transplant as Initial Treatment for Children with Biliary Atresia" is a retrospective cohort study that examines long-term outcomes for children with biliary atresia (BA) through analysis of information obtained from the California Office of Statewide Health Planning and Development (OSHPD), an administrative database. Specifically, the authors compare outcomes between a cohort of BA patients who underwent a biliary enteric drainage (BED) procedure (presumably a Kasai hepatoportoenterostomy) as the primary therapy to those who underwent a primary liver transplant (pLT) without a previous BED.

Pancreatic transplantation with duodenoduodenostomy drainage: technique, normal radiological appearance and complications.

Pancreas transplantation is considered the curative treatment for severe type 1 diabetes mellitus in selected cases. Since the first procedure in 1966, surgical techniques have been improved. The current trend among most medical centers, as well as at our Institution, is enteric drainage and systemic venous or portal anastomosis. The aim of this pictorial essay is to describe the main imaging features of pancreatic transplantation with duodenoduodenostomy drainage.

Enteric conversion after bladder-drained pancreas transplantation is not associated with worse allograft survival.

In the early experience of pancreas transplantation, bladder drainage was favored, but it often caused urologic, metabolic, and infectious complications that necessitated conversion to enteric drainage. Long-term graft survival after enteric conversion and the impact of time interval from transplantation to enteric conversion on graft survival is poorly understood. We studied all bladder-drained first-time pancreas transplantations performed at the University of Wisconsin from 1985 to 2000. Time to conversion was estimated with the Kaplan-Meier technique, whereas risk factors associated with conversion were estimated via a time-varying Cox proportional hazards model. Of 386 bladder-drained pancreata, 162 (41.9%) eventually required enteric conversion, 29 (17.9%) within the first year. Median time to conversion varied by indication: 0.68years for surgical, 3.1years for urologic, and 2.7years for metabolic disorders. In a time-varying Cox model adjusting for donor and recipient factors, enteric conversion did not affect the risk of pancreas graft loss (hazard ratio [HR] 0.86, P=.26). Kidney survival was not associated with enteric conversion. When necessary due to symptoms or complications, enteric conversion of bladder-drained pancreata is safe and does not affect overall graft survival. This relationship appears to be true no matter when the conversion is performed.

Enteric Drainage of Pancreas Transplantation. Clinical impact of intra-abdominal complications

Background: To analyze the surgical complications associated with enteric drainage in a single center over a period of 15 years Methods: From 2000 to 2015,333 pancreas transplants were performed (SPK:272, PAK:23,PA:3,Retransplantation:35).Systemic vascular drainage was performed with porto-cava anastomosis and arterial anastomosis between superior mesenteric artery or iliac graft artery to right iliac primitive artery. Enteric drainage was performed by side-to-side with handsewn duodeno-jejunostomy anastomosis Results: Nineteen patients were identified:intestinal obstruction in 7 patients, paralytic ileus in 4 patients,ischemic graft duodenum in 2 patient,dehiscence of duodeno-jejunostomy in 2 patients, intestinal fistula without anastomotic dehiscence in 3 patients and anastomotic dehiscence in jejunum after transplantectomy in one case of retransplantation. Fifteen patients required reoperation (lysis adhesions (n=7), pancreas trasplantectomy (n=5), primary closure and intestinal bypass (n=1), simple suture (n=1), intestinal resection(n=1).Vascular thrombosis was related with ischemic process of enteric drainage on 15.8% of cases (n=3), with a significant correlation for graft loss in two of the cases Conclusion: Enteric drainage for exocrine secretion of graft pancreas is a safe and feasible technique with a low rate of complications. Vascular thrombosis associated with intestinal complications is a risk factor for the viability of pancreatic graft, so early detection is important

Enteric drainage of pancreas transplantation. Clinical impact of intra-abdominal complications

Background: To analyze the surgical complications associated with enteric drainage in a single center over a period of 15 years. Methods: From 2000 to 2015,333 pancreas transplants were performed (SPK:272, PAK:23,PA:3,Retransplantation:35). Systemic vascular drainage was performed with porto-cava anastomosis and arterial anastomosis between superior mesenteric artery or iliac graft artery to right iliac primitive artery. Enteric drainage was performed by side-to-side with handsewn duodeno-jejunostomy anastomosis. Results: Nineteen patients were identified:intestinal obstruction in 7 patients, paralytic ileus in 4 patients, ischemic graft duodenum in 2 patient,dehiscence of duodeno-jejunostomy in 2 patients, intestinal fistula without anastomotic dehiscence in 3 patients and anastomotic dehiscence in jejunum after transplantectomy in one case of retransplantation. Fifteen patients required reoperation (lysis adhesions (n=7), pancreas trasplantectomy (n=5), primary closure and intestinal bypass (n=1), simple suture (n=1), intestinal resection(n=1).Vascular thrombosis was related with ischemic process of enteric drainage on 15.8% of cases (n=3), with a significant correlation for graft loss in two of the cases. Conclusion: Enteric drainage for exocrine secretion of graft pancreas is a safe and feasible technique with a low rate of complications. Vascular thrombosis associated with intestinal complications is a risk factor for the viability of pancreatic graft, so early detection is important.

Experimental porcine model in pancreas transplantation.

Background: The aim of this study is start up an experimental model valid, similar and comparable to humans in order to make it useful in future studies. Methods Sixty-four pigs took part of this research, the half of them being pig-pancreas donor,and the other half being recipient.The recipients became diabetic with two methods,10 with Streptozotocin(STZ) and 22 with total pancreatectomy.The technique in donor was the extraction the whole pancreas with the duodenum.The abdominal aorta was dissected above the iliac bifurcation for cannulation.The duodenum-pancreas graft complete with aorta patch was excised.The venous anastomosis was done between the donor portal vein and vena cava.The arterial anastomosis was done between donor aorta-patch and recipient infrarrenal aorta. Satisfactory reperfusion was indicated by a progressive normal coloration of the pancreatic graft. Enteric drainage was performed by duodeno-jejunostomy anastomosis. Results Six out of ten pigs treated with STZ died,because of his toxicity in some cases. Nine out of twenty-two with total pancreatectomy died.Once became diabetics and after transplantation, three animals had surgical complications.The rest lived with a normalization of glucose levels until the euthanasia. Conclusion This research allows establishing a large animal model in pancreas transplantation. SZT has a very high toxicity and mortality. Pancreatectomy seems an effective and safety procedure to make them diabetic.

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.

Bladder-Drained Pancreas Transplantation: Urothelial Innate Defenses and Urinary Track Infection Susceptibility

BackgroundPancreas transplantation restores insulin secretion in type 1 diabetes mellitus. The graft also produces exocrine secretions that can be drained enterically (enteric drainage [ED]) or via the bladder (bladder drainage [BD]). We suggest that in BD transplants, such secretions destroy bladder innate immunity, specifically host defense peptides/proteins (HDPs), which increases patient susceptibility to recurrent urinary tract infections (rUTIs). Materials and methodsBD and ED patient records were reviewed retrospectively for UTIs. Urine samples from ED and BD transplant recipients were analyzed for pH, the HDPs β-defensin 2 (HBD2) and lipocalin-2, and amylase concentrations. In vitro, bacterial growth curves and antimicrobial assays were used to evaluate the effects of pH, HBD2, and HBD2 + pancreatic digestive enzymes (pancreatin) on uropathogenic Escherichia coli (UPEC) survival and growth. ResultsUrinalysis revealed a significant difference in pH between the BD and ED cohorts (7.2 ± 0.8 versus 6.7 ± 0.8; P = 0.012). Urinary HDPs were measured and BD, but not ED, lipocalin-2 concentrations were significantly decreased compared with those of diabetics awaiting transplant (P < 0.05). In vitro, an alkaline environment, pH 8.0, concomitant with the urine of the patient who underwent BD transplantation, significantly reduced UPEC growth (P < 0.05); addition of pancreatin to the growth medium was associated with a significant increase (P < 0.001) in growth rate. Antimicrobial data suggested significant UPEC killing in the presence of HBD2 (P < 0.01), but not in the presence of HBD2 + pancreatin (>12,500 amylase units). ConclusionsThese in vivo and in vitro data suggest that BD pancreatic exocrine secretions inactivate the bladder innate defenses, which facilitate UPEC growth and underpins the increased susceptibility of patients who underwent BD pancreas transplantation to rUTIs.

Cellular rejection of pancreaticoduodenal graft

Aim. The evaluation of donor’s duodenum histological examination in diagnosis of pancreaticoduodenal graft rejection.Materials and methods. The 35-yo patient with terminal diabetic nephropathy undergone simultaneous retroperitoneal kidney and pancreas transplantation with enteric exocrine drainage of the graft via inter-duodenal anastomosis. When performing the esophagogastroduodenoscopy 2 years posttransplant we implemented histologic examination of the duodenum of the graft.Results. We diagnosed and verified severe cellular rejection of pancreaticoduodenal graft. Successful etiopathogenetic treatment of acute rejection of the graft (pulse therapy with glucocorticoids) was performed.Discussion. The diagnostic value of donor’s duodenum morphological examination in the diagnosis of pancreaticoduodenal graft rejection, the efficacy of anti-rejection treatment were performed in this case.

Graft dysfunction in simultaneous pancreas kidney transplantation (SPK): Results of concurrent kidney and pancreas allograft biopsies.

Simultaneous pancreas and kidney transplants offer significant therapeutic advantages but present a diagnostic approach dilemma in the diagnosis of rejection. Because both organs are from the same donor, the kidney has been treated traditionally as the "sentinel" organ to biopsy, presumably representing the status of both allografts. Truly concurrent biopsy studies, however, are needed to confirm this hypothesis. We examined 101 concurrent biopsies from 70 patients with dysfunction in either or both organs. Results showed concurrent rejection in 23 of 57 (40%) of cases with rejection; 19 of 57 (33.5%) and 15 of 57 (26.5%) showed kidney or pancreas only rejection, respectively. The degree and type of rejection differed in the majority (13 of 23, 56.5%) of cases with concurrent rejection, with the pancreas more often showing higher rejection grade. Taking into account pancreas dysfunction, a positive kidney biopsy should correctly predict pancreas rejection in 86% of the instances. However, the lack of complete concordance between the 2 organs, the discrepancies in grade and type of rejection, and the tendency for higher rejection grades in concurrent or pancreas only rejections, all support the rationale for pancreas biopsies. The latter provide additional data on the overall status of the organ, as well as information on nonrejection-related pathologies.

Endoscopic Intervention can Prevent Reoperation in Patients After Pancreas Transplantation – The Advantage of the Duodenoduodenal Anastomosis

Introduction Since the first pancreas transplantation in 1966, surgical techniques have vastly evolved. Nowadays, in most transplant centres, the preferred type of anastomosis is the one with the small intestine. However, when the duodenoduodenal anastomosis was introduced, it has become a highly beneficial type of anastomosis and is now routinely performed in our Centre. Materials and Methods We performed 193 pancreas transplantations since 2004 until September 2017. Among these patients we performed 164 duodenoduodenal and 29 duodenojejunal anastomoses. Results Among all 164 patients with duodenoduodenal anastomosis 141 were Simultaneous Pancreas Kidney transplantations (SPK), 21 Pancreas Transplantations Alone (PTA) and 2 Pancreas After Kidney (PAK) transplantations. Endoscopic intervention due to anastomotic bleeding was necessary in 32 cases. Only in one case it wasn’t successful and the patient had to be reoperated. In group of patients with duodenojejunal anastomosis the reoperation due to GI bleeding was necessary in 2 patients. Conclusion Duodenoduodenal anastomosis is a safe option of enteric drainage that provides many advantages. It enables easy, non-invasive endoscopic access to the transplanted duodenum and possible intervention in case of GI bleeding.

Bladder Versus Enteric Drainage of Exocrine Secretions in Pancreas Transplantation

The method for drainage of exocrine secretions in pancreas transplantation remains a matter of debate. Different methods have evolved over time. Most data on these methods are from single-center studies with small sample sizes. Larger studies have yielded conflicting results. Data from the United Network for Organ Sharing database on all adult subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 19,934). Subjects were divided into 3 groups: enteric drainage with Roux-en-Y (n = 4308), enteric drainage without Roux-en-Y (n = 11,145), and bladder drainage (n = 4481). Primary end points were patient and graft survival at 1, 3, 5, 10, and 15 years. There was a patient and graft survival advantage with enteric drainage without Roux-en-Y reconstruction compared with the other methods. This was consistent at 1, 3, 5, 10, and 15 years. Our study demonstrated increased graft and patient survival when comparing enteric drainage of the transplanted pancreas without Roux-en-Y reconstruction to enteric drainage with Roux-en-Y and bladder drainage at 1, 3, 5, 10, and 15 years. Based on this study, we recommend enteric drainage without Roux-en-Y reconstruction as the method of choice in pancreas transplantation.

Long-term Outcomes in Simultaneous Pancreas-Kidney Transplant Recipients: Single-center Experience From Poland

BackgroundSimultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal disease (ESRD) due to type 1 diabetes mellitus (DM1). Since the 1980s, pancreas transplantation has become the most effective strategy to restore normoglycemia in patients with DM1. The aim of this study was to present long-term outcomes data for SPKT. MethodsWe performed a retrospective analysis of 73 SPKT recipients followed in our outpatient center who underwent transplantation between 1988 and 2015. ResultsA total of 50.7% of the patients were male. At the time of surgery, patients' mean age was 37.38 ± 7.44 years. Patients were diagnosed with DM1 at an average of 25 ± 6.08 years before SPKT. For 21.9% of patients, the transplant was done preemptively. Most (91.8%) had enteric drainage. All patients received induction of immunosuppression (either polyclonal immunoglobulins anti-thymocyte globulin or thymoglobulin [64.4%] or monoclonal globulins daclizumab or basiliximab [35.6%]). Patient survival at 1, 5, 10, 15 years was 99%, 97%, 89%, and 75%; kidney survival was 99%, 96%, 84%, and 67%; and pancreas survival was 95%, 92%, 84%, and 64%, respectively. There was a notable tendency toward increased creatinine level (from 1.18 at 1 year to 1.78 at 15 years) and decreased hemoglobin level (from 13.84 at 1 year to 12.65 at 15 years). ConclusionDiabetic patients with ESRD have a poor prognosis without transplantation. SPKT provides marked prolongation of the patient's life and freedom from insulin injections. Enteric drainage is currently the surgical technique of choice. SPKT should remain as the treatment of choice in this patient population.

Does Enteric Conversion Affect Graft Survival After Pancreas Transplantation with Bladder Drainage?

BackgroundAlthough bladder drainage is effective for monitoring urine amylase levels to detect graft rejection, enteric drainage is performed more frequently. The optimal method for monitoring pancreatic enzyme secretions remains unclear. We investigated graft survival in recipients of bladder drainage and assessed the risk of graft rejection and failure after enteric conversion.Material/MethodsFrom January 1999 to October 2015, we performed 318 pancreas transplantations at our institution. We enrolled 180 recipients who underwent pancreas transplantation with bladder drainage (82 underwent enteric conversion and the rest did not).ResultsThe mean interval between pancreas transplantation and enteric conversion was 20±24 months. The graft survival rate was significantly higher in the enteric conversion group for 10 years after pancreas transplantation than in the maintain bladder drainage group. After enteric conversion, 14 recipients lost graft function. The interval between enteric conversion and graft failure was 43±26 months. In the enteric conversion group, immediate postoperative thromboembolectomy (HR=12.729, p=0.000), renal failure (HR=5.710, p=0.005), pancreas graft rejection after EC (HR=19.006, p=0.000), and delayed graft function (HR=7.021, p=0.001) had a significant relationship with graft failure.ConclusionsEnteric conversion can be safe and effective for improving short- and long-term graft survival if performed after approximately 9 months. Caution should be exercised with enteric conversion if recipients have a history of thromboembolectomy, delayed graft function, or renal failure.

Duodenal graft complications requiring duodenectomy after pancreas and pancreas-kidney transplantation.

Duodenal graft complications are poorly reported complications of pancreas transplantation that can result in graft loss. Excluding patients with early graft failure, after a median follow-up period of 126months (range 23-198) duodenectomy was required in 14 of 312 pancreas transplants (4.5%). All patients were insulin-independent at the time of diagnosis. Reasons for duodenectomy included delayed duodenal graft perforation (n=10, 71.5%) and refractory duodenal graft bleeding (n=4, 28.5%). In patients with duodenal graft bleeding, a total duodenectomy was performed. In patients with duodenal graft perforation, preservation of a duodenal segment was possible in five patients but completion duodenectomy was necessary in one patient. After total duodenectomy, immediate enteric duct drainage was feasible in seven patients. In two patients, a pancreaticocutaneous fistula was created that was subsequently converted to enteric drainage in one patient. In the other patient, enteric fistulization occurred as a consequence of silent pressure perforation of the draining catheter on the ascending colon. After a mean follow-up period of 52months (21-125), all patients were alive, well, and insulin-independent. An aggressive and timely surgical approach may permit graft rescue in patients with severe duodenal graft complications occurring after pancreas transplantation. Generalization of these results remains to be established.

Simultaneous Pancreas–Kidney Transplantation. Experience of the Doce de Octubre Hospital

IntroductionSimultaneous pancreas–kidney transplantation (SPKT) constitutes the therapy of choice for diabetes type 1 or type 2 associated with end-stage renal disease, because is the only proven method to restore normo-glicemic control in the diabetic patient. MethodsRetrospective and descriptive study of a series of 175 patients who underwent SPKT from March 1995 to April 2016. We analyze donor and recipient characteristics, perioperative variables and immunosuppression, post-transplant morbi-mortality, patient and graft survival, and risk factors related with patient and graft survival. ResultsMedian age of the donors was 28years and mean age of recipients was 38.8±7.3years, being 103 males and 72 females. Enteric drainage of the exocrine pancreas was performed in 113 patients and bladder drainage in 62. Regarding post-transplant complications, the overall rate of infections was 70.3%; graft pancreatitis 26.3%; intraabdominal bleeding 17.7%; graft thrombosis 12.6%; and overall pancreas graft rejection 10.9%. The causes of mortality were mainly cardiovascular and infectious complications. Patient survival at 1, 3 and 5-year were 95.4%, 93% and 92.4%, respectively, and pancreas graft survival at 1, 3 and 5-year were 81.6%, 77.9% and 72.3%, respectively. ConclusionsIn our 20-year experience of simultaneous pancreas–kidney transplantation, the morbidity rate, and 5-year patient and pancreas graft survivals were similar to those previously reported from the international pancreas transplant registries.

Pancreas Transplantation: Advantages of a Retroperitoneal Graft Position

IntroductionIn the 50 years since the first pancreas transplant performed at the University of Minnesota, the surgical techniques employed have undergone many modifications. Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the “native” pancreas. We herein present our experience of a modified technique for pancreatic transplant, with the organ placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodeno-duodenostomy. MethodsAll pancreas transplantations performed between May 2016 and January 2017 were prospectively entered into our transplant database and retrospectively analyzed. ResultsA total of 10 transplants were performed using the retroperitoneal technique (6 men: median age of 41 years [IQR 36–54]). Median cold ischemia time was 10.30h [IQR 5.30–12.10]. The preservation solution used was Celsior (n=7), IGL-1 (n=2), and UW (n=1).No complications related to the new surgical technique were identified. In one patient, transplantectomy at 12h was performed due to graft thrombosis, probably related to ischemic conditions from a donor with prolonged cardio-respiratory arrest. Another procedure was aborted without completing the graft implant due to an intraoperative immediate arterial thrombosis in a patient with severe iliac atheromatosis. No primary pancreas non-function occurred in the remaining 8 patients. The median hospital stay was 13.50 days [IQR 10–27]. ConclusionsRetroperitoneal graft placement appears feasible with easy access for dissection the vascular site; comfortable technical vascular reconstruction; and a decreased risk of intestinal obstruction by separation of the small bowel from the pancreas graft.

Trasplante de páncreas-riñón simultáneo. Experiencia del Hospital Doce de Octubre

IntroductionSimultaneous pancreas-kidney transplantation (SPKT) constitutes the therapy of choice for diabetes type1 or type2 associated with end-stage renal disease, because is the only proven method to restore normo-glicemic control in the diabetic patient. MethodsRetrospective and descriptive study of a series of 175 patients who underwent SPKT from March 1995 to April 2016. We analyze donor and recipient characteristics, perioperative variables and immunosuppression, post-transplant morbi-mortality, patient and graft survival, and risk factors related with patient and graft survival. ResultsMedian age of the donors was 28years and mean age of recipients was 38.8±7.3years, being 103 males and 72 females. Enteric drainage of the exocrine pancreas was performed in 113 patients and bladder drainage in 62. Regarding post-transplant complications, the overall rate of infections was 70.3%; graft pancreatitis 26.3%; intraabdominal bleeding 17.7%; graft thrombosis 12.6%; and overall pancreas graft rejection 10.9%. The causes of mortality were mainly cardiovascular and infectious complications. Patient survival at 1, 3 and 5-year were 95.4%, 93% and 92.4%, respectively, and pancreas graft survival at 1, 3 and 5-year were 81.6%, 77.9% y 72.3%, respectively. ConclusionsIn our 20-year experience of simultaneous pancreas-kidney transplantation, the morbidity rate, and 5-year patient and pancreas graft survivals were similar to those previously reported from the international pancreas transplant registries.

Surgery of pancreas transplantation.

The surgical techniques of pancreas transplantation have been evolving and significantly improved over time. This article discusses different current techniques and their modifications. At this time, the most commonly used technique is systemic venous drainage (for venous outflow) and enteric drainage (for management of exocrine pancreatic secretions). However, new modifications of established techniques such as gastric or duodenal exocrine drainage and venous drainage to the inferior vena cava continue to be introduced. This article provides a state-of the-art review of the most prevalent up-to-date surgical techniques as well as a synopsis of their specific risks and benefits. The article also provides the most current registry data regarding utilization of different surgical techniques in the United State and worldwide.