Editorials and Perspectives: Analysis and Commentary
In the field of pancreas transplantation, over the past 2 decades there has been a gradual return to enteric exocrine drainage in 81% of simultaneous pancreas-kidney, 67% of pancreas after kidney, and 56% of pancreas transplant alone cases (1). With up to 10% of technically successful pancreases being lost to rejection during the first year after transplantation, and without a reliable noninvasive marker to diagnose rejection, histopathologic findings of pancreas biopsies are the gold standard for the diagnosis and treatment of rejection (2). The shift in the drainage of pancreatic secretions and the need for histopathologic monitoring has led to the challenge of safely obtaining pancreatic tissue.
Different methods have been described for obtaining the pancreas graft biopsy in enterically drained pancreases: (a) percutaneous ultrasound scan-guided biopsy, (b) percutaneous computed tomography-guided biopsy, (c) laparoscopic biopsy, (d) open biopsy, and (e) surrogate pancreas biopsy for simultaneous pancreas-kidney (i.e., kidney transplant biopsy). Percutaneous ultrasound and computed tomography-guided biopsy are the most widely used methods and are largely dependent on local expertise and available resources. Computed tomography-guided biopsy is technically feasible in approximately 75% of patients, with 5% to 10% of these biopsies being inadequate for histologic examination. Computed tomography-guided biopsies have a reported minor complication rate of 9% and a major (requiring angiographic or surgical intervention) complication rate of 3% (2). Ultrasound-guided biopsies have a reported technical success rate of 80% to 85%, with a histopathologic yield rate of 78% and a minor (not requiring invasive intervention) complication rate of 2% (3).
Novel methods for enteric access to the pancreas graft have been reported previously in the literature. In 2001, Zibari and coworkers (4) described a roux-limb jejunostomy with the graft pancreas/duodenum anastomosed in an end-to-side fashion to the roux limb, the temporary jejunostomy providing access to the graft for biopsies and monitoring of enteric amylase and lipase levels. Double-balloon enteroscopy to reach the mid to distal jejunum where the pancreas is more commonly anastomosed (5) and gastric (through duodenogastrostomy) and duodenal (through duodenoduodenostomy) exocrine drainage with access through standard endoscopy have been described as well (6, 7), although these techniques have not been widely accepted. Still, computed tomography and ultrasound are the most prevalent tools in practice.
The authors in this article describe a novel technique for managing the exocrine secretions, that is, performing the duodenojejunostomy at the level of the proximal recipient jejunum, allowing access to the allograft duodenum by means of an enteroscope at 25 to 50 cm from the ligament of Treitz (8). As with any new technical innovation, there is a learning curve, which is operator and center dependent. From the reported experience, it seems that this is a safe technique with no reported endoscopic-related complications. The success rate, defined as the ability to endoscopically access the duodenal segment was 75%. The authors performed venous drainage to the inferior vena cava in 79% and to the superior mesenteric vein in 21% of the transplants. At a mean follow-up of 2 years, there were no complications attributed to the location of the exocrine drainage and no complications associated with enteroscopic biopsy.
The authors have reported an interesting and novel approach to monitoring of the transplanted pancreas. Additional experience with this technique from both the authors' institution and from other programs will hopefully be reported in the future, with the goal of confirming the utility of this approach.
1. Gruessner AC, Sutherland DE. Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of June 2004 Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of June 2004. Clin Transplant 2005; 19: 433.
2. Laftavi MR, Gruessner AC, Bland BJ, et al.. Diagnosis of pancreas rejection: Cystoscopic transduodenal versus percutaneous computed tomography scan-guided biopsy. Transplantation 1998; 65: 528.
3. Lee BC, McGahan JP, Perez RV, et al.. The role of percutaneous biopsy in detection of pancreatic transplant rejection. Clin Transplant 2000; 14: 493.
4. Zibari GB, Boykin KN, Sawaya DE, et al.. Pancreatic transplantation and subsequent graft surveillance by pancreatic portal-enteric anastomosis and temporary venting jejunostomy. Ann Surg 2001; 233: 639.
5. Durlik M, Kosmala W, Milewski J, et al.. Feasibility of visualization and biopsy of donor duodenum by double-balloon enteroscopy technique in a recipient of simultaneous enteric-drained pancreas-kidney transplant: Case report. Transplantation 2006; 82: 578.
6. Shokouh-Amiri H, Zakhary JM, Zibari GB. A novel technique of portal-endocrine and gastric-exocrine drainage in pancreatic transplantation. J Am Coll Surg 2011; 212: 730.
7. Hummel R, Langer M, Wolters HH, et al.. Exocrine drainage into the duodenum: A novel technique for pancreas transplantation. Transpl Int 2008; 21: 178.
8. Margreiter C, Aigner F, Resch T, et al.. Enteroscopic biopsies in the management of pancreas transplants: a proof of concept study for a novel monitoring tool. Transplantation 2012; 93: 207.