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Enteroscopic Biopsy: A Window to the Pancreas?

Mejia, Juan; Shapiro, Ron

doi: 10.1097/TP.0b013e31823cf983
Editorials and Perspectives: Analysis and Commentary

Department of Surgery, Division of Transplantation, Thomas E. Starzl Transplantation Institute, Pittsburgh, PA.

The authors declare no funding or conflicts of interest.

Address correspondence to: Ron Shapiro, M.D., Thomas E. Starzl Transplantation Institute, UPMC Montefiore, 7 South, 3459 Fifth Avenue, Pittsburgh, PA 15213. Email:

Received 11 October 2011.

Accepted 12 October 2011.

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.

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