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Endoscopic Ultrasound-Guided Biopsy of Pancreas in Simultaneous Pancreas-Kidney Transplant Recipient: Case Report

Serwańska-Świętek, Marta1; Degowska, Małgorzata2; Patena, Konrad1; Perkowska, Agnieszka3; Durlik, Marek4,5; Rydzewska, Grażyna2,5; Rydzewski, Andrzej1,5

doi: 10.1097/TP.0000000000000301
Letters to the Editor
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1 Department of Internal Medicine Nephrology and Transplantation Medicine Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland

2 Department of Internal Medicine and Gastroenterology Central Clinical Hospital of the Ministry of Interior Warsaw, Poland

3 Transplantation Institute Medical University of Warsaw Warsaw, Poland

4 Department of Gastrointestinal and Transplantation Surgery Central Clinical Hospital of the Ministry of Interior Warsaw, Poland

5 Department of Surgical Research and Transplantology Mossakowski Medical Research Centre Warsaw, Poland

The authors declare no funding or conflicts of interest.

Address correspondence to: Andrzej Rydzewski, M.D., Klinika Chorób Wewnętrznych, Nefrologii i, Transplantologii, Centralny Szpital Kliniczny, MSW, Wołoska 137, 02-507 Warszawa, Poland.

E-mail: arydzew@ujk.edu.pl

Received 9 January 2014.

Accepted 9 May 2014.

Early diagnosis and appropriate treatment of rejection are crucial in preventing irreversible damage to the transplanted organ. Currently, noninvasive diagnostic methods for the detection of the rejection lack specificity and cannot be relied on (1). Consequently, a histopathologic biopsy of the pancreas is the method of choice in diagnosing rejection. The most common technique is the ultrasonographically guided approach (2). The complication rate of this procedure is estimated to be between 2.8% and 13% (most common complications include hyperamylasemia, bleeding, acute pancreatitis and infection) (3–6). The diagnostic yield for percutaneous ultrasound-guided biopsies is estimated to be 78% to 96%, depending on operator experience and type of needle used (3, 4, 6). Failure is usually because of lack of an ultrasonographic window or obtaining inadequate tissue. If pancreas tissue cannot be obtained, patients have traditionally undergone a percutaneous computed tomography scan–guided, laparoscopic, or open biopsy. An alternative means of tissue diagnosis might be endosonography (endoscopic ultrasound [EUS])-guided transduodenal biopsy. This method enables the visualization of the gastrointestinal tract, as well as neighboring structures. It is currently used primarily in imaging of the pancreas, biliary tree, lymph nodes, and vessels. Endoscopic ultrasound is also used for guiding biopsies of the native pancreas, with a relatively low complication rate of 1.6% to 3.6% (7, 8). To the best of our knowledge, there have been no reports on the use of EUS to obtain pancreas biopsies in pancreas transplant recipients.

We performed EUS-guided pancreas biopsy in a 32-year-old woman with a history of type 1 diabetes mellitus (diagnosed at age 4) and end-stage renal disease treated by hemodialysis, who underwent simultaneous pancreas and kidney transplantation. Arterial reconstruction was performed between the donor superior mesenteric and splenic arteries, using a donor iliac artery or Y-graft. The pancreas allograft was placed in a head-up configuration with anastomoses constructed between the donor portal vein and recipient infrarenal inferior vena cava, and the donor Y-graft and the recipient right common iliac artery. The pancreas graft was placed in a head-up configuration. After revascularization, enteric drainage was executed using the duodenoduodenostomy technique (9, 10). The immunosuppressive regimen included thymoglobulin for induction and mycophenolate mofetil, tacrolimus, and steroids for maintenance treatment. The postoperative course was complicated by delayed pancreas function and fluid collection. An open biopsy of the pancreas transplant was performed during relaparotomy for postoperative fluid collection. Moderate acute cell-mediated allograft rejection (grade II) was diagnosed, and pulse steroids were started, resulting in improvement of glycemic control (normoglycemia was achieved). Despite the treatment, the increase in serum amylase and lipase activity persisted. An endoscopic biopsy of the donor duodenum has been performed on the patient as a surrogate marker for pancreas allograft rejection but was unremarkable (11, 12). Percutaneous ultrasound-guided or computed tomography–guided biopsy was deemed not technically possible because of interposed bowel, and therefore an EUS-guided biopsy was performed (the patient was reluctant to undergo an open or laparoscopic biopsy). The procedure was performed under propofol sedation, using a Pentax UTK-3870 (Pentax Europe GmbH, Hamburg, Germany) echoendoscope with a Hitachi Avius HI Vision (Hitachi Medical Corp., Tokyo, Japan) ultrasound system. The pancreas graft was sampled by means of the transplanted duodenum (Fig. 1) using a 22G EchoTip ProCore needle (Cook Ireland Ltd., Limerick, Ireland), which is an aspiration needle with a core trap. Within the pancreas, nine quick back-and-forth jabbing movements of the needle were performed (13). The biopsy yielded adequate pancreas allograft tissue fragment (Fig. 2). Histologic examination revealed no signs of inflammation or C4d deposits within the capillaries. No complications were observed after the biopsy. Amylase and lipase serum activity levels remained stably elevated. The patient was discharged the following day and is doing well at 8 months follow-up.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

It has to be mentioned that the concept of transduodenal pancreas biopsy is not new, and the technique was used in the 1990s when most pancreases were bladder-drained (14, 15). At that time 14-gauge to 16-gauge core-cut needles were used for cystoscopic transduodenal biopsies and 18-gauge core-biopsy needles for percutaneous biopsies, and even then, cystoscopic transduodenal biopsies resulted in lower rate of major complications (15). The transduodenal technique is a more “invasive” alternative to a percutaneous biopsy (although 22G or 19G needle is used (13) as compared to 18G needle for percutaneous approach) and may be attempted when an adequate ultrasound window for percutaneous biopsy is difficult or impossible to find. It is, however, less invasive than laparoscopic and open techniques. It has to be also stressed that the use of EUS to obtain a transduodenal pancreas biopsy was possible in this case only because exocrine drainage was obtained through duodenoduodenostomy.

In conclusion, in pancreatic graft recipients with drainage of exocrine secretions of the pancreatic graft in the recipient duodenum, it is possible to obtain an EUS-guided transduodenal biopsy of the transplanted pancreas.

Marta Serwańska-Świętek

1

Małgorzata Degowska2

Konrad Patena1

Agnieszka Perkowska3

Marek Durlik4,5

Grażyna Rydzewska2,5

Andrzej Rydzewski1,5

1 Department of Internal Medicine

Nephrology and Transplantation Medicine

Central Clinical Hospital of the Ministry of

Interior, Warsaw, Poland

2 Department of Internal Medicine

and Gastroenterology

Central Clinical Hospital of the

Ministry of Interior

Warsaw, Poland

3 Transplantation Institute

Medical University of Warsaw

Warsaw, Poland

4 Department of Gastrointestinal and

Transplantation Surgery

Central Clinical Hospital of the

Ministry of Interior

Warsaw, Poland

5 Department of Surgical Research

and Transplantology

Mossakowski Medical Research Centre

Warsaw, Poland

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