Duodenoduodenostomy in pancreas transplantation

Abstract

Enteric drainage (ED) using duodenojejunostomy (DJ) is an established technique in pancreatic transplantation. Duodenoduodenostomy (DD), an alternative ED technique, may provide unique advantages over DJ. We compared our experience with these two types of ED through a retrospective review of all pancreas transplants performed at our institution from November 2007 to November 2009. The allograft duodenum was anastomosed to the recipient jejunum or duodenum. Duodenal drainage was performed by a stapled or hand-sewn technique. Patient demographics, operative times, major post-operative complications, and graft survival data were analyzed. Of 57 pancreas transplants, DJ was performed in 36 patients, stapled DD in 14 patients, and hand-sewn DD in seven patients. Two DD grafts (9.5%) thrombosed compared with no DJ grafts (p = NS). Enteric leak and small-bowel obstruction occurred in 3 of 36 DJ patients and in two DD patients (p = NS). Gastrointestinal bleeding occurred more frequently in stapled DD compared with DJ (4 vs. 0, p < 0.015). In conclusion, DD is technically feasible with no increase in operative time or enteric complications. GI bleeding rates appear to be higher following DD (stapled) technique. Potential complications of DD should be balanced against the benefits conferred by this technique.

Exocrine drainage in vascularized pancreas transplantation in the new millennium

“…The bowel anastomosis is most commonly performed to a bowel loop that is not excluded from the transit of intestinal contents [4,16,17,33,[39][40][41][42][44][45][46][49][50][51][52][53][112][113][114][115][116][117][118][119][120][121] . Alternatively, the allograft duodenum can be connected directly into the native stomach or duodenum, to a diverting Roux limb without or with a venting jejunostomy, or to an omega loop [23][24][25][26][27][28][29][30][31][32]122] (Table 7). Utilizing the native stomach or duodenum affords straightforward access to the allograft duodenum and pancreas for biopsy and surveillance by endoscopic techniques and also expands the possibilities for exocrine drainage sites, particularly in cases of pancreas retransplantation (Table 8) [ [25][26][27][28][29][30]…”

“…Alternatively, the allograft duodenum can be connected directly into the native stomach or duodenum, to a diverting Roux limb without or with a venting jejunostomy, or to an omega loop [23][24][25][26][27][28][29][30][31][32]122] (Table 7). Utilizing the native stomach or duodenum affords straightforward access to the allograft duodenum and pancreas for biopsy and surveillance by endoscopic techniques and also expands the possibilities for exocrine drainage sites, particularly in cases of pancreas retransplantation (Table 8) [ [25][26][27][28][29][30][31][32]123] . However, because up to 5%-10% of transplanted pancreata are at risk for early technical failure that may lead to leaks, Duodenal leaks: (n = 11); Acute rejection (n = 6); CMV infection (n = 3); Technical failure (n = 2); Death: (n = 2) as a consequence of sepsis Reoperation for duodenal leak: Roux-en-Y technique: (n = 3) DJ technique: (n = 2) Transplantectomy: (n = 6) ND ND Toronto General Hospital, Spetzler et al [95] , Retrospective [106] , Retrospective 49; SPK; All ED Death: (n = 2) (1 patient died from multi-system organ failure and a second from graft vs host disease); Pancreatic graft failures: (2); renal graft failure: (1) Relaparotomies: (n = 5) bowel obstructions: (2) anastomotic leak: (1) ureteral stricture: (1) 96% Kidney 94%; Pancreas University of Pittsburgh, Corry et al [107] , Retrospective 104 SPK Graft loss in 6 patients, Death in one patient Splenic artery hemorrhage: (1) ND 98% 92%; Kidney 95%, Pancreas 83% University of Maryland, Bartlett et al [108] , Prospective…”

“…Consequently, > 80% of bowel drained pancreas transplants in the United States are performed without a decompressing Roux limb of small bowel and with systemic (iliac or vena cava) venous delivery of insulin [1] . Although the promise of the portal-enteric technique has not been achieved, it has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] . Previous reports have not shown any main variances in outcomes for bladder-or entericdiverted pancreas transplants regardless of method of venous drainage .…”

The current challenges for pancreas transplantation for diabetes mellitus

“…The majority of pancreas transplants today, whether solitary or in combination with a kidney, are drained enterically [40]. Such enteric drainage is usually into a segment of jejunum, but recently reports have suggested consideration of more proximal placement to facilitate surveillance biopsies [61][62][63], although there is a risk that surgical complications relating to the anastomosis will be more difficult to manage.…”

Pancreas Transplantation with Systemic-Enteric Drainage when Portal-Enteric Drainage is Contraindicated

“…In our experience, other potential contraindications to portalenteric drainage using the anterior approach are listed in Table 1. In addition to the lateral or retroperitoneal approach introduced by Boggi [3], a number of other variations of portal-enteric drainage have evolved over the years to minimize technical challenges including the use of diverting Roux-en-y limbs for the enteric anastomosis (either with or without a venting jejunostomy), duodeno-gastric drainage, and, more recently, duodeno-duodenal drainage [12,[19][20][21][22][23][24][25][26][27][28][29][30].…”