tomy leak (7.7%) that required Foley catheterization for 45 days; 2 reffux pancreatitis ... Sollinger HW, Cook K, Kamps D, et al: Transplant Proc. 16:749, 1984. 2.
Enteric Versus Bladder Drainage in Pancreas Transplantation: Initial Experience at Niguarda Hospital, Milan C.V. Sansalone, P. Aseni, M.L. Follini, A.O. Slim, O. Rossetti, G. Colella, F. Di Benedetto, G.F. Rondinara, L. De Carlis, C. Brunati, A. Meroni, G. Rombola`, G. Civati, and D. Forti
T
HE management of exocrine secretions in pancreas transplantation continues to be an area of controversy.1–3 In addition to being a safe procedure, duodenocystostomy (BD) offers the advantage of monitoring graft function by serial measurement of urine amylase, considered to be a good signal of possible early acute rejection.4 However, this kind of technique is responsible for more than 50% of urologic and metabolic complications reported in the literature that require repeat hospitalizations.5 Enteric diversion (ED) is the most physiologic technique, but exocrine function cannot be monitored permanently and it is considered to be high risk for bacterial infection. Recently, consistent data have been reported by Corry et al.6 showing similar results in BD and ED groups. In the ED group, fine needle aspiration biopsy (FNAB) was used as a safe alternative in early acute rejection diagnosis.7 We present here the initial experience with ED comparing the results with the group of BD.
catheterization for 8 and 15 days; a single episode of urinary tract infection in eight patients (61.5%) while 3 patients (23.0%) had two episodes. The median hospital stay in the BD group was 43 days (range, 21– 83). All patients are alive and well with good allografts function (one patient after pancreas retransplant due to portal thrombosis seven days after PKT) 8 to 38 months after PT. In the ED group, one patient had diarrhea which spontaneously disappeared four days after PKT. All five patients in this group are alive and well 3 to 9 months after PT. One patient underwent pancreas retransplant because of portal thrombosis three days after PKT, developed arterial thrombosis on the second graft nine months later, and is at the moment under insulin regimen. The cause of thrombosis on the second graft was probably the hyperglobulic state developed in the postoperative period. The median hospital stay in the ED group was 23 days (range, 16 to 29). DISCUSSION
MATERIALS AND METHODS
RESULTS
This preliminary study indicates that ED of exocrine pancreas eliminates urologic and metabolic morbidity and does not add significant surgical risk when compared to BD technique. In the BD group every patient had at least one complication early or late in the postoperative period. According to Sollinger et al.5 these kinds of complications significantly extend the mean hospital stay and the need for rehospitalization, but do not affect renal and pancreatic allograft function. In our series, macrohematuria, reflux pancreatitis, and urinary tract infections were almost all reversed using conservative treatment. In contrast, only one patient in the ED group presented with diarrhea, probably because duodenoenteric anastomosis was too close to the right colon. However, the diarrhea disappeared a few days after PKT. One patient in this group underwent early retransplantation because of portal thrombosis and received a second graft that was lost nine months
All patients in the BD group had one or more urologic complication: a single episode of gross hematuria occurred in 4 patients (30.7%), successfully managed with bladder irrigation (3) and electrocautery (1); one duodenocystostomy leak (7.7%) that required Foley catheterization for 45 days; 2 reflux pancreatitis (15.4%) resolved with Foley
From the Departments of General Surgery and Abdominal Organ Transplantation (C.V.S., P.A., M.L.F., A.O.S., O.R., G.C., F.D.B., G.F.R., L.D.C., A.M., D.F.), and Nephrology (C.B., G.R., G.C.), Niguarda Hospital, Milan, Italy. Address reprint requests to Dott. Cosimo Vincenzo Sansalone, Pizzamiglio II, Ospedale Niguarda, 20162 Milano, Italy.
Over a 3-year period, 20 pancreas transplants (PT) were performed on 18 patients. Seventeen patients received a simultaneous kidney– pancreas transplant (PKT) and one a pancreas transplant alone (PTA). Thirteen patients were male and 5 female, with a mean age of 36.8 years (range, 25–56). All recipients were adult type I diabetics with a mean duration of diabetes of 20 years. All but one had end-stage renal disease and 11 were on dialysis at the time of PT. A midline incision and vascular anastomoses on common iliac vessels were routinely adopted in this series. A pancreaticoduodenocystostomy (BD group) was performed in 13 patients while 5 patients had enteric drainage (ED group). In both groups, the anastomoses were performed using the two-layer hand-sewn technique. Generally, catheter drainage of the bladder was removed 10 days after PT if there were no leaks. Immunosuppression consisted of quadruple therapy (ATG, cyclosporine, azathioprine, and steroids). Acute rejection episodes were treated using steroid boluses.
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later due to arterial thrombosis. Both events were unrelated to ED. Of course, BD allows permanent monitoring of exocrine function as an indipendent early sign of rejection, especially in nonuremic recipients of pancreas grafts alone.2– 4 However, FNAB seems to be safe and useful to monitor the graft events in the early posttransplant period becoming a good alternative to amylasuria although we do not have any experience with this technique.7 In conclusion, doudenoenteric anastomosis is an effective procedure in PT. Enteric drainage avoids the urologic problems related to bladder drainage, and technical problems using this kind of anastomosis seem to be minimal. We believe the excellent results with enteric drainage should be confirmed in large samples of patients.
SANSALONE, ASENI, FOLLINI ET AL
REFERENCES 1. Sollinger HW, Cook K, Kamps D, et al: Transplant Proc 16:749, 1984 2. Sollinger HW, Stratta RJ, Kalayoglu M, et al: Surgery 102: 674, 1987 3. Groth CG, Lundgren G, Klintmann G, et al: Lancet 2:522, 1982 4. Prieto M, Sutherland DER, Goetz FC, et al: Surgery 102:680, 1987 5. Sollinger HW, Messing EM, Eckhoff DE, et al: Ann Surg 218:561, 1993 6. Corry RJ, Egidi MF, Shapiro R, et al: Transplant Proc 29:642, 1997 7. Egidi MF, Corry RJ, Sugitani A, et al: Transplant Proc 29:674, 1997
