DUODENAL GRAFT COMPLICATIONS REQUIRING DUODENECTOMY AFTER PANCREAS AND PANCREAS-KIDNEY TRANSPLANTATION

Background: Duodenal graft complications (DGC) are poorly reported complications of pancreas transplantation (PTx) that can lead to graft loss. Methods/Materials: Pancreas grafts were procured, prepared at the back table (Surgery 2004, 135:629-41) and transplanted (Transplantation 2005, 79:1137-42) according to previously described techniques. As specifically regards blood supply to graft duodenum, the patency of collateral circulation between the superior mesenteric and splenic pedicles, was checked by injecting a small amount of preservation fluid into either the superior mesenteric artery or the splenic artery and observing outflow from opposite vascular pedicles. After PTx, recipients were seen at our center every month during the first year, every three months during the second year, and every six months thereafter, if not otherwise necessary. Once a DGC was suspected, contrast-enhanced computed tomography was performed to confirm diagnosis and define anatomy of the lesion. Complete immunologic and virologic work-ups were also performed in every patient. Results: After a median follow-up period of 120 months (range 10-185) duodenectomy was required in 14 of 298 PTx recipients (4.3%). All recipients were insulin independent at the time of diagnosis. Reasons for duodenectomy were delayed duodenal graft perforation (n=10, 71.5%), and refractory duodenal graft bleeding (n=4, 28.5%). In all patients with duodenal graft bleeding, the entire duodenum was removed. In patients with duodenal graft perforation preservation of a duodenal segment was possible in 5 patients. Completion duodenectomy was necessary in one patient. After total duodenectomy immediate enteric duct drainage was feasible in 7 patients. In 2 patients a pancreatico-cutaneous fistula was created, and was subsequently converted to enteric drainage in one patient. Spontaneous duct drainage into the ascending colon occurred in the other patient, without consequences and with sustained long-term graft func.