In patients with transplanted pancreas, early technical failure accounts for more
than half of graft losses during the initial posttransplant period – a complication
that necessitates graft pancreatectomy [1]. Failure rates for pancreas recipients in the United States approximate 5 %, with
reoperative rates between 12 % and 43 % [2]
[3]. Graft thrombosis is the leading cause of technical failure, followed by anastomotic
leak, infection, pancreatitis, and bleeding. The etiology of transplant pancreas leak
may be a failure of healing/sealing of a pancreaticoenteric anastomosis, or a parenchymal
disruption originating from the pancreatic ductal system [4]. Initial management of postoperative leaks involves percutaneous drainage. If clinical
deterioration occurs, relaparotomy is mandatory [5]. Endoscopic retrograde pancreatography (ERP) offers pancreatic sphincterotomy and
placement of pancreatic ductal stents, which are effective in treating pancreatic
leaks. The postsurgical anatomy and its anastomosis with the bladder makes conventional
endoscopic access impossible.
Our patient was a 34-year-old man who had received pancreatic and renal transplants
for type 1 diabetes mellitus and end-stage renal disease. The pancreas was transplanted
using a bladder drainage approach. On postoperative day 7 the patient complained of
right lower quadrant abdominal pain and developed fever and leukocytosis. Computer
tomography (CT) showed new-onset ascites, and peritoneal fluid analysis revealed significantly
elevated amylase and lipase levels, but CT cystogram did not reveal any microperforaton
or staple line leak.
Initial placement of wire in the bladder was performed by a urologist using a standard
cystoscope. Urethral dilation was then performed using a biliary balloon dilator over
the wire ([Video 1]). Under fluoroscopy, balloon dilation was performed, with incremental increase of
the balloon size up to a size equivalent to the endoscope used; in this case up to
10 mm. Then, the balloon was used to slide and advance the endoscope. The endoscope
was advanced in the bladder and a duodenovesical anastomosis, also known as pancreaticoduodenocystostomy,
was identified ([Fig. 1]). The donor duodenum was intubated and the major papilla located on the opposite
wall from the anastomosis. The remainder of the procedure resembled ERP, with cannulation,
sphincterotomy, and placement of a plastic stent for drainage of pancreatic exocrine
secretions within the duodenum and bladder. At 6-month follow-up the patient is asymptomatic
without any weight loss.
Video 1 Transurethral endoscopic retrograde pancreatography to treat complications after
pancreatic transplantation.
Fig. 1 Endoscopic identification of a duodenovesical anastomosis, also known as pancreaticoduodenocystostomy,
in a 34-year-old man with right lower quadrant abdominal pain, fever, and leukocytosis
7 days after receiving pancreatic and renal transplants for type 1 diabetes mellitus
and end-stage renal disease.
Endoscopy_UCTN_Code_TTT_1AR_2AG
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