Corry, RJ

Egidi, F

Gritsch, HA

Randhawa, PS

Shapiro, R

Starzl, TE

English

Name not available

Spontaneous arterio-enteric fistula following pancreas transplant

D-Scholarship@Pitt

) e , . 2: Ie 1-p-s. a-Sa ac of 1£ -~ct nt m-K, se. March 27, 1997 BRIEF COMMUNICATIONS )4 tFY. I~Is:~ SPONTANEOUS ARTERIOENTERIC FISTULA Acqbg~ny1> PANCREAS TRANSPLANTATION .Lt1fq.\D H. ALBIN GRITSCH ,1,2 RON SHAPIRO,3 FRANCESCA EGIDI,3 PARMJEET S. RANDHAWA,4 THOMAS E. STARZL,3 A.t\!D ROBERT J. CORRr Division of Urologic Surgery / Renal Transplantation., Pittsburgh Transplantation Institute, and Division of Transplantation Pathology, Departments of Surgery and Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213 Chronic pancreas transplant rejection with enteric exocrine drainage can lead to significant long-term complications. We report a case of a 47-year-old male insulin-dependent diabetic who survived the compli-cations of peripancreatic abscess, enterocutaneous fistula, and arterioenteric fistula related to pancreas transplantation. To avoid these long-term complica-tions, we now recommend elective removal of non-functioning, enterically drained pancreas allografts. Bladder drainage has become the most common technique for diversion of pancreas transplant exocrine secretions (1,2). Urologic complications develop in over 50% of these patients (3). In an attempt to decrease the morbidity and cost of pancreas transplantation, we utilized enteric exocrine drain-age for the most recent simultaneous pancreas kidney trans-plants (4). The I-year pancreas graft survival rate using this technique was 879c in a recently reported series (5). The long-term complications of enteric drainage will require fur-ther study. We report herein a nearly fatal complication after pancreas transplantation with enteric drainage. The patient was a 47-year-old white man with insulin-dependent diabetes melli tus since the age of 5. When he was 36 years old, he developed chronic renal failure secondary to diabetic glomerulosclerosis. After 9 months on hemodialysis, in December 1982, an uneventful cadaveric renal transplant was performed with anastomosis of the donor vessels to the right external iliac artery and vein of the recipient. Cyclo-sporine and prednisone immunosuppression were main-tained after renal transplantation. In March 1983, he was the recipient of a pancreaticoduodenal transplant with en-teric drainage to the recipient jejunum. The donor spleen was initially transplanted with the pancreas allograft; however, the patient developed a hemolytic anemia, and a splenectomy was performed on postoperative day 6. The details of this pancreaticoduodenal transplant were reported previously (6). He remained euglycemic for 14 months until the pan-creas suddenly failed, and a left lower quadrant extraperito-neal abscess was identified and surgically drained. In July 1985, the patient received his second pancreas transplant through a midline abdominal incision. The allograft was based on both the celiac axis and the superior mesenteric artery, which were anastomosed to the left common iliac artery in an end-to-side fashion using a common Carrel patch. The portal vein was anastomosed to the left common 1 Division of Urologic SurgerylRenal Transplantation, Depart-ment of Surgery. 2 Address cOITespondence to: H. Albin Gritsch, MD, Division of Urologic SurgerylRenal Transplantation, University of Pittsburgh Medical Center, 347l Fifth Avenue, Suite 700, Pittsburgh, PA 15213. :1 Pittsburgh Transplantation Institute, Department of Surgery. 4 Division of Transplant Pathology,. Department of Pathology. iliac vein in a similar fashion. The spleen was removed after reperfusion, and a side-to-side anastomosis was made be-tween a short segment of the duodenum and the recipient jejunum. The previous pancreas transplant could be seen in the left extraperitoneal space, but it was not disturbed. On postoperative day 12, acute rejection was diagnosed and treated with OKT3. Immunosuppression was maintained with cyclosporine, azathioprine, and prednisone. In October 1985, the patient developed a recurrent left lower quadrant abscess with an enterocutaneous fistula from his first pan-creas transplant. This allograft pancreas and duodenal rem-nant were removed. Once this infection resolved, the patient had stable renal and pancreas function for 8 112 years. In 1994, he gradually required increasing doses of insulin to regulate his blood glucose; his serum creatinine was stable at approximately 2.5 mg/dl. In November 1995, the patient was admitted to his local hospital with hematochezia. After 2 days the bleeding in-creased and he was transferred by helicopter to the Univer-sity of Pittsburgh Medical Center. On admission, there was massive lower gastrointestinal hemorrhage with severe hy-potension. The patient was immediately transferred to the operating room and hemodynamically resuscitated. The old midline incision was opened, and multiple loops of small bowel were adherent to a very firm fibrotic and pulsatile pancreas in the left periumbilical area. The donor duodenum attached to the jejunum was distending rapidly with blood. The small bowel was stapled on both sides of the jejunal anastomosis, freeing the anterior portion of the pancreas graft. The posterior portion of the pancreas graft was adher-ent to the distal aorta and upper iliac vessels on the left. Although there were no planes, the organ was freed by blunt and sharp dissection from these posterior structures. The duodenal segment had to be opened, as it was pulsatile and becoming rapidly distended with arterial blood. After open-ing of the duodenal segment, a finger was inserted into a large cavity in the body of the pancreas, which had necessi-tated through to the duodenal segment (Fig. 1). While the finger controlled the bleeding, dissection was continued in the retroperitoneum. The aortic bifurcation was located, and a clamp was placed on the left common iliac immediately at its takeoff from the aorta. A vascular clamp was then placed distally on the iliac artery and vein, which were both covered with thick layers of hyalinized inflammatory material. The specimen was removed en bloc from the operating field. There was a fair amount of bleeding deep in the pelvis , which was controlled with several suture ligatures. An enteroenter-ostomy was then performed joining the two divided ends of the jejunum. The abdomen was irrigated, hemostasis was ensured, and the wound was closed. A right-to-left femoral-to-femoral artery bypass was then performed to reestablish 904 TRANSPLANTATION Vol. 63, No.6 FIGURE: L Iliac artery-enteric fistula after pancreas transplantation with enteric exocrine drainage: (top) pancreaticoduodenal allograft with chronic rejection and central area of necrosis; (bottom ) view of iliac artery fistula into the duodenal portion of the allograft. perfusion of the lower extremity. The patient received 24 U of packed red blood cells, 12 U of fresh frozen plasma, 20 U of platelets, and approximately 25 U of cell-saver blood from two blood reprocessing machines during surgery. The patient did surprisingly well after the operation. The renal a[ograft had a brief period of nonoliguric renal failure secondary to hypotension; however, the patient did not re-quire dialysis. The main postoperative problem was left lower extremity edema and foot drop. A left leg fasciotomy revealec viable muscle. He was transferred to a rehabilita-tion center for gait training on postoperative day 10. An analysis of the International Pancreas Transplant Reg-istry reports that 69% of pancreas graft failures occur within the first 6 months (2). These acutely failed grafts are usually symptomatic and are removed promptly. The indications for transplant pancreatectomy after this time period are not well defined . Troppmann et al. (7) reviewed the indications for transplant pancreatectomy at the University of Minnesota and found that graft removal was necessary after 26% of all pancreas transplants. Only 25% of the organs lost to rejection required removal (7). Tzakis et al. (8) reported four cases of mycotic aneurysm rupture after graft pancreatectomy, one of which occurred more than a year later. However, this case demonstrates the significant morbidity that may occur with a nonfunctioning pancreas allograft. The first pancreas allo-graft developed an abscess with enterocutaneous fistula and the second pancreas developed a nearly fatal iliac artery-enteric fistula . Both of these pancreas allografts had enteric exocrine drainage, which may be an important factor, al-though arteriovesical fistula has also been reported with bladder drainage (9). We now recommend elective pancreas allograft removal when graft failure has been clearly docu-mented in patients with low anesthetic risk factors. Alterna-tively, the non functioning pancreas allograft should be fol -lowed closely with serial imaging studies to detect occult abscess or fistula formation. REFERENCES 1. Nghiem DD, Corry RJ. Technique of simultaneous renal pancre-atoduodenal transplantation with urinary drainage of pancre-atic secretions. Am J Surg 1987; 153: 405. 2. Gruessner A, Sutherland DER. Pancreas transplant results in the United Network for Organ Sharing (UNOS) United States of America (USA) registry compared with non-USA data in the international registry. In: Terasaki PI, Cecka JNI, eds. Clinical transplants 1994. Los Angeles: UCLA Tissue Typing Labora-tory, 1994: 47. 3. Ploeg RJ, Eckhoff DE, D'Alessandro AM, et al. Urologic compli-cations and enteric conversion after pancreas transplantation with bladder drainage. Transplant Proc 1994; 26: 458 . 4. Corry RJ, Egidi MF, Shapiro R, et a1. Enteric drainage of pan-creas transplants revisited. Transplant Proc 1995; 27: 3048. 5. Tyden G, Tibell A, Brattstrom C, Sandberg J, Groth CG. Sim-plifying the technique for pancreaticoduodenal transplanta-tion with enteric exocrine drainage. Transplant Proc 1995; 27: 3027. 6. Starzl TE, Iwatsuki S, Shaw BW, et a1. Pancreaticoduodenal transplantation in humans. Surg Gynecol Obstet 1984; 159: 265. 7. Troppmann C, Gruessner RWG, Dunn DL, Fasola C, Najarian JS, Sutherland DER. Is transplant pancreatectomy after graft failure necessary? Transplant Proc 1994; 26: 455. 8. Tzakis AG, Carroll PB, Gordon RD, Yokoyama I, Makowka L, Starzl TE. Arterial mycotic aneurysm and rupture: a poten-tially fatal complication of pancreas transplantation in diabe-tes mellitus. Arch Surg 1989; 124: 660. 9. Nash PA, Little JS Jr. Arteriovesical fistula after pancreatic transplantation. J Urol 1995; 154: 1861. Received 9 July 1996. Accepted 31 October 1996. 

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Spontaneous arterio-enteric fistula following pancreas transplant

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