Relaparotomy After Pancreas Transplantation: Causes and Outcomes

doi:10.1016/j.transproceed.2009.06.165

Transplantation Proceedings

Volume 41, Issue 6, July–August 2009, Pages 2472-2474

https://doi.org/10.1016/j.transproceed.2009.06.165 Get rights and content

Abstract

Introduction

Surgical complications after pancreas transplantation, and subsequently relaparotomies, are frequently associated with graft loss, important morbidities, and ocasionally patient death.

Patients and methods

From March 1995 to September 2008, 118 diabetic patients underwent pancreas transplantation: 109 simultaneous pancreas-kidney and nine pancreas after kidney. There were 68 men and 50 women. Mean age at transplantation was 37.8 ± 7.8 years (range = 25–66). We analyzed donor and recipient characteristics, rate of relaparotomies, risk factors, as well as patient and graft survivals.

Results

Forty patients (33.9%) underwent one or more relaparotomies. The causes for relaparotomy were: graft thrombosis in 15 patients (12.7%), bleeding in 14 (11.9%), duodenal stump leak in 7 (5.9%), severe pancreatitis and/or abscess in 5 (4.2%), and small bowel obstruction in 3 (2.5%). Graft pancreatectomy was performed in 52.5% (21 patients). The causes of graft loss were: graft thrombosis in 15 patients (12.7%), bleeding in 14 (11.9%), and duodenal stump leaks in 7 (5.9%). Mortality rate after relaparotomy was 3.38% (four patients). Relaparotomy rate for thrombosis was higher among the portoiliac than the portocaval vein anastomosis group (20.0% vs 10.2%; P = NS), and significantly higher for the bladder drainage than the enteric drainage technique (18.2% vs 5.8%; P < .05). Patients without relaparotomy experienced a significantly higher 5-year graft survival rate than those who underwent relaparotomy (87.2% vs 37.9%; P < .001), but 5-year patient survivals were similar (96.8% without relaparotomy vs 89.6% with relaparotomy).

Conclusions

Abdominal complications and the necessity for relaparotomy were associated with important morbidity and significantly reduced pancreas graft survival.

Section snippets

Patients and Methods

From March 1995 to September 2008, 118 patients (116 with type 1 diabetes and two with type 2 diabetes) underwent pancreas transplantation: 109 simultaneous pancreas-kidney and nine pancreas after kidney. There were 68 men and 50 women, of overall mean age at transplantation of 37.8 ± 7.8 years (range = 25–66 years). Donor and recipient characteristics are shown in Table 1. Hyperglycemia, hyperamylasemia, or hemodynamic instability were not considered absolute contraindications for pancreas

Results

Forty patients (33.9%) underwent one or more relaparotomies. The causes for relaparotomy were: graft thrombosis in 15 patients (13.5%), bleeding in 14 (11.9%), duodenal stump leak and abscess in 7 (5.9%), severe pancreatitis and/or abscess in 5 (4.2%), and small bowel obstruction in 3 (2.5%). Graft pancreatectomy was performed in 52.5% of patients who underwent relaparotomy (21 patients), and the causes of graft loss are shown in Table 2. The mortality rate among recipients requiring

Discussion

The most frequent indications for relaparotomy after pancreas transplantation in the Minnesota series2, 4, 6 were vascular graft thrombosis, intra-abdominal infection, pancreatitis, bleeding, and stump or anastomotic leaks. An other cause of relaparotomy is small bowel obstruction, which was experienced by three patients in our series and was not related to graft loss. Vascular graft thrombosis was the leading cause of pancreas graft loss and also the most frequent cause of laparotomy together

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Cited by (44)

Post-pancreatic transplant enteric leaks: The role of the salvage operation
2022, American Journal of Transplantation
Enteric drainage in pancreas transplantation is complicated by an enteric leak in 5%–8%, frequently necessitating pancreatectomy. Pancreatic salvage outcomes are not well studied. Risk factors for enteric leak were examined and outcomes of attempted graft salvage were compared to immediate pancreatectomy. Pancreas transplants performed between 1995 and 2018 were reviewed. Donor, recipient, and organ variables including demographics, donor type, ischemic time, kidney donor profile index, and pancreas donor risk index were analyzed. Among 1153 patients, 33 experienced enteric leaks (2.9%). Donors of allografts that developed leak were older (37.9y vs. 29.0y, p = .001), had higher KDPI (37% vs. 24%, p < .001), higher pancreas donor risk index (1.83 vs. 1.32, p < .001), and longer cold ischemic time (16.5 vs. 14.8 h, p = .03). Intra-abdominal abscess and higher blood loss decreased the chance of successful salvage. Enteric leak increased 6-month graft loss risk (HR 13.9[CI 8.5–22.9], p < .001). However, 50% (n = 12) of allografts undergoing attempted salvage survived long-term. After 6 months of pancreas graft survival, salvage and non-leak groups had similar 5-year graft survival (82.5% vs. 81.5%) and mortality (90.9% vs. 93.5%). Enteric leaks remain a challenging complication. Pancreatic allograft salvage can be attempted in suitable patients and accomplished in 50% of cases without significantly increased graft failure or mortality risk.
Radiological initial treatment of vascular catastrophes in pancreas transplantation: Review of current literature
2021, Transplantation Reviews
Arterio-enteric fistula (AEF) is a rare but potentially devastating complication of solid organ pancreatic transplantation. Traditional management has been to remove the pancreas-duodenum allograft and control the vascular defect. Interventional radiological (IR) techniques present a new method of managing AEF related haemorrhage without re-operation and the potential to preserve graft function. This paper examines the available literature to assess efficacy and safety of this novel approach.
Aggregate results tables were constructed from 28 cases identified in the English language literature where IR was used in the management of AEF following pancreas transplantation. Outcomes recorded were death, re-bleeding, surgical intervention required and post intervention graft function. These were analysed with respect to technical factors and graft function at time of presentation.
28 cases of AEF managed by IR methods were identified. Mortality was high at 17.9%. 78.6% of all AEFs were present in failed pancreas allografts. Median time from transplant to bleeding event was 29 months. There was a trend of bleeding event occurring within 12 months of allograft failure or rejection.
Of the AEFs present in functioning grafts, graft salvage rate was 33% from available data. Coil embolization or use of haemostatic compressed sponge as primary intervention was associated with a higher rate of re-bleeding and death versus arterial stenting. Arterial stenting resulted in a higher rate of distal ischaemia requiring surgical re-vascularisation.
All deaths occurred in patients who did not have a transplant pancreatectomy as part of their definitive treatment.
IR can be an effective way to manage bleeding in the context of AEF associated with pancreas transplantation. If patient condition allows, it should be the first-choice intervention to manage AEF associated bleeding. Use of arterial stenting is more effective in controlling and preventing further bleeding. In a non-functioning graft, transplant pancreatectomy should be strongly considered, possibly in conjunction with or following arterial stenting.
Applicability and reproducibility of the CPAT-grading system for pancreas allograft thrombosis
2021, European Journal of Radiology
Citation Excerpt :
A recent study showed 1- and 2-years patient survival rates of almost 100 % and 1- and 2-year graft survival rates over 80 % in deceased-after-brain-death (DBD) organs and over 90 % in deceased-after-circulatory-death (DCD) organs [1]. Technical failure is the leading cause for early graft loss in pancreas transplantation [2–6]. Pancreas allograft thrombosis (PAT), which is the most frequent surgical complication and responsible for 29 % of all early graft loss, remains an unsolved problem and usually results in graft loss [7,8].
: Although pancreas allograft thrombosis (PAT) incidence has progressively decreased, it remains the most common cause of early graft failure. Currently, there is no consensus on documentation of PAT, which has resulted in a great variability in reporting. The Cambridge Pancreas Allograft Thrombosis (CPAT) grading system has recently been developed for classification of PAT. In this study we aimed to assess the applicability and validate the reproducibility of the CPAT grading system.
: This study is a retrospective cohort study. Selected for this study were all 177 pancreas transplantations performed at our center between January 1 st, 2008 and September 1 st, 2018 were included.
: A total of 318 Computed Tomography (CT) images was reevaluated according the CPAT system by two local radiologists. Inter-rater agreement expressed in Cohen’s kappa was 0.403 for arterial and 0.537 for venous thrombosis. Inter-rater agreement, expressed in the Fleiss’ kappa, within clinically relevant thrombosis categories was 0.626 for Grade 2 and 0.781 for Grade 3 venous thrombosis.
: Although not perfect, we believe that implementation of the CPAT system would improve current documentation on PAT. However, it is questionable whether identification of a small Grade 1 thrombosis would be relevant in clinical practice.
Furthermore, a good quality CT scan, including adequate phasing, is essential to accurately identify potential thrombus and extend after pancreas transplantation.
Gray-scale, Doppler and contrast-enhanced ultrasound in pancreatic allograft surveillance: A systematic literature review
2019, Transplantation Reviews
Gray scale ultrasound (US), Doppler and Contrast Enhanced Ultrasound (CEUS) represent important surveillance tools in the early post-operative period after pancreas transplantation (PTx), when complications are more common. This review summarizes the available evidence on their clinical application in this setting.
We searched the Pub-Med database from inception to October 2018 for English literature on the clinical use of US, Doppler and CEUS in the post-PTx surveillance. Article selection was carried out according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria (PRISMA).
Twenty-nine articles concerning the clinical applications of US, Doppler and CEUS were identified, 13 of which, involving 264 patients, were focused on the sonographic findings in immunologic rejection, whereas 11 studies reporting on 887 patients were focused on post-PTx vascular complications. The remaining five articles, involving a total of 196 patients, described US or CEUS applied in the study of pancreatic morphology and texture to diagnose peri-graft fluids collections or to obtain experimental data on allograft endocrine function.
US, Doppler and CEUS have proven to be valuable assets in post-PTx follow up, thanks to the combination of their non-invasiveness with a high accuracy in the detection of early abnormalities, in particular regarding vascular complications. Preliminary experiences are directing towards functional research; however, future prospective trials are necessary to precisely correlate organ perfusion, early abnormalities and allograft function.
Bladder-Drained Pancreas Transplantation: Urothelial Innate Defenses and UTI Susceptibility
2019, Journal of Surgical Research
Pancreas transplantation restores insulin secretion in type 1 diabetes mellitus. The graft also produces exocrine secretions that can be drained enterically (enteric drainage [ED]) or via the bladder (bladder drainage [BD]). We suggest that in BD transplants, such secretions destroy bladder innate immunity, specifically host defense peptides/proteins (HDPs), which increases patient susceptibility to recurrent urinary tract infections (rUTIs).
BD and ED patient records were reviewed retrospectively for UTIs. Urine samples from ED and BD transplant recipients were analyzed for pH, the HDPs β-defensin 2 (HBD2) and lipocalin-2, and amylase concentrations. In vitro, bacterial growth curves and antimicrobial assays were used to evaluate the effects of pH, HBD2, and HBD2 + pancreatic digestive enzymes (pancreatin) on uropathogenic Escherichia coli (UPEC) survival and growth.
Urinalysis revealed a significant difference in pH between the BD and ED cohorts (7.2 ± 0.8 versus 6.7 ± 0.8; P = 0.012). Urinary HDPs were measured and BD, but not ED, lipocalin-2 concentrations were significantly decreased compared with those of diabetics awaiting transplant (P < 0.05). In vitro, an alkaline environment, pH 8.0, concomitant with the urine of the patient who underwent BD transplantation, significantly reduced UPEC growth (P < 0.05); addition of pancreatin to the growth medium was associated with a significant increase (P < 0.001) in growth rate. Antimicrobial data suggested significant UPEC killing in the presence of HBD2 (P < 0.01), but not in the presence of HBD2 + pancreatin (>12,500 amylase units).
These in vivo and in vitro data suggest that BD pancreatic exocrine secretions inactivate the bladder innate defenses, which facilitate UPEC growth and underpins the increased susceptibility of patients who underwent BD pancreas transplantation to rUTIs.
Technical complications of pancreas allotransplantation
2019, Transplantation, Bioengineering, and Regeneration of the Endocrine Pancreas: Volume 1
Surgical complications have had a tremendous impact on the evolution of pancreas transplantation, with refined surgical techniques and management practices producing global improvements in complication rates overtime. Despite this, complications following pancreas transplantation remain prevalent and highly relevant, as it can lead to graft loss, morbidity, mortality, and increased health-care costs. Optimizing outcomes begins with well-selected candidates and donors, with ongoing care needed at the time of organ procurement, during the transplantation operation and in postoperative patient management. Graft thrombosis continues to be the leading cause of technical failure in the current era, with anastomotic leaks, pancreatitis, bleeding, infection, metabolic derangements, gastrointestinal, and urologic complications also contributing to poor outcomes.

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Pancreas transplantationRelaparotomy After Pancreas Transplantation: Causes and Outcomes

Abstract

Introduction

Patients and methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Transplant Proc

Transplant Proc

J Am Coll Surg

Transplant Proc

Decreased surgical risks of pancreas transplantation in the modern era

Ann Surg

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Relaparotomy After Pancreas Transplantation: Causes and Outcomes