Exocrine pancreas graft drainage in recipient duodenum through side‐to‐side duodeno‐duodenostomy

The interesting report by Hummel et al. in the Februaryissue of this Journal [1] conﬁrmed our previouspublication indicating that, in pancreas transplantation,side-to-side duodeno-duodenal anastomosis is technicallyfeasible and allows easy access to the graft duodenalmucosa for repeated biopsies and rejection monitoring[2]. In our experience we prefer to anastomose the graftportal vein to the infrapancreatic superior mesenteric veinsimilarly to the technique described by Boggi et al. [3]. With this procedure, the pancreas graft is positioned in apure retroperitoneal and physiologic location for bothendocrine and exocrine drainage, but it is uncertain ifthis fact has any inﬂuence on the functional results of thetransplantation.The main drawback of this technique is the potentialfor anastomotic leak that could be challenging to controlas the recipient duodenum cannot be resected. Directduodenal repair, plasty with a Roux-en-Y limb, orlaterolateral duodenojejunostomy may be surgical optionsto achieve recipient duodenal closure in case of anasto-motic leak [2]. We considered using this technique in our last ﬁvepancreas transplantations (three pancreas alone and twosimultaneous pancreas-kidney transplantations). In fourpatients, side-to-side duodeno-duodenal anastomosis wasperformed (three manually and one with a circularstapling device, according to the surgeon’s preference). Immunosuppression consisted of quadruple therapy,including induction with polyclonal antibodies andmaintenance with tacrolimus, mycophenolate mofetil andlow-dose steroids. These patients underwent regularprotocol duodenal biopsies, without any evidence of acuteor chronic rejection. Pancreas graft and patient survival is100% at follow-up. One patient required two re-laparoto-mies, for early non-infected peripancreatic hematoma andfor late (>6 months) mechanical intestinal occlusion. Nopatient experienced any complication linked to theduodenal anastomosis or to the vascular reconstruction.In the ﬁfth patient recipient of simultaneous pancreas-kidney transplantation, pancreas graft duodenum wasfound to be badly preserved at reperfusion, and we thenchose to perform duodenal drainage through a Roux-en-Y jejunal limb. This patient developed anastomoticleakage requiring life-saving pancreas graft resection afterthree unsuccessful attempts of surgical correction.This small series of duodeno-duodenal drainage ofpancreas grafts, and the case described by Hummel,provide some evidence that this technique is feasible,appears to be safe in pancreas grafts with good duodenalpreservation, and provides easy access of the duodenalmucosa for rejection monitoring. All these pancreas graftsare functioning perfectly and did not develop any episodeof rejection. These promising results need to beconﬁrmed by larger series and controlled comparisonwith classical enteric drainage.Arnaud De Roover, Olivier Detry,Carla Coimbra, Jean-Paul Squifﬂet,Pierre Honore´ and Michel MeurisseDepartment of Abdominal Surgeryand Transplantation,University of Liege,Liege, BelgiumReferences1. Hummel R, Langer M, Wolters HH, Senninger N, Brock-mann JG. Exocrine drainage into the duodenum: a noveltechnique for pancreas transplantation. Transpl Int 2008;21: 178.2. De Roover A, Coimbra C, Detry O, et al. Pancreas graftdrainage in recipient duodenum: preliminary experience.Transplantation 2007; 84: 795.3. Boggi U, Vistoli F, Signori S, et al. A technique forretroperitoneal pancreas transplantation with portal-entericdrainage. Transplantation 2005; 79: 1137.