Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants

Edic Stephanian, Rainer W G Gruessner, Kenneth L. Brayman, Paul Gores, David L. Dunn, John S. Najarian, David E R Sutherland

Research output: Contribution to journalArticle

55 Citations (Scopus)

Abstract

Between September 1984 and August 1991, 265 whole pancreaticoduodenal transplants were done at our institution, with bladder drainage of exocrine secretions through a duodenocystostomy. Seventeen patients subsequently underwent conversion from bladder to enteric drainage at 2 to 64 months after transplant. Eight conversion procedures were done to correct chronic intractable metabolic acidosis due to bicarbonate loss from the allograft: seven to alleviate severe dysuria, presumed secondary to the action of graft enzymes on uroepithelium; one to prevent recurrent allograft pancreatitis, presumed secondary to back pressure from the bladder; and one because of graft duodenectomy for severe cytomegalovirus duodenitis with perforation. None were done to correct technical complications from the initial transplant operation. The conversions were done by dividing the graft duodenocystostomy, then re-establishing drainage through a graft duodenal-recipient jejunal anastomosis. A simple loop of recipient jejunum was used for the duodenojejunostomy in 15 cases, and a Roux limb in two. One of those two cases had a previously created Roux limb that was available for use. The other was in the patient who underwent graft duodenectomy and subsequent mucosa-to-mucosa anastomosis of the pancreatic duct to a newly created Roux limb of jejunum. All patients experienced relief of their symptoms after operation. Two patients had surgical complications (12%), an enterotomy in one case, which was closed operatively, and an enterocutaneous fistula in the other case, which healed spontaneously with bowel rest and parenteral nutrition. The drawback to conversion is loss of urine amylase as a marker for rejection, particularly in recipients of solitary pancreas grafts (n = 5). In recipients of simultaneous pancreas-kidney (SPK) allografts (n = 12), the kidney can still be used to monitor for rejection (two with follow-up <1 year, 10 with follow-up >1 year). None of our solitary pancreas recipients, however, have lost graft function (follow-up, 10 to 36 months). The only pancreas allograft loss was in an SPK recipient who also rejected the kidney 6 months after conversion. She received a second SPK transplant with enteric drainage, and is insulin independent and normoglycemic 10 months after retransplantation. Patients converted for metabolic acidosis tended to have impaired renal function (mean creatinine, 2.14 ± 0.98 mg/dL at time of conversion) due to chronic rejection, progression of native kidney diabetic nephropathy, or cyclosporine toxicity, and possibly could not compensate for bicarbonate loss from the pancreas allograft. The authors conclude that cystoenteric conversion of pancreas allografts is safe and therapeutic for intractable metabolic acidosis and dysuria in patients with stable pancreas graft function, and can be done with a low risk of subsequent rejection.

Original languageEnglish (US)
Pages (from-to)663-672
Number of pages10
JournalAnnals of Surgery
Volume216
Issue number6
StatePublished - 1992
Externally publishedYes

Fingerprint

Drainage
Urinary Bladder
Transplants
Pancreas
Allografts
Kidney
Acidosis
Dysuria
Extremities
Jejunum
Bicarbonates
Mucous Membrane
Duodenitis
Intestinal Fistula
Pancreatic Ducts
Parenteral Nutrition
Diabetic Nephropathies
Amylases
Cytomegalovirus
Pancreatitis

ASJC Scopus subject areas

  • Surgery

Cite this

Stephanian, E., Gruessner, R. W. G., Brayman, K. L., Gores, P., Dunn, D. L., Najarian, J. S., & Sutherland, D. E. R. (1992). Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants. Annals of Surgery, 216(6), 663-672.

Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants. / Stephanian, Edic; Gruessner, Rainer W G; Brayman, Kenneth L.; Gores, Paul; Dunn, David L.; Najarian, John S.; Sutherland, David E R.

In: Annals of Surgery, Vol. 216, No. 6, 1992, p. 663-672.

Research output: Contribution to journalArticle

Stephanian, E, Gruessner, RWG, Brayman, KL, Gores, P, Dunn, DL, Najarian, JS & Sutherland, DER 1992, 'Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants', Annals of Surgery, vol. 216, no. 6, pp. 663-672.
Stephanian, Edic ; Gruessner, Rainer W G ; Brayman, Kenneth L. ; Gores, Paul ; Dunn, David L. ; Najarian, John S. ; Sutherland, David E R. / Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants. In: Annals of Surgery. 1992 ; Vol. 216, No. 6. pp. 663-672.
@article{55efd67ab37247f6bce81571b62a4c49,
title = "Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants",
abstract = "Between September 1984 and August 1991, 265 whole pancreaticoduodenal transplants were done at our institution, with bladder drainage of exocrine secretions through a duodenocystostomy. Seventeen patients subsequently underwent conversion from bladder to enteric drainage at 2 to 64 months after transplant. Eight conversion procedures were done to correct chronic intractable metabolic acidosis due to bicarbonate loss from the allograft: seven to alleviate severe dysuria, presumed secondary to the action of graft enzymes on uroepithelium; one to prevent recurrent allograft pancreatitis, presumed secondary to back pressure from the bladder; and one because of graft duodenectomy for severe cytomegalovirus duodenitis with perforation. None were done to correct technical complications from the initial transplant operation. The conversions were done by dividing the graft duodenocystostomy, then re-establishing drainage through a graft duodenal-recipient jejunal anastomosis. A simple loop of recipient jejunum was used for the duodenojejunostomy in 15 cases, and a Roux limb in two. One of those two cases had a previously created Roux limb that was available for use. The other was in the patient who underwent graft duodenectomy and subsequent mucosa-to-mucosa anastomosis of the pancreatic duct to a newly created Roux limb of jejunum. All patients experienced relief of their symptoms after operation. Two patients had surgical complications (12{\%}), an enterotomy in one case, which was closed operatively, and an enterocutaneous fistula in the other case, which healed spontaneously with bowel rest and parenteral nutrition. The drawback to conversion is loss of urine amylase as a marker for rejection, particularly in recipients of solitary pancreas grafts (n = 5). In recipients of simultaneous pancreas-kidney (SPK) allografts (n = 12), the kidney can still be used to monitor for rejection (two with follow-up <1 year, 10 with follow-up >1 year). None of our solitary pancreas recipients, however, have lost graft function (follow-up, 10 to 36 months). The only pancreas allograft loss was in an SPK recipient who also rejected the kidney 6 months after conversion. She received a second SPK transplant with enteric drainage, and is insulin independent and normoglycemic 10 months after retransplantation. Patients converted for metabolic acidosis tended to have impaired renal function (mean creatinine, 2.14 ± 0.98 mg/dL at time of conversion) due to chronic rejection, progression of native kidney diabetic nephropathy, or cyclosporine toxicity, and possibly could not compensate for bicarbonate loss from the pancreas allograft. The authors conclude that cystoenteric conversion of pancreas allografts is safe and therapeutic for intractable metabolic acidosis and dysuria in patients with stable pancreas graft function, and can be done with a low risk of subsequent rejection.",
author = "Edic Stephanian and Gruessner, {Rainer W G} and Brayman, {Kenneth L.} and Paul Gores and Dunn, {David L.} and Najarian, {John S.} and Sutherland, {David E R}",
year = "1992",
language = "English (US)",
volume = "216",
pages = "663--672",
journal = "Annals of Surgery",
issn = "0003-4932",
publisher = "Lippincott Williams and Wilkins",
number = "6",

}

TY - JOUR

T1 - Conversion of exocrine secretions from bladder to enteric drainage in recipients of whole pancreaticoduodenal transplants

AU - Stephanian, Edic

AU - Gruessner, Rainer W G

AU - Brayman, Kenneth L.

AU - Gores, Paul

AU - Dunn, David L.

AU - Najarian, John S.

AU - Sutherland, David E R

PY - 1992

Y1 - 1992

N2 - Between September 1984 and August 1991, 265 whole pancreaticoduodenal transplants were done at our institution, with bladder drainage of exocrine secretions through a duodenocystostomy. Seventeen patients subsequently underwent conversion from bladder to enteric drainage at 2 to 64 months after transplant. Eight conversion procedures were done to correct chronic intractable metabolic acidosis due to bicarbonate loss from the allograft: seven to alleviate severe dysuria, presumed secondary to the action of graft enzymes on uroepithelium; one to prevent recurrent allograft pancreatitis, presumed secondary to back pressure from the bladder; and one because of graft duodenectomy for severe cytomegalovirus duodenitis with perforation. None were done to correct technical complications from the initial transplant operation. The conversions were done by dividing the graft duodenocystostomy, then re-establishing drainage through a graft duodenal-recipient jejunal anastomosis. A simple loop of recipient jejunum was used for the duodenojejunostomy in 15 cases, and a Roux limb in two. One of those two cases had a previously created Roux limb that was available for use. The other was in the patient who underwent graft duodenectomy and subsequent mucosa-to-mucosa anastomosis of the pancreatic duct to a newly created Roux limb of jejunum. All patients experienced relief of their symptoms after operation. Two patients had surgical complications (12%), an enterotomy in one case, which was closed operatively, and an enterocutaneous fistula in the other case, which healed spontaneously with bowel rest and parenteral nutrition. The drawback to conversion is loss of urine amylase as a marker for rejection, particularly in recipients of solitary pancreas grafts (n = 5). In recipients of simultaneous pancreas-kidney (SPK) allografts (n = 12), the kidney can still be used to monitor for rejection (two with follow-up <1 year, 10 with follow-up >1 year). None of our solitary pancreas recipients, however, have lost graft function (follow-up, 10 to 36 months). The only pancreas allograft loss was in an SPK recipient who also rejected the kidney 6 months after conversion. She received a second SPK transplant with enteric drainage, and is insulin independent and normoglycemic 10 months after retransplantation. Patients converted for metabolic acidosis tended to have impaired renal function (mean creatinine, 2.14 ± 0.98 mg/dL at time of conversion) due to chronic rejection, progression of native kidney diabetic nephropathy, or cyclosporine toxicity, and possibly could not compensate for bicarbonate loss from the pancreas allograft. The authors conclude that cystoenteric conversion of pancreas allografts is safe and therapeutic for intractable metabolic acidosis and dysuria in patients with stable pancreas graft function, and can be done with a low risk of subsequent rejection.

AB - Between September 1984 and August 1991, 265 whole pancreaticoduodenal transplants were done at our institution, with bladder drainage of exocrine secretions through a duodenocystostomy. Seventeen patients subsequently underwent conversion from bladder to enteric drainage at 2 to 64 months after transplant. Eight conversion procedures were done to correct chronic intractable metabolic acidosis due to bicarbonate loss from the allograft: seven to alleviate severe dysuria, presumed secondary to the action of graft enzymes on uroepithelium; one to prevent recurrent allograft pancreatitis, presumed secondary to back pressure from the bladder; and one because of graft duodenectomy for severe cytomegalovirus duodenitis with perforation. None were done to correct technical complications from the initial transplant operation. The conversions were done by dividing the graft duodenocystostomy, then re-establishing drainage through a graft duodenal-recipient jejunal anastomosis. A simple loop of recipient jejunum was used for the duodenojejunostomy in 15 cases, and a Roux limb in two. One of those two cases had a previously created Roux limb that was available for use. The other was in the patient who underwent graft duodenectomy and subsequent mucosa-to-mucosa anastomosis of the pancreatic duct to a newly created Roux limb of jejunum. All patients experienced relief of their symptoms after operation. Two patients had surgical complications (12%), an enterotomy in one case, which was closed operatively, and an enterocutaneous fistula in the other case, which healed spontaneously with bowel rest and parenteral nutrition. The drawback to conversion is loss of urine amylase as a marker for rejection, particularly in recipients of solitary pancreas grafts (n = 5). In recipients of simultaneous pancreas-kidney (SPK) allografts (n = 12), the kidney can still be used to monitor for rejection (two with follow-up <1 year, 10 with follow-up >1 year). None of our solitary pancreas recipients, however, have lost graft function (follow-up, 10 to 36 months). The only pancreas allograft loss was in an SPK recipient who also rejected the kidney 6 months after conversion. She received a second SPK transplant with enteric drainage, and is insulin independent and normoglycemic 10 months after retransplantation. Patients converted for metabolic acidosis tended to have impaired renal function (mean creatinine, 2.14 ± 0.98 mg/dL at time of conversion) due to chronic rejection, progression of native kidney diabetic nephropathy, or cyclosporine toxicity, and possibly could not compensate for bicarbonate loss from the pancreas allograft. The authors conclude that cystoenteric conversion of pancreas allografts is safe and therapeutic for intractable metabolic acidosis and dysuria in patients with stable pancreas graft function, and can be done with a low risk of subsequent rejection.

UR - http://www.scopus.com/inward/record.url?scp=0026443925&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0026443925&partnerID=8YFLogxK

M3 - Article

C2 - 1466620

AN - SCOPUS:0026443925

VL - 216

SP - 663

EP - 672

JO - Annals of Surgery

JF - Annals of Surgery

SN - 0003-4932

IS - 6

ER -