CHAPTER 106: Non-Urological Complications of Pancreas Transplantation

CAUSES OF GRAFT LOSS:

• Thrombosis: 30%

• Chronic rejection: 20%

• Acute rejection: 15%

REJECTION

• Acute rejection is characterized by the presence of activated inflammatory cells in the parenchyma, in association with vascular and glandular injury.

• Chronic rejection is characterized by atrophy and fibrosis of acini, vessels, and ducts.

• There is currently no rejection serum/plasma marker with satisfactory sensitivity and specificity – urinary amylase levels (in bladder-drained pancreases) are of the best practical value.

• Biopsy represents the gold standard for diagnosis of pancreas graft rejection.

• Surrogate markers (e.g., serum amylase levels, serum lipase levels, blood glucose levels, and C-peptide levels) have limited sensitivity and/or specificity.

• Decreases in urinary amylase (in bladder-drained grafts) are usually consistent with rejection, but could also be due to other etiologies such as drug toxicity and pancreatitis.

• Acute cellular rejection is usually treated with high-dose steroids with or without anti-thymocyte globulin

BIOPSY:

• 3% incidence of complications

• 12% incidence of non-diagnosis

PANCREATIC GRAFT IMAGING

• CT scanning and MRI imaging provide complete evaluation of the graft parenchyma, ducts, vessels, anastomoses, and intestinal status.

• The use of intravenous contrast should be carefully considered particularly in patients who received a simultaneous or previous kidney transplant.

• Duplex Doppler evaluation can be impaired by the presence of air-filled intestinal loops.

• The role of angiography is diminished due to CTA/MRA/MRV availability.

• Percutaneous drainage and other interventions are of great use in addressing specific complications.

POTENTIAL COMPLICATIONS

• In order to prevent unnecessary graft injury, we do every possible effort to minimize cold (preservation) and warm (implantation) ischemic times.

• The inherent low blood flow of the pancreas makes it prone to thrombosis.

• Hemorrhage is not an infrequent complication, especially when heparin is administered.

• Complications include:

  • abscesses,

  • bleeding,

  • graft pancreatitis (as opposed to general surgery theories, none of these cases of pancreatitis are associated with gallstones),

  • infections,

  • intestinal ischemia,

  • leaks,

  • peritonitis,

  • pseudocysts,

  • rejection,

  • small bowel obstruction,

  • other.

  • Recipients can also develop complications (as a result of interventions) that represent exacerbations of preexisting comorbidities unrelated to the transplant graft itself.

COMPLICATIONS ASSOCIATED WITH ENTERIC-DRAINED PANCREATIC TRANSPLANTS

• Leaks and intra-abdominal abscesses

  • Usually manifested by infectious/septic findings

  • Diagnosis is based on clinical findings in conjunction with imaging studies

  • Treatment involves eradication of the septic focus and correction of the underlying pathology, including:

    • Drainage of abscesses

    • An initial period of nonsurgical treatment can be considered in instances where the infection is controlled

    • Revision of the anastomosis

    • Removal of the pancreas transplant (very infrequent)

  • Monitor for the presence of infectious pseudoaneurysms (life-threatening complication that usually requires removal of the pancreatic graft and repair of the involved recipient vessels)

• Anastomotic bleeds

  • Usually self-limited

  • Correct any predisposing factors such as anticoagulation

  • Rarely require surgical intervention

VASCULAR COMPLICATIONS

• Thrombosis of ...