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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 ...

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