Surgical Science, 2011, 2, 1-4
doi:10.4236/ss.2011.21001 Published Online January 2011 (
Copyright © 2011 SciRes. SS
Pancreas Transplant Salvage by Proximal Loop Ileostomy
and Distal Ileostotomy Tube for Duodenal Stump Leak
after Enteric Conversion
Monroy-Cuadros Mauricio, Rodriguez-Velez Cesar
Division of Transplantation, Department of Surgery, Foothills Medical Centre,
Calgary, AB, Canada
Received August 26, 2010; revised October 30, 2010; accept November 20, 2010
After pancreas transplantation, som e patients with bladder drainage (BD) of the pancreatic duct will need to be
converted to enteric drainage (ED) because of reflux pancreatitis, metabolic acidosis, and urological compli-
cations. However, ED is associated with higher rates of duodenal stump leak, intra-abdominal abscess, and
peritonitis. In some cases of enteric anastomosis leakage, a primary repair can be attempted, but in more se-
vere cases, graft pancreatectomy is indicated. We report one patient who received a combined kidney and
pancreas transplant with BD of exocrine secretions, but who required ED conversion 6 years later because of
persistent metabolic acidosis and adverse urological symptoms. However, a significant duodenal leak was
discovered 4 days post-operatively. To salvage the transplanted pancreas, we performed a diverting loop
ileostomy proximal to the entero-entero anastomosis and the distal section was drained retrogradely with an
ileostostomy tube, allowing the area of the leak to heal. Three months later, the ileostomy was reversed
without complications, the symptoms that led to the ED conversion resolved, and the kidney and pancreas
allografts remain functional 48 months later. We suggest that this might be a method by which transplanted
pancreas may be salvaged in the case of leakage after ED conversion.
Keywords: Pancreas, Transplant, Conversion leak
1. Introduction
The history of pancreas transplantation has been marked
by surgical complications. In the early era of pancreas
transplantation, 25% of the grafts were lost because of
technical issues [1]. Factors such as advances in preser-
vation techniques, refinements in immunosuppressive
regimens, and the development of surgical techniques
have improved the results and outcomes of the pancreas
transplant. However, pancreas transplantation still has a
higher rate of complications than other organ transplants,
including thrombosis, rejection, surgical complications
[2], infections, and urologic complications [3]. Manage-
ment of pancreatic exocrine secretions has been a matter
of debate for years, and a var i et y of t ech niq ues have been
proposed and abandoned. For decades, bladder drainage
(BD) was the most common method of duct management;
it has the advantage of fewer episodes of sepsis while
providing a means to monitor episodes of rejection
through the measure of urinary amylase [4]. However,
BD is not a physiologic procedur e and is associated with
high morbidity including reflux pancreatitis, metabolic
acidosis, and urological complications [5-7] that are be-
coming the most common indication for conversion to
enteric drainage (ED) [3,5-7]. Up to 25% of patients with
BD will need conversion to ED within 10 years of the
transplant [3,6,8]. ED is a more physiologic technique
with lower incidence of urological complications but is
associated with higher rates of duodenal stump leak, in-
tra-abdominal abscess, and peritonitis [6,9,10]; the rate
of surgical complications after ED conversion is reported
to be 10% to 20% [3,6,11]. Although major leaks from
the enteric anastomosis only occur in 5% to 7% of pa-
tients [10-12], they can represent a high rate of pancre-
atic graft loss [13,14]. In cases of a circumscribed leak, a
primary repair can be attempted, but in more severe cas-
es with significant leak, graft pancreatectomy is indi-
cated in almost 95% of patients [11].
Copyright © 2011 SciRes. SS
We herein report one patient who developed a signifi-
cant duodenal leak after pancreas transplant ED conver-
sion that was salvaged with a pancreas transplant exclu-
sion via a proximal loop ileostomy and distal ileo-
stostomy tube. No postoperative complications were re-
corded, and the patient remains insulin-independent 48
months after the conversion.
2. Methods and Results
The patient is a Caucasian male, who at the age of 14
was diagnosed with type 1 diabetes mellitus, and by the
age of 47 had reached Chronic Renal Failure Stage V
requiring dialysis. The patient received a combined kid-
ney and pancreas transplant with BD of exocrine secre-
tions. Both kidney and pancreas allografts had good renal
and pancreatic function immediately after surgery. The
patient received induction with polyclonal antibodies.
Immunosuppression was maintained with triple therapy
including FK 506, Mycophenolate Mofetil, and steroids.
During the first 18 months after the transplant, the pa-
tient had three biopsy-proven acute rejection episodes
that clinically involv ed the renal allogr aft alone. The first
two rejections were reversed with the use of an-
ti-lymphocyte globulin and the third episode with the use
of steroids.
At 4 years after transplantation, the patient presented
with hematuria on several occasions. Cystoscopy showed
only inflammation and erythema of the urethra. At 6
years after transplantation, the patient had persistent me-
tabolic acidosis and urological symptoms including se-
vere dysuria and intractable burning pain requiring rehy-
dration, sodium bicarbonate replacement, and antibiotics
on a more regular than repetitive basis. An ED conver-
sion was performed without intra-operative complica-
On post-operative day 4 after the ED conversion, the
patient presented with abdominal pain and distention,
and a drainage of intestinal contents was noted through
surgical wound. Exploratory laparotomy found a signifi-
cant duodenal leak with contamination of the abdominal
cavity. The pancreas had a normal appearance, but the
duodenal segment was viable, edematous, and fragile. A
primary closure was attempted, but as the tissues were
inflamed and fragile, a patch of small bowel was use to
cover the anastomosis disruption. We decided to exclude
the pancreas transplant with a diverting loop ileostomy
proximal to the entero-entero anastomosis with the distal
section drained retrogradely with an ileostostomy tube
and drains around the entero-entero anastomosis (Figure
1). During the post-operative time, intestinal transit was
reduced with the use of parenteral nutrition and Octrea-
todide. The postoperative course was uneventful and the
Figure 1. Diagram of the proximal diverting loop ileostomy
and distal ileostomy tube to defunctionalize the pancreas
transplant. The small bowel content was drained through
the ileostomy, and the exocrine secretion of the pancreatic
allograft was collected with the ileostomy tube, creating a
controlled fistula.
patient was discharged home. A contrast enema was done
with no evidence of strictures distal or proximal to the
ileostomy. Three months later, the ileostomy was re-
versed without complications.
After the ED conversion, the symptoms that indicated
the conversion resolved, both kidney and pancreas al-
lografts remain functional at 48 months after the proce-
dure, and the patient remains insulin-independent.
3. Discussion
The vast majority of pancreas transplants are performed
with ED of the exocrine secretions; however, approxi-
mately 20% of transp lant prog rams con tinue to repo rt the
use of BD. Metabolic acidosis, recurrent urinary tract
infections, and reflux pancreatitis are the most common
indications for conversion from BD to ED [6,13]; how-
ever, enteric leaks are a risk after ED. Some authors re-
port that in cases of circumscribed duodenoenteric leak-
age, a primary repair of the leak can be attempted. How-
ever when moderate or severe peritonitis and sepsis is
manifested, graft pancreatectom y is the best option [6].
Several methods have been reported for rescue of the
transplant after enteric leakage. In 2003, Orsenigo et al.
described a surgical technique for management of a du-
odenojejunostomy leakage in four patients by occluding
the main pancreatic duct with a synthetic polymer injec-
tion [15]. In 2009, Ablorsu et al. reported a case where
the graft duodenum was removed and the main pancre-
atic duct was anastomosed to the bladder [16]. In 2010,
Boggi et al. reported a total duodenectomy with enteric
duct drainage for the management of duodenal complica-
Copyright © 2011 SciRes. SS
tions occurring after pancreas transplantation [17]. The
case history described here is unique in several aspects.
In the case reported by Ablorsu, there was a necrosis of
the duodenal segment after reperfusion of the pancreas,
and a duodenectomy with BD was performed; preserva-
tion or reperfusion injuries and edema of the duodenal
stump were important factors that led to this treatment
choice. In our case, the perfusion of the graft was not an
issue, but the important factors were that the patient was
already receiving immunosuppression therapy and the
presence of an intra-abdominal abscess may have had a
high risk for morbidity and mortality. The intraoperative
findings suggested that a primary closure or reanastomo-
sis of the duodenal stump was not a good option given
the degree of inflammation, edema, and contamination
with intestinal contents; however the condition of the
duodenal stump was appropriate and did not require a
duodenectomy as reported by Ablorsu and Boggi.
Our decision to exclude the pancreas transplant was
mainly based on good results of the pyloric exclusion
technique used on the management of pancreatico-duo-
denal complex injuries [18]. Our decision to achieve
pancreatic exclusion through a diverting loop proximal
ileostomy with a distal retrograde ileostostomy tube gave
us the opportunity to divert the intestinal contents
through the ileostomy, allowing the area of the leak to
heal. The exocrine secretions from the pancreas were
collected by the distal ileostomy tube, creating a con-
trolled pancreatic fistula. To our knowledge, this is the
first time this procedure has been used for this circum-
stance. We suggest that proximal diverting loop ileo-
stomy with distal ileostomy tube insertion might be a
method by which transplanted pancreas may be salvaged
in the case of leakage after ED conversion.
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