Successful embolization of a cytomegalovirus-related duodenal ulcer in a kidney-pancreas transplant recipient

Radiological initial treatment of vascular catastrophes in pancreas transplantation: Review of current literature

BACKGROUND

Arterio-enteric fistula (AEF) is a rare but potentially devastating complication of solid organ pancreatic transplantation. Traditional management has been to remove the pancreas-duodenum allograft and control the vascular defect. Interventional radiological (IR) techniques present a new method of managing AEF related haemorrhage without re-operation and the potential to preserve graft function. This paper examines the available literature to assess efficacy and safety of this novel approach.

METHODS

Aggregate results tables were constructed from 28 cases identified in the English language literature where IR was used in the management of AEF following pancreas transplantation. Outcomes recorded were death, re-bleeding, surgical intervention required and post intervention graft function. These were analysed with respect to technical factors and graft function at time of presentation.

RESULTS

28 cases of AEF managed by IR methods were identified. Mortality was high at 17.9%. 78.6% of all AEFs were present in failed pancreas allografts. Median time from transplant to bleeding event was 29 months. There was a trend of bleeding event occurring within 12 months of allograft failure or rejection. Of the AEFs present in functioning grafts, graft salvage rate was 33% from available data. Coil embolization or use of haemostatic compressed sponge as primary intervention was associated with a higher rate of re-bleeding and death versus arterial stenting. Arterial stenting resulted in a higher rate of distal ischaemia requiring surgical re-vascularisation. All deaths occurred in patients who did not have a transplant pancreatectomy as part of their definitive treatment.

CONCLUSION

IR can be an effective way to manage bleeding in the context of AEF associated with pancreas transplantation. If patient condition allows, it should be the first-choice intervention to manage AEF associated bleeding. Use of arterial stenting is more effective in controlling and preventing further bleeding. In a non-functioning graft, transplant pancreatectomy should be strongly considered, possibly in conjunction with or following arterial stenting.

Late recurrent bleeding episodes from duodenojejunostomy after pancreas transplantation

In response to a number of late, repetitive bleeding episodes from the site of the enteric anastomosis, we herein analyze the clinical courses and etiologies of 379 consecutively performed pancreas transplants between January 2000 and December 2016. Duodenojejunostomies for enteric drainage were performed at the upper jejunum in a side to side, double layer fashion. Five patients (1.3%) developed recurrent late hemorrhagic episodes originating from the graft duodenal anastomosis. Bleeding from the anastomotic site was associated with hematochezia, hemodynamic instability and decrease in serum hemoglobin. Mean onset was 6.4(±2.8) years after transplantation. Bleeding was recurrent (mean 5.2 ± 2.6) and required 9(±2.5) interventions. Hypervascularization, mucosal vulnerability, and bleeding at the site of the enteric anastomosis could be identified in all cases. In four patients, the enteric pancreas anastomosis was resected and a new duodenojejunostomy was performed. No pancreas graft loss occurred due to bleeding. In two patients, hepatic cirrhosis and portal hypertension were identified, one patient had a liver fibrosis as putative cause for the repetitive bleeding episodes. Late anastomotic hemorrhage is a rare but severe complication following pancreas transplantation. The treatment is challenging and includes endoscopy, interventional radiology, and surgery. Hepatic conditions with an increased portal pressure may be the underlying cause.