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World J Transplant. Dec 28, 2020; 10(12): 392-403
Published online Dec 28, 2020. doi: 10.5500/wjt.v10.i12.392
Exocrine drainage in pancreas transplantation: Complications and management
Joana Ferrer-Fàbrega, Laureano Fernández-Cruz
Joana Ferrer-Fàbrega, HepatoBiliaryPancreatic Surgery and Liver and Pancreas Transplantation Department, ICMDM, Hospital Clinic Barcelona, University of Barcelona, Barcelona Clinic Liver Cancer Group, August Pi i Sunyer Biomedical Research Institute, Barcelona 08036, Barcelona, Spain
Laureano Fernández-Cruz, Department of Surgery, ICMDM, Hospital Clinic Barcelona, Barcelona 08036, Barcelona, Spain
Author contributions: Ferrer-Fàbrega J and Fernández-Cruz L designed the study, performed the research and analyzed the data; Ferrer-Fàbrega J wrote the manuscript; all authors have read and approved the final manuscript.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Joana Ferrer-Fàbrega, MD, PhD, Associate Professor, Surgeon, HepatoBiliaryPancreatic Surgery and Liver and Pancreas Transplantation Department, ICMDM, Hospital Clinic Barcelona, University of Barcelona, Barcelona Clinic Liver Cancer Group, August Pi i Sunyer Biomedical Research Institute, Carrer de Villarroel, 170, Barcelona 08036, Barcelona, Spain. 2008jff@gmail.com
Received: June 22, 2020
Peer-review started: June 22, 2020
First decision: October 6, 2020
Revised: November 23, 2020
Accepted: December 8, 2020
Article in press: December 8, 2020
Published online: December 28, 2020
Processing time: 184 Days and 13 Hours
Abstract

The aim of this minireview is to compare various pancreas transplantation exocrine drainage techniques i.e., bladder vs enteric. Both techniques have different difficulties and complications. Numerous comparisons have been made in the literature between exocrine drainage techniques throughout the history of pancreas transplantation, detailing complications and their impact on graft and patient survival. Specific emphasis has been made on the early postoperative management of these complications and the related surgical infections and their consequences. In light of the results, a number of bladder-drained pancreas grafts required conversion to enteric drainage. As a result of technical improvements, outcomes of the varied enteric exocrine drainage techniques (duodenojejunostomy, duodenoduodenostomy or gastric drainage) have also been discussed i.e., assessing specific risks vs benefits. Pancreatic exocrine secretions can be drained to the urinary or intestinal tracts. Until the late 1990s the bladder drainage technique was used in the majority of transplant centers due to ease of monitoring urine amylase and lipase levels for evaluation of possible rejection. Moreover, bladder drainage was associated at that time with fewer surgical complications, which in contrast to enteric drainage, could be managed with conservative therapies. Nowadays, the most commonly used technique for proper driving of exocrine pancreatic secretions is enteric drainage due to the high rate of urological and metabolic complications associated with bladder drainage. Of note, 10% to 40% of bladder-drained pancreata eventually required enteric conversion at no detriment to overall graft survival. Various surgical techniques were originally described using the small bowel for enteric anastomosis with Roux-en-Y loop or a direct side-to-side anastomosis. Despite the improvements in surgery, enteric drainage complication rates ranging from 2%-20% have been reported. Treatment depends on the presence of any associated complications and the condition of the patient. Intra-abdominal infection represents a potentially very serious problem. Up to 30% of deep wound infections are associated with an anastomotic leak. They can lead not only to high rates of graft loss, but also to substantial mortality. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage. Duodenoduodenostomy is an interesting option, in which the pancreas is placed behind the right colon and is oriented cephalad. The main concern of this technique is the challenge of repairing the native duodenum when allograft pancreatectomy is necessary. Identification and prevention of technical failure remains the main objective for pancreas transplantation surgeons. In conclusion, despite numerous techniques to minimize exocrine pancreatic drainage complications e.g., leakage and infection, no universal technique has been standardized. A prospective study/registry analysis may resolve this.

Keywords: Graft survival; Patient survival; Anastomotic leak; Morbidity; Infection; Surgery

Core Tip: A review of recent post-transplant complications regarding bladder drainage (urologic complications), enteric drainage (leak), surgical infections and abdominal compartment syndrome.  Although safe and effective, bladder drainage brings metabolic and urologic complications; therefore, physiologic enteric drainage is preferred. Nevertheless, intra-abdominal infections and laparotomies arising from complications may result in significant graft loss. New modifications of established techniques are being developed, such as gastric or duodenal exocrine drainage.  Donor-related factors, preservation injury, and surgical techniques should be managed to minimize adverse post-transplant events.