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World J Transplant. Jun 24, 2016; 6(2): 255-271
Published online Jun 24, 2016. doi: 10.5500/wjt.v6.i2.255
Exocrine drainage in vascularized pancreas transplantation in the new millennium
Hany El-Hennawy, Robert J Stratta, Fowler Smith
Hany El-Hennawy, Robert J Stratta, Fowler Smith, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
Author contributions: El-Hennawy H and Stratta RJ studier conception, designs, acquisition of data, analysis and interpretation of data; all the authors do drafting of manuscript and critical revision.
Conflict-of-interest statement: The authors acknowledge that the above manuscript represents original work that has not been previously published or submitted for publication. There are no conflicts of interest, grant support, sponsorship, or other financial arrangements to report by any of the authors.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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/
Correspondence to: Dr. Robert J Stratta, MD, Department of Surgery, Wake Forest School of Medicine, One Medical Center Blvd, Winston-Salem, NC 27157, United States. rstratta@wakehealth.edu
Telephone: +1-336-7160548 Fax: +1-336-7135055
Received: February 16, 2016
Peer-review started: February 16, 2016
First decision: March 1, 2016
Revised: May 6, 2016
Accepted: May 31, 2016
Article in press: June 2, 2016
Published online: June 24, 2016
Processing time: 127 Days and 11.4 Hours
Abstract

The history of vascularized pancreas transplantation largely parallels developments in immunosuppression and technical refinements in transplant surgery. From the late-1980s to 1995, most pancreas transplants were whole organ pancreatic grafts with insulin delivery to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). The advent of bladder drainage revolutionized the safety and improved the success of pancreas transplantation. However, starting in 1995, a seismic change occurred from bladder to bowel exocrine drainage coincident with improvements in immunosuppression, preservation techniques, diagnostic monitoring, general medical care, and the success and frequency of enteric conversion. In the new millennium, pancreas transplants are performed predominantly as pancreatico-duodenal grafts with enteric diversion of the pancreatic ductal secretions coupled with iliac vein provision of insulin (systemic-enteric technique) although the systemic-bladder technique endures as a preferred alternative in selected cases. In the early 1990s, a novel technique of venous drainage into the superior mesenteric vein combined with bowel exocrine diversion (portal-enteric technique) was designed and subsequently refined over the next ≥ 20 years to re-create the natural physiology of the pancreas with first-pass hepatic processing of insulin. Enteric drainage usually refers to jejunal or ileal diversion of the exocrine secretions either with a primary enteric anastomosis or with an additional Roux limb. The portal-enteric technique has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion. Reports in the literature suggest no differences in pancreas transplant outcomes irrespective of type of either venous or exocrine diversion. The purpose of this review is to examine the literature on exocrine drainage in the new millennium (the purported “enteric drainage” era) with special attention to technical variations and nuances in vascularized pancreas transplantation that have been proposed and studied in this time period.

Keywords: Pancreas transplantation; Portal-enteric drainage; Simultaneous pancreas-kidney transplant; Systemic-bladder drainage; Enteric conversion; Solitary pancreas transplant; Systemic-enteric drainage

Core tip: The history of vascularized pancreas transplantation largely parallels advances in surgical techniques. Prior to 1995, most pancreas transplants were performed with delivery of insulin to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). Starting in 1995, however, a seismic change occurred from bladder to bowel drainage of the pancreatic secretions that was spurred in part by the success of enteric conversion. In the new millennium, most pancreas transplants are performed as pancreatico-duodenal grafts with either iliac vein and bowel exocrine diversion (systemic-enteric technique) or portal-enteric drainage. With refinements in surgical techniques, exocrine drainage is no longer considered the “Achilles’ heel” of pancreas transplantation.