Transplant International ISSN 0934-0874 ORIGINAL ARTICLE 125 Cases of duodenoduodenostomy in pancreas transplantation: a single-centre experience of an alternative enteric drainage Martin Walter,1 Martin Jazra,1 Stylianos Kykalos,1 Petra Kuehn,1 Stefan Michalski,1 Thomas Klein,2 Andreas Wunsch,1 Richard Viebahn1 and Peter Schenker1 1 Department of General, Visceral and Transplant Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany 2 Department of Medicine I, Marienhospital Herne, Ruhr-University Bochum, Herne, Germany Keywords Summary duodenoduodenostomy, duodenum, enteric drainage, pancreas transplantation. Several exocrine drainage procedures have been successfully developed to perform pancreas transplantation (PT). Retroperitoneal graft placement allows exocrine Correspondence drainage via direct duodenoduodenostomy (DD). This technique provides easy Peter Schenker MD, Department of General, access for endoscopic surveillance and biopsy. A total of 241 PT procedures were Visceral and Transplant Surgery, University performed in our centre between 2002 and 2012. DD was performed in 125 Hospital Knappschaftskrankenhaus Bochum, patients, and duodenojejunostomy (DJ) in 116 patients. We retrospectively com- Ruhr-University Bochum, In der Schornau 23- 25, 44892 Bochum, Germany. pared our experience with these two types of enteric drainage, focusing on graft Tel.: +49 234 2993201; and patient survivals, as well as postoperative complications. With a mean follow- fax: +49 234 2993209; up of 59 months, both groups demonstrated comparable patient and graft surviv- e-mail: [email protected] als. 14 (11%) of 125 cases in the DD group and 21 (18%) of 116 cases in the DJ group had pancreatic graft loss (P = 0.142). Graft thrombosis [5 (4%) vs. 18 Conflicts of interest (16%) P = 0.002], anastomotic insufficiency [2 (1.6%) vs. 8 (7%) P = 0.052] and The authors have declared no conflicts of relaparotomy [52 (41%) vs. 56 (48%) P = 0.29] occurred more frequently in the interest. DJ group, whereas gastrointestinal bleeding [14 (11%) vs. 4 (3%) P = 0.026] Received: 4 February 2014 occurred more often in the DD group. DD is a feasible and safe technique in PT, Revision requested: 20 February 2014 with no increase in enteric complications. It is equivalent to other established Accepted: 14 April 2014 techniques and extends the feasibility of anastomotic sites, especially in recipients Published online: 24 May 2014 who have undergone a second transplantation. doi:10.1111/tri.12337 simultaneous pancreas–kidney (SPK) transplantation Introduction were treated with enteric drainage [2]. The most com- Pancreas transplantation (PT) has undergone remarkable mon method of enteric drainage is performing an anas- development since its first implementation in 1966. It tomosis between the donor duodenum and the recipient has become an accepted therapeutic option for diabetes jejunum, with the pancreas graft in an intraperitoneal mellitus owing to improvements in the procedure, pro- position. This particular method has been modified in gress behind organ conservation and intensive care med- recent years. Boggi et al. [3] achieved excellent results by icine, and the increase in the availability of improved means of a side-to-side duodenojejunostomy (DJ) with immunosuppressants [1]. Regarding surgical techniques, the Roux-en-Y method, including pancreas graft place- the bladder drainage method favoured until the mid- ment in a retroperitoneal position. If the pancreas is 1990s has been increasingly replaced worldwide by placed in the right retrocolic space, a further option is enteric drainage [2]. Enteric drainage of the pancreas direct side-to-side duodenoduodenostomy (DD) [4–8]. graft is considered the current standard method in PT; Gastric-exocrine drainage techniques were also reported hence, in 2010, more than 90% of the patients with [9,10]. © 2014 Steunstichting ESOT 27 (2014) 805–815 805 Duodenoduodenostomy in pancreas transplantation Walter et al. The advantage of DD is that both the small bowel anas- artery, was performed using a donor iliac artery Y-graft. tomosis and the pancreatic head of the graft can be accessed Venous extension graft of the portal vein was not necessary endoscopically. This facilitates biopsy for diagnosis of rejec- in any of the cases examined. tion. In addition, in cases of intestinal bleeding at the anas- All the PT procedures were performed through a median tomotic site, an endoscopic intervention for haemostasis laparotomy for surgical access. In case of planned DJ, the may follow. Possible disadvantages appear in cases of anas- pancreas graft is placed intraperitoneally in a head-up posi- tomotic insufficiency or graft loss because subsequent leaks tion. The venous anastomosis is usually performed first and at the native duodenal site are more difficult to repair. is placed to the proximal superior mesenteric vein, or alter- Because of these potential complications, the safety of natively to the inferior caval vein. The arterial graft is ori- DD has been controversial [5,6,11,12]. However, the few ented caudally through a window made in the ileocecal published reports on this topic generally involve small case mesentery. The arterial anastomosis is created between the sample sizes. Hence, the aim of this study was to review our Y-graft and the recipient’s right common iliac artery (CIA) experience with 125 DD procedures performed after PT. with an end-to-side anastomosis using two half-running We focused on the results and complications of DD in sutures of 5-0 or 6-0 polypropylene. The DJ is placed at the comparison with DJ performed in a group of patients who second jejunal loop level by a two-layer, hand-sewn, side- had undergone PT. to-side anastomosis with running sutures using 4-0 polydi- In this study, we further aimed to describe DD as a surgi- oxanone. cal technique and its development over the years with In case of a planned DD, the right colon is mobilized respect to cases requiring treatment for duodenal leak after and a Kocher manoeuvre is performed. Exploration in the pancreas graft failure and removal. Here, we present data mesenteric root area of the superior mesenteric vein follows from 125 cases of DD in PT, the largest reported series of to assess the feasibility of anastomosis. In case of a small this technique to date. calibre mesenteric vein or distinct mesenteric root steatosis, venous anastomosis is created alternatively to the inferior caval vein. The pancreas is inserted vertically with the head Patients and methods upright. The arterial anastomosis is then created end-to- A total of 241 adult patients underwent PT at our centre side between the donor’s Y-iliac graft and the recipient’s between September 2002 and September 2012. SPK trans- right CIA. After sufficient mobilization of the recipient plantation was performed in 219 patients; pancreas after duodenum, both duodena are approximated side-to-side, kidney (PAK) transplantation, in 16 patients; and PT alone roughly at the level between the second and third portions (PTA), in six patients. All the patients had C-peptide-nega- of the recipient’s duodenum. The external suture line is tive type 1 diabetes. Between 2002 and 2005, DJ became the then applied to the posterior wall using 4-0 polydioxanone standard procedure in our centre. The first DD was then in a running suture style. Subsequently, a 2.5- to 3-cm lon- performed in 2005. Between 2005 and 2007, DD and DJ gitudinal incision of both duodena is made (Fig. 1a). The were applied. Since 2007, DD has been the standard proce- inner layer is performed with a full-thickness running dure in our centre. This produced two groups of patients in suture using 4-0 nonabsorbable polypropylene in conse- our cohort as follows: patients with enteric drainage by DJ quence of the highly vascularized duodenum. Finally, the (n = 116) and those with DD (n = 125), who were analy- second external running suture line of the anterior wall is sed, retrospectively compared and evaluated for postopera- applied, again using 4-0 polydioxanone (Fig. 1b). The tive results and surgical complications. mobilized right colon is returned to its native position, thus completely covering the pancreas and making it a retroperi- toneal organ. We do not routinely perform appendectomy. Operative technique After reperfusion of the pancreatic graft and completion Standard back-table preparation is performed before PT. of the enteric anastomosis in cases of combined pancreas– The spleen is then removed, and the vessels are ligated, as kidney transplantation, the kidney transplantation is per- well as the bile duct and gastroduodenal artery. The donor formed with arterial and venous anastomosis to the recipi- duodenum is reduced to a length of 8–12 cm and closed ent’s left-sided pelvic vessels. Finally, two Jackson–Pratt proximally and distally with a linear stapler. In our drains are inserted routinely. One drain is placed in a retro- approach, these staple lines are inverted with seromuscular peritoneal position beside the pancreas graft, ending behind interrupted stitches using absorbable sutures. The mesen- the DD. A second drainage is positioned on the kidney teric root that was previously transected by staple lines is graft. sewed over in a double-row continuous technique (4-0 In this study, all pancreas transplant operations were polypropylene). Arterial reconstruction of the pancreas performed by a group of five surgeons. In the transition graft, which includes the superior mesenteric