Conversion from bladder to enteric drainage after pancreaticoduodenal transplantations

Abstract

Background: Bladder drainage is the most common technique for managing the exocrine secretions of pancreaticoduodenal grafts. However, bladder drainage can cause urinary, pancreatic, and metabolic complications that may require conversion to enteric drainage. With enteric drainage, urinary amylase levels cannot be monitored as a marker for rejection. After enteric conversion, rejection is the major cause of graft loss. Timing the conversion to reduce immunologic graft loss would greatly improve patient and graft survival rates. Our study was designed to assess the incidence of, indications for, and complications of converting from bladder to enteric drainage after pancreaticoduodenal transplantations.

Methods: We retrospectively reviewed our experience with 80 recipients who underwent enteric conversion. We studied the recipient category, the interval from transplantation to conversion, the interval from the last rejection episode to conversion, the indications for conversion, the type of enteric drainage at conversion (loop versus Roux-en-Y), the results of the conversion, and postconversion complications.

Results: The major indications for conversion were metabolic acidosis (n = 26, 33%), recurrent urinary tract infections (UTIs) (n = 16, 20%), reflux pancreatitis (n = 15, 19%), and hematuria (n = 12, 15%). For most recipients, their symptoms resolved after conversion (n = 76, 95%). The cumulative probability of undergoing conversion was 13% at 12 months, 21% at 36 months, and 25% at 60 months. Of the recipients with surgical complications after conversion (n = 12, 15%), one lost his graft as a result of pancreatitis. Overall, of the 80 recipients who underwent conversion, 12 (15%) lost their graft, most due to rejection (n = 8, 75%). Immunologic graft loss was highest for recipients of pancreas transplants alone who underwent conversion < or = 6 months after transplantation or < or = 1 year after their last rejection episode.

Conclusions: Enteric conversion is safe and therapeutic in recipients with complications related to the exocrine secretions of bladder-drained pancreas grafts. After conversion, rejection accounted for 75% of the grafts lost. However, waiting at least 1 year after the last rejection episode significantly reduced immunologic graft loss.