Introduction

Pancreas transplantation (PT) is a preferable surgical option for diabetes mellitus. However, this procedure is characterized by the highest incidence of early surgical complications compared to transplantation of other organs [1 — 3]. One of the most common complications after PT is pancreatic fluid collections often complicated by infection. These adverse events are associated not only with the loss of pancreatoduodenal graft, but also with high mortality [4]. Surgical debridement and drainage for this complication are not always effective and often require redo interventions which worsen portative outcomes [5, 6]. Percutaneous drainage of pancreatic fluid collections with endoscopic stenting of the main pancreatic duct of pancreatoduodenal graft showed high efficiency in the treatment of fluid collections in the native pancreas [7 — 9]. We found no Russian-language studies devoted to combined treatment of pancreatic fluid collections with percutaneous drainage and stenting of the main pancreatic duct.

The purpose of the study was to improve the outcomes after pancreas transplantation complicated by pancreatitis using percutaneous drainage and endoscopic stenting of the main pancreatic duct.

Material and methods

There were 64 transplantations of the pancreatoduodenal complex between January 1, 2012 and December 31, 2021 at the Sklifosovsky Research Institute for Emergency Care. In 11 (17.2%) cases, early postoperative period was complicated by acute pancreatitis and parapancreatic fluid accumulations. Of these, 7 patients underwent ultrasound-guided percutaneous drainage of focal destructions. This procedure was effective and did not require additional treatment. In 4 patients, debridement and drainage were ineffective and required additional endoscopic stenting of the main pancreatic duct. These patients comprised the study group. Their characteristics are presented in Table. There were 3 men and 1 woman aged 36±4.7 years.

Characteristics of study patients

All patients underwent retroperitoneal pancreatic transplantation with systemic venous outflow and duodenoduodenostomy.

Parapancreatic fluid accumulations in these patients were detected in 1, 12, 18 and 47 days after transplantation of the pancreatoduodenal complex.

At the first stage, we inserted percutaneous drainage tubes in the areas of parapancreatic fluid accumulations.

The indications for endoscopic stenting of the main pancreatic duct were ineffective drainage and debridement, no reduction of volume of parapancreatic fluid accumulations and/or progression of this complication (enlargement).

We applied a gastroscope with end optics Olympus GIF-IT Q160 (endoscopic system EXERA II) for stenting of the main pancreatic duct. This endoscope was passed towards major duodenal papilla of the pancreatoduodenal complex.

As soon as longitudinal fold of the pancreatoduodenal complex was visualized, we selectively catheterized pancreatic duct using a catheter and guidewire with subsequent contrast enhancement using a water-soluble contrast agent. Then, we localized the defect in intraductal system considering X-ray signs of extravasation of contrast agent. At the next stage, plastic pancreatic stent with a diameter of 5—7 Fr and a length of 7 cm was installed along the guidewire without preliminary wirsungotomy. Stent was installed in such a way that its proximal end was located within the body of the donor pancreas and distal end protruded into intestinal lumen by 1.0—1.5 cm.

Fistulography through percutaneous drainage tubes was performed in 2-4 days after surgery to assess position and effectiveness of pancreatic stent.

Results

We described the ultrasonic signs of pancreatic fluid collections (100%) up to 18.9±1.2 cm³. Three (75%) patients had minimum amount of fluid in abdominal cavity. Sensitivity of this method is 100%.

In all patients (n=4), CT of the abdomen and retroperitoneal space revealed infiltrative-inflammatory lesions in retroperitoneal peripancreatic tissue and fluid collections up to 20.2±1.3 cm³. Moreover, three (75%) patients had enlargement of main pancreatic duct of the donor pancreas. Sensitivity of this method was 100%.

All patients underwent percutaneous drainage of peripancreatic fluid collections and subsequent fistulography. All patients had inhomogeneous cavities with irregular shape and volume of 19.6±1.8 cm³. In 3 (75%) out of 4 patients, there was a passage of contrast agent into the main pancreatic duct of the graft and donor duodenal stump. We did not find contrast enhancement of ductal system in 1 (25%) patient since filling of the cavity with a contrast agent was not tight. Sensitivity of this method for detecting pancreatic ductal defects was 75%.

Indications for stenting of the main pancreatic duct were established in 22.5±9.6 days after transplantation. Drainage and debridement were ineffective in 2 (50%) patients. In other 2 (50%) patients, peripancreatic fluid collections enlarged.

Fig. 1. Spatial relationships of endoscope and organs after transplantation of the pancreatoduodenal complex.

All patients underwent endoscopic stenting of the main pancreatic duct (Fig. 2).

Fig. 2. Endoscopic image. Donor major duodenal papilla after stenting. Distal end of plastic pancreatic stent (arrow).

In all cases, injection of contrast agent into the main pancreatic duct was followed by imaging of ductal system and fluid collections (Fig. 3a, b).

Fig. 3. Pancreatography.

a — before stenting, extravasation of the contrast agent (arrow), b — after stenting, pancreatic stent (arrow).

There was reduction of volumes and dimensions of fluid accumulations within 10.7±3.7 postoperative days in all patients. Data after stenting of the main pancreatic duct are shown in Fig. 4.

Fig. 4. Diagnostic data after stenting of the main pancreatic duct.

Postoperative stent dislocation occurred in 1 (25%) patient that required stent repositioning (Clavien-Dindo grade 3).

Fistulography through percutaneous drainage tubes in 23.4±6 days after stenting revealed no peripancreatic fluid accumulations, and drainage tubes were removed. All patients were discharged after 40.2±5 days. Pancreatic stents were removed after 6 months ± 7 days.

Follow-up examination in 34.2 ± 2 days after stent removal confirmed normal clinical and laboratory data in all patients. Ultrasound and CT of the abdomen and retroperitoneal space revealed no peripancreatic fluid accumulations.

Conclusion

Endoscopic stenting of the main pancreatic duct of the donor pancreas combined with percutaneous drainage of peripancreatic fluid accumulations is a highly effective and minimally invasive approach for fluid collections after transplantation of the pancreatoduodenal complex. This method also minimizes the incidence of postoperative complications. Thanks to this method, we avoided redo open surgeries in all cases.

The authors declare no conflicts of interest.