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Fig. 7.10. Surgical procedure of enteric conversion. (Reprinted with permission from: Surgery, Vol 112, 1992).

high index of suspicion for urinary leak is necessary to accurately and swiftly make the diagnosis. Supporting imaging studies utilizing a cystogram or CT scanning is necessary to confirm the diagnosis. Operative repair is usually required with exploration. The degree of leakage can be best determined intraoperatively and proper judgment made whether direct repair is possible or more aggressive surgery involving enteric diversion or even graft pancreatectomy is indicated.

4. Complications of the Enteric-Drained Pancreas Transplant

The most serious complication of the enteric-drained pancreas transplant is that of a leak and intra-abdominal abscess. This serious problem usually occurs 16 months posttransplant. Patients present with fever, abdominal discomfort, and leukocytosis. A high index of suspicion is required to make a swift and accurate diagnosis. Imaging studies involving CT scan are very helpful. Percutaneous access of intra-abdominal fluid collection for gram stain and culture is essential. The flora is typically mixed with bacteria and often times fungus, particularly Candida. Broad-spectrum antibiosis is essential. Surgical exploration and repair of the enteric leak is necessary. A decision must be made whether the infection can be eradicated without removing the pancreas allograft. Incomplete eradication of the infection will result in progression to sepsis and multiple organ system failure. Peripancreatic infections can result in development of a mycotic aneurysm at the arterial anastomosis that could cause arterial rupture. Transplant pancreatectomy is indicated if mycotic aneurysm is diagnosed.

The occurrence of intra-abdominal abscess has been greatly reduced with greater recognition of the criteria for suitable cadaveric pancreas grafts for transplantation. Improved perioperative antibiosis, including anti-fungal agents, has contributed to the decreased incidence of intra-abdominal infection, as well. There is no convincing evidence that a Roux-en-Y intestinal reconstruction decreases its incidence. Perhaps the most significant contribution to reducing the incidence of intra-abdominal abscess is the efficacy of the immunosuppressive agents in reducing the incidence of acute rejection and thereby minimizing the need for intensive anti-rejection immunotherapy.

GI bleeding occurs after the enteric-drained pancreas from a combination of perioperative anticoagulation and bleeding from the suture line of the duodenoenteric anastomosis. This is self-limited and will manifest as diminished hemoglobin level associated with heme-positive or melanotic stool. Conservative management is appropriate, it is extremely unusual for reoperative exploration.

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