Treatment of a Duodenal-Enteric Leak With Peritonitis After Pancreas Transplantation?

Robert J. Stratta, MD

Disclosures

July 24, 2002

Question

What is the best manner to treat a duodenal-enteric leak with peritonitis after pancreas transplantation?

Andre David, MD

Response from Robert J. Stratta, MD

The best treatment of a duodenal-enteric leak with peritonitis after pancreas transplant is re-laparotomy with primary repair of the enteric leak, whether it be at the anastomosis or at one of the duodenal staple lines. One needs to ensure that there is no evidence of distal obstruction, foreign body, undrained infection, or bowel ischemia as the cause of the leak. Moreover, one needs to rule out rejection or cytomegalovirus infection as a cause of the leak, so an excisional biopsy of the surrounding duodenal tissue is indicated, followed by primary closure. On occasion, the entire anastomosis or staple line may need to be reconstructed, depending on the size of the leak, location, and viability of the surrounding tissue. The area of repair can then be patched with either omentum or surrounding viscera. I usually try to close the repair in 2 layers, with 3-0 PDS and then 3-0 silk. I would then create a diverting Roux limb to protect the area of repair and anastomose the afferent limb to the more distal small bowel. If the patient already has a Roux limb, I would advise placing a tube enterostomy into the Roux limb and through the enteric anastomosis into the transplant duodenum to further decompress the repair and divert the pancreatic exocrine secretions. This tube can then be brought out of the abdominal wall as a temporary intraluminal drainage tube that permits sinography for assessing the integrity of the repair.

I would then spend a lot of time irrigating the abdomen with intraperitoneal antibiotics, and place 1-2 10-mm flat Jackson-Pratt drains around the pancreas and in proximity to the area of repair. If the degree of contamination and peritonitis is severe, I might plan a "second look" procedure 48-72 hours later and perform a temporary abdominal wall closure (mesh, vacuum-assisted wound closure). If the patient has evidence for pancreatitis in addition to the leak, I would definitely plan a second-look procedure. I would also advise nasogastric tube decompression, total parenteral nutrition, a continuous infusion of octreotide acetate, and systemic intravenous antibiotics guided by culture results. I would administer antifungal prophylaxis (usually fluconazole), reduce immunosuppression (stop mycophenolate mofetil or azathioprine, and reduce dosages of prednisone and either tacrolimus or cyclosporine), and keep the patient NPO until return of bowel function.

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