Simultaneous Pancreas-Kidney Transplant Recipient With a Fistula in the Pancreas Allograft?

Robert J. Stratta, MD

Disclosures

November 26, 2003

Question

My transplant team has a simultaneous pancreas-kidney transplant (SPKT) recipient who has a fistula in the pancreas allograft. He is 2 months post-SPKT, and it has been 1 month since he underwent 2 laparotomies for the fistula (enteric drainage). He is in otherwise good condition, and renal and endocrine pancreas function are good. Secretion varies from 250 mL to 500 mL, and amylase is about 80,000. Lately, we isolated different organisms in the drainage, but he is without signs of systemic infection. What can you suggest?

Denis Gustin-Masinovic, MD

Response from Robert J. Stratta, MD

Treatment of a pancreatic allograft failure is not dissimilar from treatment of a native pancreatic fistula; the basic principles include establishing adequate drainage, treating infection, ruling out distal obstruction/ischemia/foreign body as a cause, providing adequate nutrition, and placing the pancreas at rest. In addition, one might want to rule out rejection, cytomegalovirus infection, or other pathology unique to the allograft pancreas. Since the fistula has not responded to surgical debridement/drainage x 2, I would recommend:

  1. Total parenteral nutrition with complete bowel rest

  2. Continuous infusion of octreotide acetate to reduce fistula output

  3. Intravenous (IV) antibiotic therapy to treat any colonization/infection based on cultures of the drainage

  4. Antifungal prophylaxis with fluconazole

  5. Imaging studies (including sinogram/fistulogram as well as small bowel contrast studies and abdominal/pelvic CT scan with oral and IV contrast) to define the pathology and rule out an enteric leak, distal obstruction, devitalized/necrotic tissue, undrained abscess, or necrosis, etc.

  6. Nasogastric tube decompression if the patient has evidence of allograft pancreatitis

  7. Reduction in immunosuppression to promote healing and decrease the risk of superinfection (stop mycophenolate mofetil and reduce doses of prednisone, sirolimus, and/or either tacrolimus or cyclosporine)

  8. Repeat laparotomy (with pancreas biopsy) if nonoperative management fails after 2-4 weeks.

In some cases, the oral administration of pancreatic enzyme replacement (

Creon, Viokase, Pancrease

, etc) may likewise decrease fistula output through a negative feedback loop. In the absence of a pancreatic ductal obstruction (which might be diagnosed by the sinogram/fistulogram noted above), if the above principles are followed (ruling out ongoing inflammation, infection, ischemia, necrosis, etc and providing adequate nutrition and drainage), the fistula should eventually close and heal.

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