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:
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.
Medscape Transplantation. 2003;4(2) © 2003 Medscape
Cite this: Robert J Stratta. Simultaneous Pancreas-Kidney Transplant Recipient With a Fistula in the Pancreas Allograft? - Medscape - Nov 26, 2003.