DIAGNOSIS OF PANCREAS REJECTION - CYSTOSCOPIC TRANSDUODENAL VERSUS PERCUTANEOUS COMPUTED-TOMOGRAPHY SCAN-GUIDED BIOPSY

Background. The most common cause of graft failure after technically s uccessful pancreas transplants is rejection. Laboratory parameters for detecting pancreas graft rejection are not consistently reliable and can lead to unnecessary antirejection treatment. Histopathologic evalu ation is the gold standard in the differential diagnosis of pancreas g raft dysfunction. Four biopsy techniques have been described: cystosco pic transduodenal (CB), percutaneous computed tomography scan-guided ( PB), open, and laparoscopic biopsy. Methods. We studied the two most c ommon techniques, CB and PB, in pancreas transplant recipients with pr esumed rejection. Group 1 comprised 103 attempts at CB in 82 recipient s (53 men, 29 women) with bladder-drained (ED) pancreas transplants, a t 1 to 80 (median, 14) months after transplant. Group 2 comprised 93 a ttempts at PB in 68 recipients (41 men, 27 women), at 0.5 to 64 (media n, 14) months after transplant. Results. In group 1, of 103 attempts a t CB, adequate tissue was obtained in 90 (87%): pancreas alone in 23 ( 22%), pancreas + duodenum in 35 (34%), duodenum alone in 32 (31%). Of the 58 pancreas biopsies, 23 (40%) showed acute rejection. Of the 67 d uodenal biopsies, 16 (24%) showed acute rejection. Complications of CB included macrohematuria in 4 recipients (4%) and microhematuria in 32 (31%). We noted no biopsy-related pancreatitis. The mean cost of CB w as $2561+/-246. In group 2, of 93 attempts at PB, adequate tissue (all pancreas) was obtained in 67 (72%); of these, 29 (43%) showed acute r ejection. Of 23 inaccessible pancreases, 9 (39%) underwent CB; pancrea tic tissue was obtained in four (45%), and results were consistent wit h rejection in all four. Complications of PB included biopsy-related p ancreatitis (serum amylase greater than or equal to 25%) in five (7%) recipients, macrohematuria in one (1%), and abdominal hemorrhage in tw o (3%). The mean cost of PB was $1038+/-78. (1) CB and PB prevented un necessary antirejection treatment in 44% of our recipients with succes sful biopsies; (2) CB had a higher success rate for obtaining tissue ( including duodenal specimens) and a lower rate of major complications; (3) PB was easier and cheaper, did not require general anesthesia, an d was performed as an outpatient procedure. Conclusions. We conclude t hat PB should become the biopsy technique of choice in recipients with presumed pancreas graft rejection. If PB fails, recipients with bladd er-drained pancreas transplants should undergo CB. If CB fails, or in recipients with enteric-drained or duct-injected pancreas transplants, a laparoscopic or open biopsy should be considered.