Roux-en-y venting jejunostomy in pancreatic transplantation: a novel approach to monitor rejection and prevent anastomotic leak

Introduction: Pancreatic transplantation (PTx) with portal venous delivery of insulin and enteric drainage of the exocrine secretion is more physiolog ic than bladder-systemic (BS) drainage. With portalenteric (PE) PTx, the di agnosis of acute rejection (AR) requires a percutaneous biopsy. The roux-en -y (RNY) venting jejunostomy in patients with PEPTx offers a novel approach to monitor rejection and prevent anastomatic leaks. Methods. From January 1996 to December 1998, we performed 17 simultaneous k idney/pancreas transplants (SKPTx). The initial 4 patients underwent BS dra inage and the subsequent 13 patients underwent RNY venting jejunostomy with PE drainage. All patients were treated with quadruple therapy. There were 9 males, 14 patients were Caucasian with a mean age of 32 yr (range 30-54 y r), and a mean pre-transplantation duration of diabetes of 25 yr. Six patie nts underwent endoscopic donor duodenal biopsy through the jejunostomy to r ule out clinically suspected AR. Gastrograffin was inserted into the jejuno stomy to examine the integrity of anastamosis when indicated. In 9 out of 1 3 patients, the venting jejunostomy was taken down 9-12 months post-transpl antation after allograft function was stable. Results. Actual patient, kidney, and pancreas graft survival rates were 100 , 100 and 94%, respectively, after a mean follow-up of 16 months. Renal all ografts functioned immediately in 89% of patients. The mean length of hospi tal stay was 19 d. Four (23%) patients (2 with BS drainage and 2 with PE dr ainage) suffered an AR episode in the first month, and 4 (23%) patients had five AR from 3-36 months posttransplantation. Other complications were pos t-operative bleeding in 3 patients, wound infection in 2 patients and a pro ximal duodenal stump leak in 1 patient. In patients with clinical rejection , endoscopy through the venting jejunostomy showed inflamed, friable douden al mucosa and doudenal biopsy findings were compatible with AR. Conclusion. These preliminary results suggest that RNY venting jejunostomy with PE drainage can be used safely to diagnose and monitor pancreas AR and to diagnose and prevent anastamotic leaks. This technique will be even mor e useful to visualize transplanted duodenal mucosa, collect pancreatic secr etions (amylase) for analysis and perform endoscopic retrograde cholangiopa ncreatography if needed to obtain pancreatic biopsies.