SURGEON AT WORK
Use of the End-to-End Anastamotic Circular Stapler
for Creation of the Duodenoenterostomy for Enteric
Drainage of the Pancreas Allograft
Jonathan A Fridell, MD, Martin L Milgrom, MD, PhD, FACS, Sharon Henson, LPN, CCRC,
Mark D Pescovitz, MD, FACS
Pancreatic transplantation offers the potential for normalization of blood sugar levels for patients with diabetes mellitus. This procedure is most often reserved for
patients who will be receiving a simultaneous kidney
transplant or who have already undergone renal transplantation. Historically many approaches to exocrine secretion drainage have been used, but currently pancreatic exocrine secretions are most often drained either
into the bladder or small intestine. The primary advantage of bladder drainage is that it allows monitoring of
urine amylase. This is particularly useful for recipients of
isolated pancreas allografts in whom it is otherwise difficult to detect acute rejection. Proponents of enteric
drainage believe that this technique is more physiologic
than bladder drainage. Intestinal absorption of fluid and
bicarbonate prevents the severe metabolic acidosis frequently associated with bladder drainage.1-3 Enteric
drainage also eliminates urologic complications of bladder drainage such as hematuria, urinary tract infections,
urethritis, cystitis, and reflux pancreatitis.1-5 The technical failure rate and graft survival are similar using either
technique.1-7
The enteric anastamosis is normally performed between the donor duodenum and the recipient small intestine and is classically described as a two-layered handsewn anastamosis. In this article we describe a new
technique applying the End-to-End Anastamotic (EEA)
Curved Intraluminal Stapler (Ethicon Endo-Surgery,
Inc) to create this anastamosis.
SURGICAL TECHNIQUE
The pancreas is procured using an en-bloc technique
after aortic flush with preservation solution and topical
cooling with saline slush as previously described.8-10 At
the donor operation the proximal duodenum just distal
to the pylorus and the proximal jejunum are divided
with the Gastrointestinal Anastamotic (GIA) Stapler
(Ethicon Endo-Surgery, Inc). We typically divide the
small bowel mesentery with the GIA stapler as well. If
the liver is simultaneously procured, as was the case in all
the pancreas transplantations performed in this series,
the pancreas and liver are separated on the back table
while maintaining topical cold solution on saline slush.
The splenic and superior mesenteric arteries are identified and tagged with polypropylene sutures for later reconstruction. The portal vein is divided approximately
halfway between the pancreas and the liver.
Further preparation of the graft is carried out on the
back table before implantation. The mesentery is oversewn and the GIA staple line on the proximal duodenum
is inverted. The pancreatic arterial supply is reconstructed with a donor iliac artery Y-graft. Typically the
donor internal iliac artery is sewn to the splenic artery
and the donor external iliac artery is sewn to the superior
mesenteric artery using running polypropylene suture.
The splenic hilar vessels are serially ligated but not divided. The distal duodenum and proximal jejunal mesentery is divided with ties, but this segment of bowel is
left attached to facilitate later anastamosis to the recipient’s bowel.
In the case of simultaneous kidney and pancreas
transplantation, we typically implant both organs intraperitoneally to the right iliac vessels using a midline incision. Ligation and division of all internal iliac veins
facilitate this approach by reducing tension on the venous anastamosis. The portal vein and the pancreatic
Y-graft are anastamosed to the right common iliac vein
and artery, respectively. The kidney is placed only after
No competing interests declared.
Received June 11, 2003; Revised September 10, 2003; Accepted September
12, 2003.
From the Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN.
Correspondence address: Jonathan A Fridell, MD, Department of Surgery,
Indiana University School of Medicine, 550 N University Blvd, #4258, Indianapolis, IN 46202.
© 2004 by the American College of Surgeons
Published by Elsevier Inc.
495
ISSN 1072-7515/04/$30.00
doi:10.1016/j.jamcollsurg.2003.09.006
496
Fridell et al
EEA Circular Stapler for Duodenoenterostomy
J Am Coll Surg
Figure 1. (A) End-to-End Anastamotic (EEA)-stapled duodenoenterostomy. The anvil of the EEA
stapler is inserted into the jejunum through an enterotomy and secured with a purse-string
suture. The EEA stapler device is advanced into the second portion of the donor duodenum
through the open jejunal end, reattached to the anvil, closed, and then fired, creating the
anastamosis. (B) The distal donor duodenum and jejunum are then removed with a single fire of
a Gastrointestinal Anastomatic stapler. (From: Indiana University School of Medicine, Office of
Visual Media, with permission.)
completion of the pancreas transplantation. This allows
cross-clamping of the external iliac vessels without interrupting the blood flow to the pancreas. If the patient has
had a previous right-sided kidney transplantation, the
pancreas may still be placed on the common iliac vessels
on the right side or on the left iliac vessels if necessary. In
all cases, the pancreas was positioned with the tail toward
the pelvis and the head and duodenum oriented superiorly to facilitate creation of a tension-free enteric anastamosis. The spleen, which is not revascularized, is removed after reperfusion of the pancreas graft.
After the pancreas has been reperfused and hemostasis
obtained, a circular EEA stapler is selected by passing
metal sizers into the duodenum through the jejunal end
of the donor bowel. The recipient site for the enteric
anastamosis is typically selected in the proximal jejunum
in a portion that reaches the pancreas without tension.
Noncrushing bowel clamps are applied proximally and
distally to the proposed recipient anastamosis site. A
full-thickness purse-string suture is placed on the antimesenteric side and an enterotomy is created. The anvil
of the EEA stapler is removed and placed into the jejunum through the enterotomy and the purse-string su-
ture is tied. The stapler device is advanced into the second portion of the donor duodenum through the open
jejunal end. The rod projecting from within the ring of
staples is pushed through the wall of the duodenum
opposite the ampulla. The anvil is then reattached to the
stapler rod projecting from the duodenum, closed, and
fired, creating the anastamosis (Fig. 1A).The distal donor duodenum and jejunum are then removed with a
single fire of a GIA stapler (Fig. 1B).
The EEA circular stapler was used to construct the
duodenoenterostomy in 14 pancreas transplantations
performed at our institution between July 2002 and
May 2003 with a mean followup of 4.3 ⫾ 2.4 months
(range 1 to 8 months). Ten patients underwent simultaneous kidney and pancreas transplantation (nine men,
one woman, mean age at transplantation 37 ⫾ 9 years).
Three patients underwent pancreas transplantation after
kidney transplantation (two men, one woman, mean age
at transplantation 36 ⫾ 9 years, mean time to pancreas
transplantation 3.4 ⫾ 2.8 years after renal transplantation), and one patient (a woman, age 22 years) underwent simultaneous liver and pancreas transplantation
for cystic fibrosis. Patients receiving simultaneous kid-
Vol. 198, No. 3, March 2004
Fridell et al
ney and pancreas transplants received induction therapy
with rabbit antithymocyte globulin, steroid withdrawal
by postoperative day 5, and maintenance therapy with
tacrolimus and sirolimus as described by Kaufman and
colleagues.11 Recipients of pancreas transplants after previous renal transplantation received similar induction
and maintenance treatment, with rapid weaning of the
steroids to 2.5 mg of prednisone daily.
DISCUSSION
The anastamosis was found to be easy and quick to perform. One of these transplants was complicated by a
small bowel obstruction resulting from an internal hernia posterior to the enteric anastamosis. This subsequently placed tension on the staple line, causing an
anastamotic leak. This was corrected by reducing the
hernia, repairing the retropancreatic defect, and suturing the opening in the anastamotic staple line. The enteric anastamosis did not require revision. All pancreas
grafts are functioning well at a mean followup of
2.79 ⫾ 2.12 months.
In summary, in this article we have described a new
technique for creating the duodenoenterostomy necessary for enteric drainage of the pancreatic allograft exocrine secretions. This procedure is easy and quick to
perform with a low complication rate. A similar technique was described for performing the duodenoneocystostomy for bladder drainage.12-15
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