Cystoscopically Placed Pancreatic Duct Stent for Management of Bladder-Drained Pancreas Transplant with Pancreatic Duct Leak

Abstract

Background: Historically, exocrine pancreas secretions during pancreas transplant were commonly managed by bladder drainage. Although this technique has fallen out of favor because of significant rates of urologic complications, urologists must still be prepared to assist when they arise. We describe the first reported case of a cystoscopically placed pancreatic duct stent for management of a pancreas transplant duodenocystostomy leak in the setting of normal bladder function.

Case Presentation: A 63-year-old male with a history of type 1 diabetes mellitus complicated by end-stage renal disease underwent a simultaneous bladder-drained pancreas and kidney transplant 25 years ago. He developed hematuria and acute rejection of his pancreas, with CT showing large volume ascites concerning for pancreatic leak. Cystoscopy revealed an intact and patent duodenal-cystostomy anastomosis; however, intraperitoneal extravasation on intraoperative cystogram raised concern for pancreatic head necrosis. The patient underwent intraperitoneal drain placement and Foley catheter bladder decompression, but drain output and drain amylase and lipase remained markedly elevated. He was taken back to the operating room for attempted cystoscopic stenting of the pancreatic duct, which was effective using a 5F × 4 cm Zimmon^® pancreatic stent. His drain output normalized in the following days and the pancreatic stent and intraperitoneal drain were removed 4 and 5 weeks after discharge, respectively. Outpatient urodynamics revealed no signs of obstruction and his catheter was removed with minimal postvoid residuals on follow-up.

Conclusion: Anastomotic leak after duodenocystostomy during pancreas transplant is a complication typically related to elevated intravesical pressures, managed with bladder decompression and subsequent bladder outlet procedure. We present a novel technique for cystoscopic pancreatic duct stenting in the setting of intact anastomosis and normal bladder function with delayed leak secondary to necrotic pancreatic head. Endoscopic stent placement, intraperitoneal drainage, and bladder decompression with Foley catheter are an effective technique to avoid unnecessary reconstructive surgery.

Introduction and Background

As of 2012, >27,000 pancreas transplants had been reported to the International Pancreas Transplant Registry.¹ Historically, management of exocrine pancreas secretions was commonly accomplished by bladder drainage, whereby the allograft duodenum is anastomosed side-to-side to the recipient's bladder. However, the preferred duct management technique has become enteric drainage as the rate of urologic complications with bladder drainage was significant (63%).² Nevertheless, given the prevalence of bladder-drained pancreas transplants in the past, it is important for urologists to understand the management of potential urologic complications. We describe the first reported case of a cystoscopically placed pancreatic duct stent for management of a delayed pancreas transplant duodenocystostomy leak.

Case Presentation

A 63-year-old male with history of type 1 diabetes mellitus complicated by end-stage renal disease underwent a simultaneous pancreas and kidney transplant 25 years ago, with bladder drainage of exocrine pancreas. He subsequently developed kidney transplant failure requiring dialysis for ∼1 year followed by a living unrelated kidney transplantation. The second transplant failed after 12 years, at which time in-home dialysis was initiated.

He subsequently developed acute rejection of his pancreas treated with outpatient oral steroids, but was soon after admitted to the hospital with hypotension, hypokalemia, and poor oral intake, concerning for worsening pancreas transplant rejection. CT obtained at the time of admission showed large volume pancreatic ascites, concerning for pancreatic leak. He also developed an episode of gross hematuria around the time of admission, suggesting necrosis of the pancreatic allograft.

Urology was consulted, at which time the patient had minimal complaints, although distended with mild abdominal tenderness to palpation. The decision was made to take patient to the operating room on hospital day (HD)2 for cystoscopy, intraoperative cystogram, and retrograde pancreaticoductogram to evaluate for an anastomotic leak. Cystoscopy revealed an intact and widely patent duodenal-cystostomy with no visible disruption of the pancreatic duct. Cystogram, however, revealed contrast passing into the pancreatic duct with extravasation highlighting loops of small bowel, confirming intraperitoneal extravasation (Fig. 1) consistent with a necrotic pancreatic head.

FIG. 1.

Intraoperative cystogram showing intraperitoneal extravasation of contrast, highlighting loops of small bowel.

A urethral catheter was placed for decompression and percutaneous placement of an intraperitoneal drain was ordered to prevent further damage by the ascitic fluid rich in pancreatic enzymes. Despite decompression, he continued to have large volume output from his intraperitoneal drain (3000 mL on HD3 and 550 mL on HD4) and drain amylase and lipase remained markedly elevated (lipase >16,000 and amylase >3000). Ultimately, the decision was made to return to the operating room to attempt placing a pancreatic duct stent cystoscopically.

On HD5, the patient returned to the operating room and duodenocystostomy anastomosis was observed under cystoscopy and the ampulla of Vater was identified. Multiple attempts to cannulate the ampulla with an angled tip Glidewire and a sensor guidewire were unsuccessful. With assistance from our gastroenterologist colleagues, we then used a Glo-Tip^® ERCP catheter—5.5F catheter that tapers to 3.5F at its distal point—to effectively cannulate the ampulla.

A retrograde pancreaticoductogram was then performed with placement of a 0.038″ Roadrunner^® guidewire along the length of the pancreatic duct (Fig. 2). We then loaded a 5F × 4 cm Zimmon^® pancreatic stent over the wire, which was advanced using a 5F Mini-Tome^® catheter as a pusher (Fig. 3). The stent was deployed across the ampulla with distal curl within the duodenal patch in the bladder (Fig. 4). Intraoperative pancreaticoductogram and postoperative plain film depict appropriate pancreatic duct stent placement (Fig. 5). A urethral catheter was kept in place for maximal drainage.

FIG. 2.

Pancreatic duct cannulated by 0.038″ Roadrunner^® guidewire.

FIG. 3.

5F × 4 cm Zimmon^® pancreatic stent placement over the guidewire and advanced using a 5F Mini-Tome^® catheter as a pusher.

FIG. 4.

Pancreatic duct stent deployed across the ampulla with distal curl within the duodenal patch in the bladder.

FIG. 5.

Left: Intraoperative pancreaticoductogram. Right: Postoperative plain film depicting appropriate stent placement and intraperitoneal drain.

Intraperitoneal drain output decreased significantly to 100 to 150 mL/day in the following days and drain amylase and lipase normalized. Repeat CT obtained on HD8 showed significant improvement in abdominal ascites and the patient was discharged home with intraperitoneal drain and Foley catheter on HD20.

After 4 weeks, the patient's intraperitoneal drain output decreased significantly to 5 to 10 mL/day and his stent was removed cystoscopically. His drain output remained low, indicating resolution of his pancreatic leak, and was removed 1 week later. His indwelling Foley catheter was left in place and he returned to clinic in 1 week to undergo urodynamic testing, which revealed no signs of obstruction or incomplete emptying, normal compliance, and low pressures throughout filling and voiding. His catheter was removed and he returned to clinic in 1 month with minimal postvoid residual. The patient was seen again 1 year later without issues and subsequently underwent another effective kidney transplantation.

Discussion

Although duodenocystostomy is a technique that has fallen out of favor in pancreas transplants in the United States, urologists must be aware of bladder drainage in this setting and their ability to assist if consulted. Most common complications include anastomotic leak, metabolic acidosis, pancreatitis, and recurrent infections, and typically require definitive surgical intervention between 15 months and 4.3 years.³ The majority of endoscopic techniques in the past served to reduce intravesical pressure as complications were presumably caused by bladder outlet obstruction. One study reported its findings after bladder decompression with insertion of Foley catheter during the acute episode with subsequent bladder outlet procedure; however, 16% of these patients ultimately required enterocystoplasty.³

Our patient presented much later, after 25 years, and did not have signs or symptoms of bladder outlet obstruction, which was confirmed on follow-up urodynamics. Although the etiology of his leak is still unknown, there were no signs of extravasation at the anastomosis. Delayed rejection type was the most likely etiology, causing necrosis of the pancreatic head with resultant leak of pancreatic secretions from the pancreatic duct itself. Thus, we present a novel technique for endoscopic management of pancreatic duct leak.

Traditional urologic wires and stents did not allow for cannulation of the ampulla of Vater, requiring a gastroenterology tapered catheter typically utilized during endoscopic retrograde cholangiopancreatography. Historically, stent placement in the setting of ureteral injury permits sufficient healing time to allow for extravasation to resolve after 6 weeks.⁴ Although the enzymatic contents of pancreatic exocrine secretions differ from those of urine, in our patient's case, 6 weeks of maximal decompression resolved his leak. Urologists should feel confident that in this setting, maximal drainage with additional intraperitoneal drain can effectively resolve pancreatic duct leaks endoscopically. Avoiding additional reconstructive surgery in these patients is preferred considering the likely adhesions after leak of enzymatic secretions.

Conclusion

Anastomotic leak after duodenocystostomy during pancreas transplant is a common complication typically related to elevated intravesical pressures caused by bladder outlet obstruction. Although these cases have been managed with bladder decompression and subsequent bladder outlet procedure, we present a unique case of pancreatic duct leak secondary to necrotic pancreatic head rather than bladder outlet obstruction. Therefore, we propose a novel technique of endoscopic pancreatic duct stenting for management of delayed leak in the setting of normal bladder function. Cystoscopic pancreatic duct stent placement, intraperitoneal drainage, and bladder decompression with Foley catheter are an effective technique to avoid unnecessary reconstructive surgery.

Abbreviations Used

CT

computed tomography

HD

hospital day

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: El-Arabi AM, Pittman SP, Dekonenko C, Locke NJ, Duchene DA (2020) Cystoscopically placed pancreatic duct stent for management of bladder-drained pancreas transplant with pancreatic duct leak, Journal of Endourology Case Reports 6:4, 249–252, DOI: 10.1089/cren.2020.0042.