Biopsies in pancreas transplantation: The laparoscopic approach
Pablo D Uva1, Luis Leon1, Ignacio C Cabrera1, Elena Minue1, Amos Gonzalez1, Eduardo Chuluyan1, Fernanda Toniolo1, Domingo Casadei1.
1Pancreas Transplantation, Nephrology, Buenos Aires, Argentina
In pancreas transplantation there is no reliable laboratory test or imaging study for detection of graft rejection. Pancreas biopsies have been performed percutaneously, transcystoscopic, laparoscopic or by open laparotomy. We describe our series of 121 laparoscopic biopsies in pancreas transplant patients over the past four years.
Methods: This is a retrospective review of a prospectively collected database. We evaluated reason for biopsy, yield of tissue samples, need of conversion to open surgery and postoperative complications. Operative technique: A Foley catheter was placed in site. Carbon dioxide was used through an Optiview port placed in the left upper quadrant. Two 5mm trocars were placed in the right upper quadrant and in the midline incision below the umbilicus. The kidney biopsy was performed by a core biopsy needle (16G) under direct visualization and hemostasis performed by compression and cautery. Then the tail of the pancreas was dissected and a biopsy was performed using scissors and cautery. After surgery a weight was positioned over the kidney to provide compression for a few hours.
Results: From October 2011 to April 2015 we have attempted 121 pancreas biopsies in 77 patients with either simultaneous pancreas kidney (SPK) or pancreas alone transplant patients (71 and 6 cases). Biopsies were performed because of dysfunction (68) or protocol (53). 11 cases had an additional procedure performed at time of biopsy (7 incisional hernia repair and 4 laparoscopic cholecystectomy). In 11 opportunities only pancreas biopsy was attempted because of PTA (8 cases) or kidney loss in SPK (3 cases). In one protocol biopsy the case was cancelled due extensive adhesions of the viscerae in a patient with history of peritoneal dialysis and a percutaneous kidney biopsy was performed at a later moment. In the rest of the kidney biopsy attempts, tissue was obtained for proper diagnosis representing a yield of 99.1% (120 of 121 cases). On the pancreas yield, 4 patients had adhesions that did not allow reaching the pancreas, and in one case the pancreas biopsy was not done because of a laceration of the duodenum and in an en-bloc kidney pancreas case that with the pancreas was hidden between the kidneys. Pancreas was visualized and tissue was obtained in 115 cases. Of these, 4 samples were classified as adipose tissue, 1 lymphoid tissue and the rest were pancreas tissue that allowed a pathologic diagnosis representing a yield of 91% (110 of 121 cases). There was a need for a small laparotomy in 9 cases. One to oversaw the duodenum laceration, one to reach the kidney behind strong bowel adhesions, four to reach the pancreas through small bowel adhesions in cases with pancreas dysfunction, two for kidney hemostasis in the same patient with a severe humoral rejection and one because of a diagnosis of small bowel pseudo obstruction causing pancreas dysfunction. Postoperative complications included one patient with hematuria requiring a three way Foley catheter with Saline infusion and one relaparoscopy to drain a hematoma due to bleeding of a trocar site. No graft was lost due to a biopsy procedure complication.
Conclusions: Laparoscopic biopsies of both grafts can be performed with safety in patients after pancreas transplantation with high yield and with an acceptable morbidity.
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11:00 - 12:30
|Pancreas and Islet Transplantation: Imaging, Biopsies, and Biomarkers||Biopsies in pancreas transplantation: The laparoscopic approach||Room 110|
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