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Endoscopic ultrasound-guided biopsy of pancreas in simultaneous pancreas-kidney transplant recipient: case report.

Pancreas-Kidney Transplant Recipient: Case Report E arly diagnosis and appropriate treatment of rejection are crucial in preventing irreversible damage to the transplanted organ. Currently, noninvasive diagnostic methods for the detection of the rejection lack specificity and cannot be relied on (1). Consequently, a histopathologic biopsy of the pancreas is the method of choice in diagnosing rejection. The most common technique is the ultrasonographically guided approach (2). The complication rate of this procedure is estimated to be between 2.8% and 13% (most common complications include hyperamylasemia, bleeding, acute pancreatitis and infection) (3Y6). The diagnostic yield for percutaneous ultrasound-guided biopsies is estimated to be 78% to 96%, depending on operator experience and type of needle used (3, 4, 6). Failure is usually because of lack of an ultrasonographic window or obtaining inadequate tissue. If pancreas tissue cannot be obtained, patients have traditionally undergone a percutaneous computed tomography scanYguided, laparoscopic, or open biopsy. An alternative means of tissue diagnosis might be endosonography (endoscopic ultrasound [EUS])-guided transduodenal biopsy. This method enables the visualization of the gastrointestinal tract, as well as neighboring structures. It is currently used primarily in imaging of the pancreas, biliary tree, lymph nodes, and vessels. Endoscopic ultrasound is also used for guiding biopsies of the native pancreas, with a relatively low complication rate of 1.6% to 3.6% (7, 8). To the best of our knowledge, there have been no reports on the use of EUS to obtain pancreas biopsies in pancreas transplant recipients. We performed EUS-guided pancreas biopsy in a 32-year-old woman with a history of type 1 diabetes mellitus (diagnosed at age 4) and end-stage renal disease treated by hemodialysis, who underwent simultaneous pancreas and kidney transplantation. Arterial reconstruction was performed between the donor superior mesenteric and splenic arteries, using a donor iliac artery or Y-graft. The pancreas allograft was placed in a head-up configuration with anastomoses constructed between the donor portal vein and recipient infrarenal inferior vena cava, and the donor Y-graft and the recipient right common iliac artery. The pancreas graft was placed in a head-up configuration. After revascularization, enteric drainage was executed using the duodenoduodenostomy technique (9, 10). The immunosuppressive regimen included thymoglobulin for induction and mycophenolate mofetil, tacrolimus, and steroids for maintenance treatment. The postoperative course was complicated by delayed pancreas function and fluid collection. An open biopsy of the pancreas transplant was performed during relaparotomy for postoperative fluid collection. Moderate acute cellmediated allograft rejection (grade II) was diagnosed, and pulse steroids were started, resulting in improvement of glycemic control (normoglycemia was achieved). Despite the treatment, the increase in serum amylase and lipase activity persisted. An endoscopic biopsy of the donor duodenum has been performed on the patient as a surrogate marker for pancreas allograft rejection but was unremarkable (11, 12). Percutaneous ultrasound-guided or computed tomographyYguided biopsy was deemed not technically possible because of interposed bowel, and therefore an EUSguided biopsy was performed (the patient was reluctant to undergo an open or laparoscopic biopsy). The procedure was performed under propofol sedation, using a Pentax UTK-3870 (Pentax Europe GmbH, Hamburg, Germany) echoendoscope with a Hitachi Avius HI Vision (Hitachi Medical Corp., Tokyo, Japan) ultrasound system. The pancreas graft was sampled by means of the transplanted duodenum (Fig. 1) using a 22G EchoTip ProCore needle (Cook Ireland Ltd., Limerick, Ireland), which is an aspiration needle with a core trap. Within the pancreas, nine quick back-and-forth jabbing movements of the needle were performed (13). The biopsy yielded adequate pancreas allograft tissue fragment (Fig. 2). Histologic examination revealed no signs of inflammation or C4d deposits within the capillaries. No complications were observed after the biopsy. Amylase and lipase serum activity levels remained stably elevated. The patient was discharged the following day and is doing well at 8 months follow-up. It has to be mentioned that the concept of transduodenal pancreas biopsy is not new, and the technique was used in the 1990s when most pancreases were bladder-drained (14, 15). At that time 14-gauge to 16-gauge corecut needles were used for cystoscopic