Pancreas transplantation is usually performed in patients with denovo type I diabetes, who have advanced secondary complications. We report a case in which whole pancreaticoduodenal
transplantation, with enteric drainage, was performed to correct both endocrine and exocrine deficiencies in a patient with hyperlabile diabetes and
steatorrhea, unresponsive to oral
enzyme replacement therapy, following staged total
pancreatectomy for idiopathic or familial
chronic pancreatitis. The transplant was performed one year after completion of native
pancreatectomy and immediately established an
insulin-independent euglycemic state, with normal oral and intravenous
glucose tolerance test results and correction of
steatorrhea. Beginning one year posttransplant, the patient had intermittent episodes of
steatorrhea, associated with mild elevation of
blood sugar levels, which were presumed to be due to rejection and, indeed, responded to antirejection treatment with
antilymphocyte globulin and temporary increases in
steroids dosages. At 20 months posttransplant,
steatorrhea did not respond to antirejection treatment and an
acute abdomen developed.
Laparotomy revealed a perforated graft duodenum, which was resected; pathology showed transmural
necrosis secondary to chronic rejection. The pancreas graft itself was left in situ, disconnected from the intestinal tract. The patient remained normoglycemic after graft duodenectomy but resumed oral
enzyme replacement therapy in an attempt to combat recurrence of severe
steatorrhea. However, his overall situation remained improved compared to pretransplant, since the exocrine deficiency was tolerable in the absence of a diabetic state. Ten months postgraft duodenectomy (38 months posttransplant), elevations in
blood sugar levels were treated with another course of antirejection treatment and levels temporarily declined. At 14 months postgraft duodenectomy (42 months posttransplant), graft endocrine function again declined and exogenous
insulin was resumed. Six months later, four years after the original transplant, a new enteric-drained pancreaticoduodenal graft was placed, once again resulting in an
insulin-independent, steatorrheafree state. With improvements in immunosuppression,
pancreas transplantation could be offered to selected patients with hyperlabile diabetes, following total
pancreatectomy for benign disease; if the enteric drainage technique is used, in the absence of rejection, exocrine deficiency could be corrected as well.