title: Nonmarginal-donor duodenal ulcers caused by rejection after simultaneous pancreas and kidney transplantation: a case report.
abstract: OBJECTIVE
  Pancreas transplantation has been associated with the highest surgical complication rate among routinely performed organ transplant procedures. Complications can be caused not only from the pancreas itself but also from the simultaneously transplanted duodenum: gastrointestinal bleeding, duodenal ulcer, pseudoaneurysm, arterioenteric fistula, and severe rejection. Herein we report a patient who underwent simultaneous pancreas-kidney transplantation (SPKT) and experienced a duodenal perforation because of rejection.
  
  
  METHODS
  The 60-year-old man with insulin-dependent diabetes underwent SPKT with enteric drainage. At 15 days there after he displayed melena.
  
  
  RESULTS
  We suspected it to be caused by rejection and ischemic changes. We slightly increased the doses, of tacrolimus and methylprednisolone. But 17 days after SPKT, the ulcer perforated, requiring a repair operation and increased dose of mycophenolate mofetil. However, the ulcers perforated repeatedly, requiring 4 repair operations. Unfortunately the patient developed pneumonia that mitigated continues repairs or rejection therapies, so we expated the duodenum and pancreas but saved the kidney. The pathologic findings showed the ulcer to have been caused by severe rejection. Despite those episodes, the patient was weaned from hemodialysis.
  
  
  CONCLUSIONS
  Perforation of the transplanted duodenum is one of the most difficult complications among SPKT patients. This potentially lethal complication may be caused by mucosal rejection, ischemic changes, and the exocrine output from the pancreatic graft.
authors.affiliation: Division of Transplantation, Reconstruction, and Endoscopic Surgery, Tohoku University, Sendai, Japan. msmsmiyagi@yahoo.co.jp
authors.forename: S
authors.initials: S
authors.lastname: Miyagi
authors.forename: S
authors.initials: S
authors.lastname: Sekiguchi
authors.forename: N
authors.initials: N
authors.lastname: Kawagishi
authors.forename: Y
authors.initials: Y
authors.lastname: Akamatsu
authors.forename: K
authors.initials: K
authors.lastname: Satoh
authors.forename: I
authors.initials: I
authors.lastname: Takeda
authors.forename: K
authors.initials: K
authors.lastname: Fujimori
authors.forename: S
authors.initials: S
authors.lastname: Satomi
mesh_terms: D004381:Duodenal Ulcer / Q000175:diagnosis* / Q000209:etiology*; D006084:Graft Rejection; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D016035:Pancreas Transplantation / Q000009:adverse effects*; D011183:Postoperative Complications; D014019:Tissue Donors; D016896:Treatment Outcome