title: Excessively Long Duodenum of the Pancreatic Graft Segment as a Rare Cause of Hyperammonemia After Simultaneous Pancreas-Kidney Transplant.
abstract: Simultaneous pancreas-kidney transplant is currently standard therapy to achieve long-term insulin-free euglycemia in patients with type 1 diabetes mellitus and concomitant end-stage kidney failure. A patient with symptoms of encephalopathy caused by hyperammonemia and with new-onset iron deficiency anemia was admitted to our institution 20 months after a simultaneous pancreas-kidney transplant. Detailed screening did not reveal any specific cause for the hyperammonemia, and despite standard treatment, hyperammonemia did not resolve. An abdominal computed tomographic scan was performed, which showed a distended duodenal segment of the pancreas graft. This was confirmed during exploratory laparotomy when the anastomosis between duodenum and ileum was dismantled and found not to be stenotic. The excessively long stumps of the duodenum were then dissected and shortened, and a new anastomosis between graft-duodenum and recipient-ileum was created. The operation was followed by an uncomplicated postoperative course in which the serum ammonia normalized on the first postoperative day and remained normal afterwards. An excessively long segment of the duodenum of the pancreatic graft may lead to encephalopathy with hyperammonemia after a simultaneous pancreas-kidney transplant. This emphasizes the need for meticulous preparation of the graft to avoid this complication.
authors.affiliation: From the Leiden University Medical Centre, Department of Surgery, Division of Transplantation, Hungary.
authors.forename: Dávid Ágoston
authors.initials: DÁ
authors.lastname: Kovács
authors.forename: Volkert
authors.initials: V
authors.lastname: Al Huurman
authors.forename: Maciej
authors.initials: M
authors.lastname: Wojcicki
authors.forename: Darius
authors.initials: D
authors.lastname: Soonowala
authors.forename: Andrzej
authors.initials: A
authors.lastname: Baranski
mesh_terms: D000328:Adult; D000641:Ammonia / Q000097:blood; D000714:Anastomosis, Surgical; D018798:Anemia, Iron-Deficiency / Q000209:etiology; D015415:Biomarkers / Q000097:blood; D003922:Diabetes Mellitus, Type 1 / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D004386:Duodenum / Q000000981:diagnostic imaging / Q000637:transplantation*; D005260:Female; D006801:Humans; D022124:Hyperammonemia / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D007082:Ileum / Q000601:surgery; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D016030:Kidney Transplantation / Q000009:adverse effects*; D016035:Pancreas Transplantation / Q000009:adverse effects* / Q000379:methods; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D000641:Ammonia