Figure 1517

Pancreatic enzyme and urinary leaks. A leak of urine, activated pancreatic enzymes, or both, is one of the most devastating and life-threatening infectious complications after pancreas transplantation. Patients exhibit sudden-onset lower abdominal pain, fever, leukocytosis, increased serum amylase levels, and increased serum creatinine levels. Diagnosis is confirmed by cystogram. When no leak is identified, voiding cystourethrography (VCUG) with gastrograf-fin (panel A) or a VCUG using technetium (Tc99m) in normal saline is performed (panels B-E).

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FIGURE 15-17 (Continued)

In our opinion, a Tc99m-VCUG is the most sensitive test, because extravasation may occur only during the high-pressure phase of voiding [19]. B, This gastrograffin-VCUG demonstrates duodenal segment and anastomosis in the region of the dome of the bladder in an oblique anteroposterior projection. A leak of contrast is identified at the lateral duodenal segment staple line. B and C, Normal Tc99m-VCUG scintigraphy is shown. Radioactive tracer is seen within the confines of the intact urinary tract, refluxing into the duodenal segment (large black arrow) and renal transplantation collecting system (small black arrow). D and E, Tc99m-VCUG demonstrates spill of radioactive tracer outside of the bladder and duodenal segment (large white arrowhead). Later, radioactive tracer is also present in the pelvis and between loops of bowel throughout the peritoneal cavity (small white arrowheads).

For small leaks that are contained early, treatment consists of bladder decompression with a urinary catheter for 2 to 3 weeks. Large leaks and those that recur after conservative therapy require exploration, repair of the involved suture line, and enteric conversion.

Careful inspection of the duodenal segment is essential, and biopsy of the duodenal mucosa to search for rejection or cytomegalovirus pathology may be revealing in determining the cause. In most cases, however, the exact cause remains enigmatic despite careful investigation. In some cases, simultaneous diversion of the fecal stream with a Roux-en-Y anastomosis or proximal ileotransverse colosto-my is advocated. Rarely is a urinary leak secondary to disruption of the ureteroneocystostomy. Enzyme leaks are more difficult to diagnose in enterically drained pancreata. A diagnosis in this setting relies on contrast-enhanced computed tomography (CT) scan, which usually demonstrates peripancreatic fluid collections. When drained percutaneously, these fluid collections reveal infection with enteric organisms and an elevated fluid amylase level. Surgical treatment of leaks in ED pancreata requires an individualized approach that usually involves repair, drainage, and diversion of the fecal stream. An expeditious diagnosis, depending on a high index of suspicion, and aggressive surgical intervention are essential to manage these life-threatening complications.

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