Feasibility of visualization and biopsy of donor duodenum by double-balloon enteroscopy technique in a recipient of simultaneous enteric-drained pancreas-kidney transplant: case report.

Histologic examination of the tissue sample is the only definitive way of diagnosing pancreatic rejection. Percutaneous pancreasbiopsyunderimagingcontrolisthe method of choice for obtaining tissue sample. Adequate sample is obtained, however, in 73–89% of biopsy attempts (1, 2). Even when laparoscopic biopsy is performed the success rate is 90% (3). It was shown that the duodenal histology predicts the initial diagnosis of rejection of the pancreas, being less accurate for monitoring recovery from rejection (4). It was also reported that rejection process might occur independently in either organ (5). Duodenal biopsy was reported in recipients of pancreatic transplants with bladder drainage. In case of enteric drainage, which at present is the most commonly employed technique, duodenal biopsies were reported only inspecialcircumstances,either through temporal venting enterostomy (6) or when the donor duodenum was anastomosed to recipient’s duodenum, so access with a “classic” duodenoscope was possible (7). Therefore an enteroscopic approach to visualize directly the transplanted duodenum and obtain tissue samples might be of clinical importance. Double– balloon enteroscopy (push-and-pull enteroscopy) is a new method that allows visualization, biopsy and carrying out endoscopic interventions in the small bowel (8). This method uses two balloons, one attached to the tip of the endoscopeandanotheratthedistalendofan overtube. Inflation of the second balloon to grip intestinal wall allows insertion of the endoscope without forming redundant loops. To our knowledge up till now there have been no reports on the use of this technique in recipients of pancreas transplant. Our patient is a 32-year-old female who underwent simultaneous pancreas kidney transplantation (SPK) for type 1 diabetes mellitus of 17 years duration and end-stagerenaldisease, treatedbyhemodialysis. The transplanted duodenal segment was attached to the recipient‘s jejunum in a side-to-side manner, approximately 40 cm below the Treitz’ ligament. Immunosuppressive regimen included daclizumab and thymoglobulin for induction, and mycophenolate mofetil, tacrolimus, and shortterm steroids for maintenance treatment. The immediate postoperative course was complicated by a mild bleeding from the gastrointestinal tract treated by intravenous proton-pump inhibitor, and nonST-segment-elevationmyocardialinfarction which was accompanied by pulmonary edema. The patient was temporarily intubated and mechanically ventilated, and responded well to furosemide. On the 15th postoperative day, she complained of a sudden, severe upper abdominal pain for which no apparent cause could be determined. A decision was made, therefore, to perform enteroscopy. Endoscopy was performed with propofol sedation, using Fujinon EN-450T5 enteroscope. Extreme care was taken to minimize threading on of the small bowel. Endoscopic image of the esophagus and stomach was normal. Mucous membrane of sewn-in duodenum with it’s papilla and anastomosis had normal appearance (Fig. 1). Biopsies of