Which of the following statement(s) is/are true concerning the options for managing the exocrine secretions following pancreatic transplantation?

b. Drainage of the pancreatic ductal system into the bladder is useful in the early diagnosis of rejection

d. Complications following enteric drainage of the pancreas (without the duodenum) are primarily associated with anastomatic leakage

There are, in principal, three options in managing the exocrine secretions following pancreatic transplant. In the first option, maintenance of exocrine secretions by internal drainage of the exocrine pancreas can be achieved by anastomosing the ductal system to either the intestinal tract (stomach, small intestine) or the urinary tract (ureter, bladder). These techniques are the most common in use today and provide the best overall results. The second technique, free drainage of the pancreatic juice into the peritoneal cavity, is certainly the least technically demanding method of transplantation. It is, however, associated with many other complications. Ablation of the exocrine secretion, the third option, can be accomplished by two techniques. The first, duct ligation, has been associated with exocrine atrophy and extensive fibrosis, usually resulting eventually in endocrine insufficiency. Ductal ligation has also had unpredictable effects on the exocrine tissue, associated with a high risk of acute pancreatitis and peripancreatic sepsis. The other method of ductal ligation involves injecting the pancreatic system with a synthetic polymer that solidifies within several minutes, with a result that exocrine secretion is completely blocked. The enterically drained pancreas (without duodenum) has in the past been associated with a significant incidence of anastomatic leakage, leading to pancreatic fistula, perigraft abscess, and systemic sepsis. Many of these allografts had to be removed. These problems can be oveated to a large extent if the donor duodenum (removed in block with the pancreas) is used to establish anastomosis. The bladder drainage technique greatly facilitates early diagnosis of rejection by providing a means to measure the output of amylase from the graft, as determined by the urinary amylase activity.

Regardless of the type of graft transplanted (either whole organ or segmental), most transplant surgeons agree that graft should be placed intraperitoneally. The extensive surface of the peritoneum is probably of considerable help in absorbing the exudate that escapes from the surface of the pancreas. The incidence of anastomatic leaks and wound complications has been greatly reduced with the intraperitoneal placement of grafts.