We describe the case of a 46-years old man suffering from type 1 diabetes (T1D) complicated by end-stage renal disease and severe diabetic retinopathy. A simultaneous pancreas and kidney transplantation was performed with enteric drainage (latero-lateral anastomosis between graft duodenum and a jejunal loop). Both graft functions were satisfactory under triple immunosuppression. Three years posttransplant he experienced an occlusive syndrome due to an internal hernia, requiring partial ileal resection.

Six years posttransplant he was admitted with occlusive syndrome secondary to an internal hernia, with extended ischemia with necrosis of the small bowel. A resection of small intestine was performed, including the duodenal graft anastomosis, followed by a jejuno-ileal anastomosis. The pancreas graft exocrine secretions drainage was handled by placing a drain in the remaining duodenal segment. An unexpected mobilization of the pancreatic drain led to a pancreatic fistula. It was technically not possible to perform a new enteric anastomosis, nor a bladder drainage. An islet transplantation was considered as pancreas allograft endocrine function was preserved (no insulin need). The pancreas was surgically retrieved, the same day the islets were isolated and injected into the mesenteric vein. The patient was maintained on triple immunosuppressive therapy. During postoperative care, insulin therapy was needed. Nine months after islet auto-allo-transplantation, glycemic control requires 20 to 25 insulin units a day with a significative endogeneous insulin secretion (fasting c-peptide 0.83 ng/mL) and the absence of severe hypoglycemia, thus considered as partial graft function.

Internal hernias are rare but described complications of pancreas transplantation with enteric drainage¹. Unfortunately in our patient the hernia was complicated by necrosis of the graft duodenal anastomosis, and subsequent resection induced the removal of exocrine drainage, however endocrine function was maintained. Islet autotransplantation is a procedure performed in patients undergoing surgery for chronic pancreatitis and also increasingly for pancreas malignancies². Insulin-independence rate after total pancreatectomy and islet autotransplantation has been reported around 25-30% at one year in these patients that had for the majority no insulin requirement before surgery^2,3. Factors influencing glycemic outcomes are abnormal glycemia or HbA1c before transplantation and islet yield⁴. One study reported 27% insulin-independence at 5 years, with stable insulin requirement similar to those of our patient⁵. The impact of performing an auto-transplantation on the occurrence of long-term diabetes complication have not been evaluated. In our case, we can assume some degree of fibrosis of the graft, lowering the islet yield. However, despite a suboptimal islet function and in this situation of continued immunosuppression (because of the renal graft), we assume that this strategy can be beneficial to maintain a degree of endogenous insulin secretion and avoid severe hypoglycemia⁶