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tions have been increasing [1]. Access to the surgical anastomosis is desirable for monitoring of rejection and management of bleeding complications. A 34−year−old diabetic man with nephropathy requiring hemodialysis underwent simultaneous enteric−drained pancreas±kidney trans− plantation. On postoperative day 6, he de− veloped hematochezia. Physical examina− tion revealed red blood in the rectum. The hematocrit declined from 35% to 23% within 24 hours. After volume resuscita− tion, esophagogastroduodenoscopy and colonoscopy were performed, demon− strating esophagitis, sigmoid diverticulo− sis, and old blood. The terminal ileum was evaluated but the surgical anastomo− sis was not reached. The next day, hema− tochezia recurred, with a drop in hemato− crit from 27 % to 23%. A retrograde single− balloon enteroscopy (SIFQ180; Olympus Inc., Tokyo, Japan) with a disposable over− tube (ST−SB1, Disposable Sliding Tube; Olympus) was performed. The duodenal stump±ileal anastomosis was reached, approximately 60 cm proximal to the ileocecal valve, revealing active, spurting bleeding from a visible vessel within an anastomotic ulcer (l" Fig. 1). Three endo− clips (QuickClip2; Olympus) were placed at the bleeding site, with successful he− mostasis (l" Fig. 2). The donor duodenum could be easily visualized (l" Fig. 3). The patient had no further bleeding episodes. The use of enteric−drained pancreas transplantation for treatment of diabetes mellitus has been limited by the frequent occurrence of complications. Repeat lapa− rotomy is required in up to 37 % of pa− tients within 3 months of operation [1]. Anastomotic ulcers have been reported in 11.5% of patients; the risk is higher for the Roux technique [2]. Angiography may be implemented to manage such bleeding complications [3], but contrast nephro− pathy remains a risk. The single−balloon system was developed as an alternative to explore the small intestine [4]. This technique is particularly attractive be− cause it can assess areas of the small in− testine not evaluated by standard endo− scopic instruments. Single−balloon en− teroscopy may be used for monitoring pancreas rejection and management of postoperative anastomotic bleeding.

Single-balloon enteroscopy-guided hemostasis of an anastomotic ulcer in a patient with simultaneous enteric-drained pancreas–kidney transplant