Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes.

Studies have found similar outcomes of Simultaneous Pancreas-Kidney transplantation (SPKT) in patients with Type 2 (T2D) and Type 1 diabetes (T1D). However, there are scarce data evaluating the association of recipient factors such as age, BMI, or pretransplant insulin requirements with outcomes, thus the criteria for the optimal recipient selection remains unclear. In this study, 284 T1D and 39 T2D patients, who underwent SPKT between 2006 and 2017 with 1 year of follow-up at minimum, were assessed for potential relationship of pretransplant BMI and insulin requirements with posttransplant diabetes and pancreatic graft failure. Kaplan-Meier analysis showed similar rates of freedom from posttransplant diabetes (94.7% T2D vs. 92.3% T1D at 1 yr, and 88.1% T2D vs. 81.1% T1D at 5 yrs) and graft survival (89.7% T2D vs. 90.4% T1D at 1 yr, and 89.7% T2D vs. 81.2% T1D at 5 yrs). There was no significant association between BMI or pretransplant insulin requirements with posttransplant diabetes occurrence in either T1D (p = .10, .43, respectively) or T2D (p = .12, .63) patients in the cohort; or with graft failure (T1D: p = .40, .09; T2D: p = .71, .28). These observations suggest a less restricted approach to selective use of SPKT in patients with T2D.

Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement.

Patients undergoing evaluation for solid organ transplantation (SOT) often have a history of malignancy. Although the cancer has been treated in these patients, the benefits of transplantation need to be balanced against the risk of tumor recurrence, especially in the setting of immunosuppression. Prior guidelines of when to transplant patients with a prior treated malignancy do not take in to account current staging, disease biology, or advances in cancer treatments. To develop contemporary recommendations, the American Society of Transplantation held a consensus workshop to perform a comprehensive review of current literature regarding cancer therapies, cancer stage-specific prognosis, the kinetics of cancer recurrence, and the limited data on the effects of immunosuppression on cancer-specific outcomes. This document contains prognosis based on contemporary treatment and transplant recommendations for breast, colorectal, anal, urological, gynecological, and nonsmall cell lung cancers. This conference and consensus documents aim to provide recommendations to assist in the evaluation of patients for SOT given a history of a pretransplant malignancy.

Preexisting melanoma and hematological malignancies, prognosis, and timing to solid organ transplantation: A consensus expert opinion statement.

Patients undergoing evaluation for solid organ transplantation (SOT) frequently have a history of malignancy. Only patients with treated cancer are considered for SOT but the benefits of transplantation need to be balanced against the risk of tumor recurrence, taking into consideration the potential effects of immunosuppression. Prior guidelines on timing to transplant in patients with a prior treated malignancy do not account for current staging, disease biology, or advances in cancer treatments. To update these recommendations, the American Society of Transplantation (AST) facilitated a consensus workshop to comprehensively review contemporary literature regarding cancer therapies, cancer stage specific prognosis, the kinetics of cancer recurrence, as well as the limited data on the effects of immunosuppression on cancer-specific outcomes. This document contains prognosis, treatment, and transplant recommendations for melanoma and hematological malignancies. Given the limited data regarding the risk of cancer recurrence in transplant recipients, the goal of the AST-sponsored conference and the consensus documents produced are to provide expert opinion recommendations that help in the evaluation of patients with a history of a pretransplant malignancy for transplant candidacy.

Characteristics and Graft Survival of Kidney Transplant Recipients with Renal Cell Carcinoma.

BACKGROUND: The incidence of renal cell carcinoma (RCC) is higher in kidney transplant recipients (KTRs) compared to the general population. However, the risk factors and outcomes based on the diagnosis of RCC after kidney transplantation are limited. METHODS: We analyzed risk factors for the development of RCC in KTRs transplanted at our institution between 1994 and 2016. We compared the incidence of graft failure and mortality in KTRs with RCC to matched controls using 5:1 event density sampling. Identifying the risk factors of RCC and patient and graft survival were outcomes of interest. RESULTS: There were 4,178 KTRs performed at our institution during the study period, and 51 patients were diagnosed with RCC. Recipients were followed until graft failure or death. We did not identify commonly looked at baseline characteristics associated with the risk of RCC. Comparing KTRs with RCC to matched controls, RCC patients were younger (47.5 vs. 49.6 years, p < 0.01), received basiliximab induction more commonly (p = 0.01), had hypertension and glomerulonephritis as causes of end-stage renal disease (p = 0.01), and were more likely to be smokers (p < 0.01). RCC was significantly associated with death-censored graft failure (adjusted hazard ratio [HR]: 1.76; 95% CI: 1.02-3.03; p = 0.04) but not patient death (adjusted HR: 0.95; 95% CI: 0.50-1.83; p = 0.89). CONCLUSION: In our experience, RCC had a detrimental impact on graft survival among KTRs, highlighting the potential benefit of early diagnosis and optimal immunosuppression management in optimizing graft survival.

Outcomes of simultaneous pancreas and kidney transplants based on preemptive transplant compared to those who were on dialysis before transplant - a retrospective study.

Among kidney transplant recipients, the duration of pretransplant dialysis is significantly associated with worse post-transplant outcomes. However, data on the outcomes of preemptive simultaneous pancreas and kidney (SPK) are limited. We analyzed primary SPK recipients transplanted between January 2000 and December 2017. Patients were divided into two groups based on pretransplant dialysis history of preemptive versus non-preemptive. Patient and survival of grafts were outcomes of interest. Of the 644 recipients, 174 (27%) were preemptive and 470 (73%) were not. Most of the baseline characteristics were similar between the groups. In the univariable analysis, the non-preemptive transplant was associated with 54% increased risk for kidney death-censored graft failure (DCGF; HR: 1.54; 95% CI: 1.01-2.35; P = 0.05). There was a 29% increased risk after adjustment for confounding factors (HR: 1.29; 95% CI: 0.83-2.02; P = 0.26), although this association was not statistically significant. Similarly, there was a 16% increased risk of pancreas DCGF in univariable analysis and 1% after adjustment, which was also not statistically significant. When outcomes were based on the duration of pretransplant dialysis, the duration was not associated with either patient survival or survival of either graft in K-M analysis. In SPK recipients, with pretransplant dialysis history, there was a tendency toward inferior graft survival, mainly for the kidney more than the pancreas.

Pancreas transplants from small donors: are the outcomes acceptable? A retrospective study.

Despite good organ quality, pancreata from extremely small pediatric donors (<30 kg) are generally avoided by many centers because of concerns of reduced islet cell mass and early technical failure. Therefore, we sought to compare the outcomes of small pancreas grafts (<30 kg) to those from higher weight donors from transplants performed between 1994 and 2015 (n = 1183). A total of 33 pancreata were from donors' ≤30 kg (3%), with a mean weight of 23.8 kg and mean age of 7.8 years. Patient survival was similar at 1, 5, and 10 years between recipients of ≤30 and >30 kg donors (≤30 kg: 96.8%, 86.8%, and 78.1% vs. >30 kg: 96.8%, 89.5%, and 79.1%, P = 0.5). Pancreas graft survival at 1, 5, and 10 years was also similar, ≤30 kg: 93.9%, 73.2%, and 61.0% vs. >30 kg: 87%, 73.3%, and 58.3% (P = 0.7). This graft survival pattern was also seen when comparing pancreata from ≤20 kg donors to those from >20 to 30 kg. Cause of graft loss, and metabolic and physiologic outcomes did not differ between the groups. After assessing the impact of donor weight as a continuous variable and calculating recipient-to-donor weight ratio (RDWR), we observed no effect of donor weight on patient and graft outcomes.

Alloimmunity in pancreas transplantation.

PURPOSE OF REVIEW: Despite significant improvement in pancreas allograft survival, rejection continues to be a major clinical problem. This review will focus on emerging literature related to the impact of pretransplant and de-novo DSA (dnDSA) in pancreas transplant recipients, and the diagnosis and treatment of T-cell-medicated rejection (TCMR) and antibody-mediated rejection (ABMR) in this complex group of patients. RECENT FINDINGS: Recent data suggest that pretransplant DSA and the emergence of dnDSA in pancreas transplant recipients are both associated with increased risk of ABMR. The pancreas allograft biopsy is essential for the specific diagnosis of TCMR and/or ABMR, distinguish rejection from other causes of graft dysfunction, and to guide-targeted therapy. This distinction is important especially in the setting of solitary pancreas transplants but also in simultaneous pancreas-kidney transplants where solid evidence has now emerged demonstrating discordant biopsy findings. Treatment of rejection in a functioning pancreas can prolong allograft survival. SUMMARY: The accurate and timely diagnosis of active alloimmune destruction in pancreas transplant recipients is paramount to preserving graft function in the long term. This review will discuss new, rapidly evolving information that is valuable for the physician caring for these patients to achieve optimal immunological outcomes.

Prevalence and outcomes of cystic lesions of the transplant pancreas: The University of Wisconsin Experience.

Literature on the behavior of cystic lesions in pancreas transplants is scarce, and hence a better understanding is warranted. Data on recipients and their respective donors that underwent simultaneous kidney and pancreas, pancreas transplant alone, and pancreas after kidney between 1994 and 2015 were reviewed (n = 1185). Cystic lesions of the transplant pancreas developed in 22 patients (1.8%): 12 pseudocysts, 2 cysts/remnants, 4 intraductal papillary mucinous neoplasms (IPMN), 2 adenocarcinomas, 1 low-grade intraepithelial pancreatic neoplasia, and 1 case of polycystic kidney disease. The median size was 3.6 cm (1.6-5.5 cm), and occurred at a median time of 65.5 months (2-183 months) posttransplant. The median age of the graft at time of diagnosis was 42 years (25.7-54.5), with 17 of 22 grafts (77%) functioning at time of diagnosis. Triggers for investigation were elevations in pancreatic enzymes, re-admissions for abdominal pain, and incidentalomas. High-resolution imaging and diagnostic biopsy/aspiration with ancillary tests were the main diagnostic tests. Most pseudocysts were managed by percutaneous drainage, and although no firm inference can be made from such a small series, we have observed that the behavior and management of IPMN and adenocarcinoma in the pancreas graft appears congruent to that of the native pancreas.

Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up.

INTRODUCTION: Ritual circumcision complicated by gangrene is a leading cause of penile loss in young men in South Africa. This deeply rooted cultural tradition is unlikely to be abolished. Conventional reconstructive techniques using free vascularised tissue flaps with penile implants are undesirable in this often socioeconomically challenged group because donor site morbidity can hinder manual labour and vigorous sexual activity might lead to penile implant extrusion. The psychosociological effects of penile loss in a young man are devastating and replacing it with the same organ is likely to produce the maximum benefit. METHODS: We first performed a cadaver-to-cadaver penile transplantation as preparation. After approval from the Human Research Ethics Committee was obtained, we recruited potential recipients. We screened the potential participants for both physical and psychological characteristics, including penile stump length, and emotional suitability for the procedure. A suitable donor became available and the penis was harvested. We surgically prepared the penile stump of the recipient and attached the penile graft. Immunosuppression treatment with antithymyocyte globulin, methylprednisolone, tacrolimus, mycophenolate mofetil, and prednisone were commenced. Tadalafil at 5 mg once per day was commenced after 1 week as penile rehabilitation and was continued for 3 months. We collected on quality-of-life scores (Short Form 36 version 2 [SF-36v2] questionnaires) before surgery and during follow-up and measured erectile function (International Index for Erectile Function [IIEF] score) and urine flow rates at 24 months post transplant. FINDINGS: The warm ischaemia time for the graft after removal was 4 min and the cold ischaemia time was 16 h. The surgery lasted 9 h. An arterial thrombus required urgent revision 8 h after the operation. On post operative day 6, an infected haematoma and an area of proximal skin necrosis were surgically treated. The recipient was discharged after 1 month and first reported satisfactory sexual intercourse 1 week later (despite advice to the contrary). The recipient reported regular sexual intercourse from 3 months after the operation. An episode of acute kidney injury at 7 months was reversed by reducing the tacrolimus dose to 14 mg twice per day. At 8 months after surgery, the patient had a skin infection with phaeohyphomycosis due to Alternaria alternata, which we treated with topical antifungal medication. Quality-of-life scores improved substantially after the operation (SF-36v2 mental health scores improved from 25 preoperatively, to 57 at 6 months and 46 at 24 months post transplant; physical health scores improved from 37 at baseline to 60 at 6 months and 59 at 24 months post-transplant). At 24 months, measured maximum urine flow rate (16·3 mL/s from a volume voided of 109 mL) and IIEF score (overall satisfaction score of 8 from a maximum of 10) were normal, showing normal voiding and erectile function, respectively. INTERPRETATION: Penile transplantation restored normal physiological functions in this transplant recipient without major complications in the first 24 months. FUNDING: Department of Health, Western Cape Government.

Pancreas transplantation in type 2 diabetes: expanding the criteria.

PURPOSE OF REVIEW: Pancreas transplantation in type 2 diabetes mellitus (T2DM) candidates remains disproportionately lower than in type 1 diabetes mellitus (T1DM); however, outcomes in carefully selected patients mirrors that of T1DM. Despite the 2014 United Network for Organ Sharing (UNOS) eligibility criteria for simultaneous pancreas/kidney transplant (SPK) transplantation in T2DM patients, an expected increase in the number of transplants was not observed. RECENT FINDINGS: In an updated International Pancreas and Transplant Registry (IPTR) analysis, 1514 primary deceased donor pancreas transplants were performed in T2DM recipients [1995-2015, SPK 88%, pancreas after kidney (PAK) 9%, pancreas transplant alone (PTA) 3%]. In contrast to the declining number of SPK transplants for T1DM, the number of primary SPK transplants in T2DM patients is increasing over time in the USA. Improvement over time was noted for T2DM SPK patient and graft survival, and the rate of technical failures decreased, paralleling similar overall trends for pancreas transplants in general. Long-term follow-up data of pancreas outcomes in C-peptide positive vs. negative demonstrate noninferior outcomes. BMI does not appear to impact outcomes in carefully selected T2DM candidates. SUMMARY: The current UNOS regulations that currently limit access of T2DM to pancreas transplantation based on strict BMI criteria and C-peptide levels need to be liberated.

Novel uroflow stop test at time of catheter removal is a strong predictor of early urinary continence recovery following robotic-assisted radical prostatectomy: a pilot study.

AIM: To study whether the ability to completely stop urinary flow during voiding at time of catheter removal, measured objectively using uroflowmetry, can predict early recovery of urine continence following robotic-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: In this pilot study, 108 patients with a minimum of 2 years follow-up, operated by a single surgeon (AEH) were subjected to an uroflowmetry at the time of urethral catheter removal following RARP. Normal Saline (150 ml) was instilled intravesically prior to catheter removal and patients were instructed to attempt to stop urine flow during voiding in uroflowmeter. Two groups were studied, group one with positive Stop Test (n = 80) and group two with negative Stop Test (n = 28). Covariates included age, BMI, IPSS score, PSA, tumor stage, prostate volume, nerve sparing status, and estimated blood loss. RESULTS: Basic characteristics were not statistically different between both groups. Early continence recovery was significantly higher in group one. Pad-free continence rates in group one and two at 1, 3, 6, 12, 18, and 24 months were 62% vs. 7% (P < 0.001), 85% vs. 28% (P < 0.001), 93% vs. 67% (P 0.001), 93% vs. 82% (P 0.079), 97% vs. 82% (P 0.006), and 97% vs. 85% (P 0.023), respectively. Uroflow Stop Test was the only independent predictor of early urine continence recovery on univariate and multivariate regression analysis [OR 2.87 (95%CI 1.34-4.38, P = < 0.001)]. CONCLUSION: Novel use of uroflowmetry at time of urethral catheter removal is a simple, non-invasive study with independent ability to predict early continence recovery following RARP.

Cancer Surveillance in Solid Organ Transplant Recipients With a Pretransplant History of Malignancy: Multidisciplinary Collaborative Expert Opinion.

With improved medical treatments, the prognosis for many malignancies has improved, and more patients are presenting for transplant evaluation with a history of treated cancer. Solid organ transplant (SOT) recipients with a prior malignancy are at higher risk of posttransplant recurrence or de novo malignancy, and they may require a cancer surveillance program that is individualized to their specific needs. There is a dearth of literature on optimal surveillance strategies specific to SOT recipients. A working group of transplant physicians and cancer-specific specialists met to provide expert opinion recommendations on optimal cancer surveillance after transplantation for patients with a history of malignancy. Surveillance strategies provided are mainly based on general population recurrence risk data, immunosuppression effects, and limited transplant-specific data and should be considered expert opinion based on current knowledge. Prospective studies of cancer-specific surveillance models in SOT recipients should be supported to inform posttransplant management of this high-risk population.

Compartment syndrome secondary to intra-operative IV methylene blue extravasation to detect ureteral injury.

Compartment syndrome of the extremities is a rare but potentially devastating condition. We herein report a case of a 53-year old female with an unusual case of hand compartment syndrome and fasciitis secondary to methylene blue (MB) extravasation to detect urinary tract injury intraoperatively. This was recognized immediately and fasciotomy was performed. Features of this case are discussed together with its implications. Despite MB's long history of use, few adverse events of an accidental extravasation have been reported.

A Contemporary Evaluation of Urological Outcomes After Renal Transplantation.

INTRODUCTION: Urological surgery after renal transplantation leaves patients at risk of infection and further urological complications. Our objective was to discern patient factors associated with adverse outcomes following renal transplantation to identify patients who would benefit from close urological follow-up. METHODS: Retrospective chart review was conducted for patients undergoing renal transplantation between August 1, 2016 and July 30, 2019 at a tertiary care academic center. Data on patient demographics, medical history, and surgical history were collected. Primary outcomes observed were urinary tract infection, urosepsis, urinary retention, unexpected urology visit, and urological procedures within 3 months of transplant. Variables determined significant by hypothesis testing were used in logistic regression modeling for each primary outcome. RESULTS: Of the 789 renal transplant patients, 217 (27.5%) developed postoperative urinary tract infection and 124 (15.7%) developed postoperative urosepsis. Patients with postoperative urinary tract infection were more likely to be female (OR 2.2, P < .01), have pre-existing prostate cancer (OR 3.1, P < .01), and recurrent urinary tract infections (OR 2.1, P < .01). After renal transplant, unexpected urology visits were observed in 191 (24.2%) patients, and urological procedures were performed in 65 (8.2%) patients. Postoperative urinary retention was noted in 47 (6.0%) patients and seen more often in patients with benign prostatic hyperplasia (OR 2.8, P = .033) and prior prostate surgery (OR 3.0, P = .072). CONCLUSIONS: Identifiable risk factors associated with urological complications after renal transplantation include benign prostatic hyperplasia, prostate cancer, urinary retention, and recurrent urinary tract infections. Female renal transplant patients are at increased risk of postoperative urinary tract infection and urosepsis. These patient subsets would benefit from establishing urological care and pre-transplant urological evaluation including urinalysis, urine cultures, urodynamic studies, and close follow-up post-transplant.

De Novo Malignancies after Kidney Transplantation.

Cancer is an important outcome after kidney transplantation because it is the second leading cause of death in most Western countries. The excess risk of cancer after transplantation is approximately two to three times higher than the age- and sex-matched general population, driven largely by viral- and immune-related cancers. Once cancer develops, outcomes are generally poor, particularly for those with melanoma, renal cell carcinoma, and post-transplant lymphoproliferative disease. More importantly, effective screening and treatment strategies are limited in this high-risk population. In this review, we begin with a patient's journey that maps the experience of living with a kidney transplant and understand the patient's knowledge, education, and experience of cancer in the context of transplantation. The epidemiology and burden of cancer in recipients of kidney transplants, along with the up-to-date screening and treatment strategies, are discussed. We also focus on the current understanding of optimal care for recipients of kidney transplants who are living with cancer from the patients' perspectives.

Socioeconomic status and reduced kidney function in the Whitehall II Study: role of obesity and metabolic syndrome.

BACKGROUND: Previous US-based studies have found that chronic kidney disease (CKD) disproportionately affects those of more adverse social circumstances. Our aim was to show the association between socioeconomic status (SES) and decreased kidney function in a European context and explore the role of obesity and metabolic syndrome. We consider the potential confounding effect of lean muscle mass. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: White participants in the follow-up of the Whitehall II cohort: UK-based European population (age, 55-79 years; n = 5,533), of whom 4,066 men (73%) and 1,467 women (27%) with complete data were analyzed. PREDICTORS: Self-reported occupational grade/salary range. OUTCOMES: Estimated glomerular filtration rate (GFR) using the CKD-EPI (CKD Epidemiology Collaboration) equation. MEASUREMENTS: Body mass index (BMI), serum lipid levels, blood pressure, Tanita TBF-300 body composition analyzer, impedance-derived lean mass index (LMI). RESULTS: Participants in a lower compared with higher occupational grade were at increased odds of having decreased GFR (age- and sex-adjusted OR, 1.31; 95% CI, 1.12-1.53; P = 0.001). Socioeconomic disparity in LMI was evident in women, but not men. After further adjustment for BMI and components of metabolic syndrome, the odds of decreased GFR in whites with a lower compared with higher occupational grade was attenuated by 23.3% (OR, 1.23; 95% CI, 1.06-1.45; P = 0.008). Adjustment for LMI explained 15% of the association between SES and estimated GFR. LIMITATIONS: Cross-sectional design, missing data for subset of participants, no urinary data. CONCLUSIONS: BMI and components of metabolic syndrome may explain up to a quarter of the association between low SES and decreased GFR, suggesting potential modifiable factors.

Frailty in Pancreas Transplantation.

There are a variety of definitions and criteria used in clinical practice to define frailty. In the absence of a gold-standard definition, frailty has been operationally defined as meeting 3 out of 5 phenotypic criteria indicating compromised function: low grip strength, low energy, slowed walking speed, low physical activity, and unintentional weight loss. Frailty is a common problem in solid organ transplant candidates who are in the process of being listed for a transplant, as well as after transplantation. Patients with diabetes or chronic kidney disease (CKD) are known to be at increased risk of being frail. As pancreas transplantation is exclusively performed among patients with diabetes and the majority of them also have CKD, pancreas transplant candidates and recipients are at high risk of being frail. Sarcopenia, fatigue, low walking speed, low physical activity, and unintentional weight loss, which are some of the phenotypes of frailty, are very prevalent in this population. In various solid organs, frail patients are less likely to be listed or transplanted and have high waitlist mortality. Even after a transplant, they have increased risk of prolonged hospitalization, readmission, and delayed graft function. Given the negative impact of frailty on solid organ transplants, we believe that frailty would have a similar or even worse impact on pancreas transplantation. Due to the paucity of data specifically among pancreas transplant recipients, here we include frailty data from patients with CKD, diabetes, and various solid organ transplant recipients.

Complex Ureteral Reconstruction in Kidney Transplantation.

OBJECTIVES: Despite advances in surgical techniques and organ preservation, transplant ureteric strictures remain a common complication in kidney transplantation. A variety of endourological and surgical techniques have been utilized; however, there is a lack of consensus on the optimal modality in dealing with these complex cases. MATERIALS AND METHODS: We present challenging ureteral reconstruction cases after failed attempts at ureteral dilatation, failed conventional open repairs, and/or with bladder dysfunction. RESULTS: All renal allografts were salvaged by successful use of bladder Boari flap and intestinal segment interpositions/diversions. CONCLUSIONS: Operative repair remains the most durable and successful approach, and minimally invasive options should be reserved for nonsurgical candidates, with consideration of a single attempt in patients with early, distal, short (<2 cm), nonischemic strictures.

Is Prophylactic Drainage After Pancreas Transplant Associated With Reduced Reoperation Rate?

OBJECTIVES: Advances in surgery and perioperative care have contributed to improved outcomes after pancreas transplant. However, the development of peripancreatic infections carries a poor prognosis. It is not clear whether abdominal drainage is helpful in collection prevention. MATERIALS AND METHODS: A retrospective review of adult consecutive pancreas transplants at a single institution between January 2017 and December 2018 was undertaken. Postoperative outcomes were compared between patients in whom prophylactic intraoperative drains were placed and patients with no drains. RESULTS: We identified 83 patients who underwent pancreas transplant with a median age of 45 years; 54.2% were males, and median body mass index was 25.8. Thirty patients had 1 or 2 drains placed (36.1%). There was no difference in the readmission rate (70.0% vs 60.4%; P = .48), reoperation (20.0% vs 30.2%; P = .44), or percutaneous drainage of peripancreatic infections (20.0% vs 15.1%; P = .56) between patients with drains and no drains, respectively. However, prophylactic drainage was associated with a lower rate of reoperation for peripancreatic infections compared with those who were not drained (0.0% vs 13.2%; P < .05). No graft loss occurred in the drain group. CONCLUSIONS: Prophylactic drainage after pancreas transplant may be helpful for reduction in the infection rate after reoperation. The risks of drain placement should be weighed against those of drain avoidance.

Salvage Renal Autotransplant Following Previous Renal Vein Stenting in Nutcracker Syndrome.

OBJECTIVES: Nutcracker syndrome is rare, and a proportion of patients with this syndrome continue to have intractable pain and symptoms. Due to the heterogeneity of patients' chief complaints and symptoms, the surgeon's preferred approach may be inherently different but is of paramount importance to the outcome. MATERIALS AND METHODS: We present 4 cases in which renal autotransplant with extraction and ligation of previously placed gonadal coils was performed following previously attempted renal vein stenting or combined renal vein transposition followed by renal vein stenting. RESULTS: Autotransplant resulted in flank pain resolution with improvement in symptoms associated with pelvic congestion syndrome. CONCLUSIONS: The approach to such cases requires meticulous and adequate vena cava exposure, with preparation for potential caval reconstruction. No firm inferences can be made from such a small series; however, we believe in renal autotransplant as first-line therapy, and failure after an initial renal vein stent should be salvaged by renal autotransplant over further endovascular attempts.