Subcapsular Renal Hematoma in Simultaneous Pancreas Kidney Transplantation.

Subcapsular renal hematoma (SRH) is a challenging condition, which may jeopardize kidney function or constitute a life-threatening event. This is particularly true in single-kidney patients, such as kidney-transplant recipients. SRH may exert an excessive pressure on the surrounding parenchyma, thus resulting in hypoperfusion and ischemia, with high risk of acute kidney failure and graft loss. Moreover, SRH may precede an overt renal rupture with subsequent hemorrhage and hemodynamic instability. The indication to an interventional management for this condition is still a matter of debate, with some authors advocating the high possibilities of spontaneous resolution and others advocating the high-risk of graft loss and even internal bleeding in case of overt renal rupture. Herein, we report the case of a 51-year-old simultaneous pancreas-kidney transplantation recipient who presented a SRH following a mild trauma. The therapeutic choices were carefully balanced on the specific case, and the conservative management proved successful.

Role of abdominal ultrasound for the surveillance follow-up of pancreatic cystic neoplasms: a cost-effective safe alternative to the routine use of magnetic resonance imaging.

BACKGROUND: Patients with pancreatic cystic neoplasms (PCN), without surgical indication at the time of diagnosis according to current guidelines, require lifetime image-based surveillance follow-up. In these patients, the current European evidenced-based guidelines advise magnetic resonance imaging (MRI) scanning every 6 mo in the first year, then annually for the next five years, without reference to any role for trans-abdominal ultrasound (US). In this study, we report on our clinical experience of a follow-up strategy of image-based surveillance with US, and restricted use of MRI every two years and for urgent evaluation whenever suspicious changes are detected by US. AIM: To report the results and cost-efficacy of a US-based surveillance follow-up for known PCNs, with restricted use of MRI. METHODS: We retrospectively evaluated the records of all the patients treated in our institution with non-surgical PCN who received follow-up abdominal US and restricted MRI from the time of diagnosis, between January 2012 and January 2017. After US diagnosis and MRI confirmation, all patients underwent US surveillance every 6 mo for the first year, and then annually. A MRI scan was routinely performed every 2 years, or at any stage for all suspicious US findings. In this communication, we reported the clinical results of this alternative follow-up, and the results of a comparative cost-analysis between our surveillance protocol (abdominal US and restricted MRI) and the same patient cohort that has been followed-up in strict accordance with the European guidelines recommended for an exclusive MRI-based surveillance protocol. RESULTS: In the 5-year period, 200 patients entered the prescribed US-restricted MRI surveillance follow-up. Mean follow-up period was 25.1 ± 18.2 mo. Surgery was required in two patients (1%) because of the appearance of suspicious features at imaging (with complete concordance between the US scan and the on-demand MRI). During the follow-up, US revealed changes in PCN appearance in 28 patients (14%). These comprised main pancreatic duct dilatation (n = 1), increased size of the main cyst (n = 14) and increased number of PNC (n = 13). In all of these patients, MRI confirmed US findings, without adding more information. The bi-annual MRI identified evolution of the lesions not identified by US in only 11 patients with intraductal papillary mucinous neoplasms (5.5%), largely consisting of an increased number of very small PCN (P = 0.14). The overall mean cost of surveillance, based on a theoretical use of the European evidenced-based exclusive MRI surveillance in the same group of patients, would have been 1158.9 ± 798.6 € per patient, in contrast with a significantly lower cost of 366.4 ± 348.7 € (P < 0.0001) incurred by the US-restricted MRI surveillance used at our institution. CONCLUSION: In patients with non-surgical PCN at the time of diagnosis, US surveillance could be a safe complementary approach to MRI, delaying and reducing the numbers of second level examinations and therefore reducing the costs.

Gray-scale, Doppler and contrast-enhanced ultrasound in pancreatic allograft surveillance: A systematic literature review.

BACKGROUND: Gray scale ultrasound (US), Doppler and Contrast Enhanced Ultrasound (CEUS) represent important surveillance tools in the early post-operative period after pancreas transplantation (PTx), when complications are more common. This review summarizes the available evidence on their clinical application in this setting. METHODS: We searched the Pub-Med database from inception to October 2018 for English literature on the clinical use of US, Doppler and CEUS in the post-PTx surveillance. Article selection was carried out according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria (PRISMA). RESULTS: Twenty-nine articles concerning the clinical applications of US, Doppler and CEUS were identified, 13 of which, involving 264 patients, were focused on the sonographic findings in immunologic rejection, whereas 11 studies reporting on 887 patients were focused on post-PTx vascular complications. The remaining five articles, involving a total of 196 patients, described US or CEUS applied in the study of pancreatic morphology and texture to diagnose peri-graft fluids collections or to obtain experimental data on allograft endocrine function. CONCLUSIONS: US, Doppler and CEUS have proven to be valuable assets in post-PTx follow up, thanks to the combination of their non-invasiveness with a high accuracy in the detection of early abnormalities, in particular regarding vascular complications. Preliminary experiences are directing towards functional research; however, future prospective trials are necessary to precisely correlate organ perfusion, early abnormalities and allograft function.