INTRODUCTION:The study aim was to analyze the presentation, management, and follow-up of renal transplant patients developing bladder calculi. METHODS:Patients who underwent renal transplant with postoperative follow-up at our institution were retrospectively analyzed (1984-2023) to assess for the development of posttransplant bladder stones. All bladder stones were identified by computerized tomography imaging and stone size was measured using this imaging modality. RESULTS:The prevalence of bladder calculi post-renal transplantation during the study window was 0.22% (N = 20/8,835) with a median time to bladder stone diagnosis of 13 years posttransplant. Of all bladder stone patients, 6 (30%) received deceased donor and 14 (70%) living donor transplants. There were 11 patients with known bladder stone composition available; the most common being calcium oxalate (N = 6). Eleven (55%) patients had clinical signs or symptoms (most commonly microhematuria). Fourteen of the bladder stone cohort patients (70%) underwent treatment including cystolitholapaxy in 12 subjects. Of these 14 patients, 9 (64%) were found to have nonabsorbable suture used for their ureteroneocystostomy closure. CONCLUSIONS:The prevalence of bladder stones post-renal transplant is low. The utilization of nonabsorbable suture for ureteral implantation was the main risk factor identified in our series. This technique is no longer used at our institution. Other factors contributing to bladder stone formation in this population warrant identification.

AbstractObjectivesTo analyse the presentation, management and long‐term outcomes of renal transplant patients who formed kidney stones in their allograft. The secondary aim was to identify risk factors for stone formation in this cohort.Materials and MethodsPatient information from an institutional renal transplant database was used to identify individuals who both did and did not form kidney stones following renal transplantation. Computerized tomography (CT) imaging was used to make the diagnosis of kidney stones and measure stone size. Age‐ and gender‐matched controls never forming a stone in their allograft were used for comparative analysis to identify risk factors for stone formation in transplant patients.ResultsA total of 8835 transplant patients were included in the study, of which 128 (1.4%) formed a kidney stone in their allograft after surgery. The mean time to kidney stone identification was 6.2 years, and the mean number of stones formed was 1.7, with a mean maximum size dimension on a CT scan of 5.7 mm per stone. A total of 26 patients were subjected to stone‐removing procedures, the most common being ureteroscopy (42.3%). The primary intervention failed in eight patients requiring a secondary intervention, and percutaneous nephrolithotomy (PCNL) had the lowest success rate (60%). A total of 164 controls were identified. In comparison to controls, stone formers had lower serum calcium (p = 0.008), lower estimated glomerular filtration rates (p = 0.019), higher lymphocyte counts (p = 0.021) and greater rate of urinary tract infection (p = 0.003). Graft failure rates were the same (p = 0.524), but time to graft failure was significantly longer in stone patients compared with controls (p = 0.008).ConclusionsThe rate of stone formation is low in transplant patients. Success rates for stone treatment vary based on the surgery selected, with PCNL being the worst. Graft survival rates were equivocal, but survival time was better in stone patients. Our analysis calls for further investigation of this important topic.

BACKGROUND: Functional gallbladder disorder is most commonly defined by biliary colic and low ejection fraction (EF) on cholescintigraphy. Biliary hyperkinesia is a controversial type of functional gallbladder disorder, and its definition and the role of cholecystectomy in treating functional gallbladder disorder remains unclear. STUDY DESIGN: We conducted a retrospective review of patients who underwent cholecystokinin-stimulated cholescintigraphy and cholecystectomy at 3 Mayo Clinic sites between 2007 and 2020. Eligible patients were 18 years or older, presented with symptoms of biliary disease, had an EF greater than 50%, underwent cholecystectomy, and had no evidence of acute cholecystitis or cholelithiasis on imaging. We used receiver operating characteristics curve analysis to identify the optimal cutoff value that predicted symptom resolution within 30 days of cholecystectomy. RESULTS: A total of 2,929 cholecystokinin-stimulated cholescintigraphy scans were performed during the study period; the average EF was 67.5% and the median EF was 77%. Analyzing those with EFs greater than or equal to 50% yielded 1,596 patients with 141 (8.8%) going on to have cholecystectomy. No significant differences were found in age, sex, BMI, final pathology between patients with and without pain resolution. Using a cutoff EF of 81% was significantly associated with pain resolution after cholecystectomy (78.2% for EF greater than or equal to 81% vs 60.0% for EF less than 81%, p = 0.03). Chronic cholecystitis was found in 61.7% of the patients on final pathology. CONCLUSIONS: We determined that an EF cutoff of 81% is a reasonable upper limit of normal gallbladder EF. Patients with biliary symptoms and an EF greater than 81% but no evidence of biliary disease on ultrasound or scintigraphy can be classified as having biliary hyperkinesia. Based on our findings, we recommend cholecystectomy for this patient population.

Introduction: The influence of gender on outcomes following simultaneous pancreas-kidney transplantation (SPKT) in the new millennium is uncertain. Methods: We retrospectively studied 255 consecutive patients undergoing SPKT from 11/2001 to 8/2020. Cases were stratified according to donor (D) gender, recipient (R) gender, 4 D/R gender categories, and D/R gender-matched vs mismatched. Results: A total of 170 donors were male and 85 were female. Male donors were younger, had a lower kidney donor profile index (KDPI), were more commonly non-Caucasian, weighed more and were taller, and more frequently sustained brain death secondary to head trauma compared to female donors (all p<0.05). The incidences of early pancreas graft loss secondary to thrombosis (5.9%) and early relaparotomy (32.9%) were identical according to donor gender. There were no differences in patient or pancreas survival rates (GSRs) according to donor gender. However, the kidney GSR was significantly higher with male donors.A total of 142 recipients were male and 113 were female. There were no significant survival differences according to recipient gender but female recipients did experience slightly higher pancreas thrombosis (8% R-female vs 4.2% R-male, p=0.28) and early relaparotomy rates (38% R-female vs 29% R-male, p=0.14) compared to male recipients. When analyzing the 4 D/R gender categories, there were no differences in patient or pancreas GSRs. Early relaparotomy (40.5% vs 31.7%, p=0.34) and pancreas thrombosis (10.8% vs 5.0%, p=0.25) rates were numerically higher in the female/female group compared to the other three D/R groups combined. The two D-male groups had higher kidney GSRs (83%) compared to the two D-female groups (72%, p=0.02) irrespective of recipient gender.There were no significant differences in outcomes between gender-matched (n=131) and gender-mismatched (n=124) groups although overall survival outcomes were slightly lower with female donors irrespective of recipient gender. In multivariate analysis, no significant differences were noted in patient or pancreas GSRs according to donor or recipient gender whereas kidney graft loss was influenced by female donors (HR 2.12, p=0.005). Conclusions: The influence of D/R gender following SPKT is subject to multiple confounding factors but kidney GSRs appear to be higher in D-male/R-male and lower in D-female/R-female categories.

Background: Thyroid nodules discovered incidentally during transplant may prolong time to transplantation. Although data suggest that incidence of thyroid cancer increases after solid organ transplantation, the impact on prognosis in differentiated thyroid cancer is not well characterized. Methods: We performed a retrospective review of patients with history of thyroid cancer and solid organ transplantation at our institution. Results: A total of 13,037 patients underwent solid organ transplantation of which there were 94 patients with differentiated thyroid cancer (0.7%). Of these, 50 patients (53%) had cancer pre-solid organ transplantation, whereas 44 patients (47%) developed cancer post-solid organ transplantation. Papillary histology was most common (88%), followed by follicular (3%), Hurthle cell (3%), and medullary (2%) carcinomas. One patient in the post-transplant cohort died from metastatic thyroid cancer 11.8 years after transplantation. There were 5 patients in the pre-transplant group and 4 patients in the post transplant group who had recurrent thyroid disease. There were no patients treated for differentiated thyroid cancer pre-solid organ transplantation that experienced disease recurrence after transplantation. Disease-free survival at 5 and 10 years was 95.8% and 92.1% (confidence interval 84.9-99.2%, 80.0-97.4%) in the pre-solid organ transplantation group vs 89.7% and 84.4% in the post (confidence interval: 80.0-96.3% and 79.0-93.1%, P = .363), respectively. Conclusion: Survival outcomes and recurrence rates in patients with thyroid cancer are not significantly affected by solid organ transplantation. A history of thyroid cancer or discovery of thyroid nodules during transplant screening should not be a contraindication for transplant listing. (C) 2020 Elsevier Inc. All rights reserved.

Appendiceal cancers represent a diverse group of malignancies with varying biological behavior. The significance of lymph node metastases in relation to long‐term survival and chemotherapy response is poorly defined.

Upper age limits for bariatric surgery are questioned on the merits of increased complication rates in the elderly and questionable efficacy. This study evaluates outcomes of bariatric surgery in patients ≥ 70 years of age. Retrospective review was performed of patients ≥ 70 years of age who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) between 2001 and 2018. Primary endpoints were 30-day readmission, Clavien-Dindo grade III–V (CD III–IV) complications, and mortality. Secondary data included were weight loss, long-term outcomes, comorbidity resolution, hemoglobin A1C, and lipid panels. A total of 23 patients with an average age of 72 years (range 70–80 years) and mean BMI of 43.3 (range 37.3–56.0) were reviewed. Average length-of-stay was 2.4 days (range 1–6 days), with the only acute complication being aspiration pneumonia in one patient. Median follow-up was 69.3 weeks (range 9–875 weeks). One-year follow-up rate was 96%, during which no deaths or CD III-IV complications occurred. Subsequently, one patient experienced failure-to-thrive requiring temporary enteral nutrition. Average 1 year percent total weight loss (%TWL) was 29%, and this was maintained on subsequent follow-ups. Average 1 year percent excess weight loss (%EWL) was 60%, maintained long-term at 61%. Significant serum biochemical improvements included hemoglobin A1C (6.9 ± 1.4% to 5.6 ± 1.3%, p = 0.001), triglycerides (155 ± 49 mg/dL to 102 ± 41 mg/dL, p = 0.0003), and high-density lipoprotein cholesterol (48 ± 14 mg/dL to 58 ± 22 mg/dL, p = 0.004). Laparoscopic RYGB is a safe and effective treatment for obesity and obesity-related comorbidities in septuagenarians.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC. Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes. Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (− 2.89 days, 95% CI − 4.84 to − 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08–0.57). Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.

Background: The Choosing Wisely Organization and the American College of Surgeons have issued recommendations for patients >70 with breast cancer involving screening and use of radiation therapy (RT) and sentinel lymph node biopsies (SNLB) in early stage tumors. This study evaluated compliance and implementation of these recommendations. Methods: A database of patients undergoing breast cancer surgery was retrospectively queried from 2002 to 2017. Patients were divided into cohorts before and after the year of each guideline publication. Results: The rate of presentation on mammography was not different before 2009 (65%) vs. after 2009 (66%). RT was given to 57% of patients with T1 ER + Her2-prior to 2013 vs. 27% after (p=<0.001). SLNB was performed in 91% of patients with T1, grade1/2, ER + Her2-tumors prior to 2016 vs. 56% after (p=<0.001). Conclusion: Rates of mammography detected breast cancer have not decreased but adjuvant RT and SLNB are less frequently performed in low risk breast cancer in the elderly. (C) 2019 Elsevier Inc. All rights reserved.

Background: Nipple-sparing mastectomy (NSM) use is increasing. We investigated the relationships between body mass index (BMI), operative time (OT), and ischemic complications. Methods: A single center, retrospective review was performed of NSMs from 2006 to 2018. Analysis included descriptive statistics, Wilcoxon rank-sum test and logistic regression. Results: Among 294 patients, 510 breast reconstructions were performed (216 bilateral). Median OTs in the prosthetic-based (266 patients, 90.5%) and autologous tissue groups (28 patients, 9.5%) were 266 and 529 min, respectively. Median OTs ranged from 236 to 358 min for those with BMI <20 and >= 40, respectively. Increasing BMI correlated with OT (r = 0.33, p < 0.001) and was associated with slightly higher odds of major NAC ischemic complications (OR = 1.09, p = 0.02). Conclusion: Higher BMI is associated with up to 50% longer OT, but is not a contraindication to NSM with reconstruction. Surgeons should recognize increased time and resource utilization. (c) 2019 Elsevier Inc. All rights reserved.