- Email: [email protected]
Compative Study of Bladder Versus Enteric Drainage in Pancreas Transplantation
Compative Study of Bladder Versus Enteric Drainage in Pancreas Transplantation C. Jiménez-Romero, A. Manrique, J.C. Meneu, F. Cambra, A. Andrés, J.M. Morales, E. González, E. Hernández, E. Morales, M. Praga, E. Gutierrez, and E. Moreno ABSTRACT Introduction. There is some controversy concerning the choice of best technique for drainage of exocrine secretions in pancreas transplantation. We compared patients with bladder drainage (BD) versus those with enteric drainage (ED). Patients and methods. From March 1995 to September 2008, 118 patients (68 men and 50 women) of overall mean age of 37.8 ⫾ 7.8 years underwent pancreas transplantation. There were 109 simultaneous pancreas-kidney, and 9 pancreas after kidney procedures. Recipients were divided in a BD (n ⫽ 66 patients) and an ED group (n ⫽ 52). Results. Donor characteristics were similar in both groups. Thirty-two patients (48.5%) of the BD group versus none in the ED group experienced urinary tract infections (UTI; P ⬍ .001), and 16 patients (24.2%) BD versus 15 (29.4%) ED developed intraabdominal infections (P ⫽ NS). The overall rate of relaparotomies was 33.9% (n ⫽ 40): 34.8% (n ⫽ 23) in the BD versus 32.7% (n ⫽ 17) in the ED group (P ⫽ NS). Thirty patients (25.4%) lost their pancreas grafts: 21 (31.8%) in the BD group versus 9 (17.3%) in the ED group (P ⫽ .055). The acute rejection rates were 12.7%; namely, 15.2% in the BD versus 9.8% in the ED (P ⫽ NS). Three-year patient and graft survivals were equivalent in both groups: 96.1% and 65.3% in the BD versus 89.0% and 74.0% in the ED group, respectively (P ⫽ NS). Conclusions. ED is a good alternative to BD for drainage of pancreatic graft exocrine secretions because both techniques have the same patient and graft survival, but BD is associated with a significantly higher rate of UTI and urologic complications. LADDER DRAINAGE (BD) AND ENTERIC DRAINAGE (ED) are the most common techniques for diverting pancreas exocrine secretions. BD allows physicians to monitor urinary amylase levels for the diagnosis of pancreas rejection, but is associated with metabolic acidosis and dehydration due to loss of the alkaline pancreatic secretions as well as urologic complications of infection, chemical cystitis and urethritis, reflux pancreatitis, hematuria, and bladder stones.1,2 However, these complications do not usually affect patient and pancreas graft survivals. In contrast, ED is now the preferable technique, because it is considered more physiologic, namely, there is direct drainage of exocrine secretions into the intestinal lumen, and because the incidences of urinary tract infections and urologic complications are significantly lower.3–5 However, it has some serious disadvantages, such intra-abdominal infections, anastomotic leaks, and diffuse peritonitis.3,4 The aim of this study was to compare the outcomes of BD versus
B
ED techniques in two groups of pancreas transplantation patients. PATIENTS AND METHODS From March 1995 to September 2008, 118 patients (116 with type 1 diabetes and two with type 2 diabetes) underwent pancreas transplantation: namely, 109 simultaneous pancreas-kidney and nine pancreas after kidney procedures. There were 68 men and 50 women of overall mean age at transplantation of 37.8 ⫾ 7.8 years (range ⫽ 25– 66 years). Recipients were divided into two groups according to the drainage of exocrine pancreatic secretions: (A) BD (n ⫽ 66) and (B) ED (distal ileum; n ⫽ 52). All pancreas graft From the Servicio de Cirugı´a General y Trasplante de Organos Abdominales, Hospital “Doce de Octubre,” Madrid, Spain. Address reprint requests to: Carlos Jiménez-Romero, Hospital “Doce de Octubre,” Servicio de Cirugı´a General y Trasplante de Organos Abdominales, 4a Planta, Ctra Andalucı´a Km 5.4, 28041 Madrid, Spain. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.164
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
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Transplantation Proceedings, 41, 2466 –2468 (2009)
BLADDER VERSUS ENTERIC DRAINAGE donors were younger than 45 years of age. Donor characteristics of hyperglycemia, hyperamylasemia, or hemodynamic instability were not considered absolute contraindications. In all patients, the pancreas graft was placed on the right side of the pelvis with an arterial anastomosis (“Y” graft) to the common iliac artery. The immunosuppressive regimen included antithymocyte globulin induction (range ⫽ 6 –12 days), tacrolimus, mycophenolate mofetil (1–2 g/d), and steroids. We analyzed donor and recipient characteristics, as well as posttransplant complications and patient and pancreas graft survivals in both study groups. Differences between means and proportions were assessed by Student t test and chi-square test, respectively. Comparison of qualitative and quantitative variables was performed by analysis of variance. Patient and graft survivals were calculated using the Kaplan-Meier method with survival curves compared by the log-rank test. P ⬍ .05 was considered significant.
RESULTS Donor Characteristics
Mean age, sex distribution, body mass index (BMI), serum glycemia and amylase levels, cold ischemia time, and rate of arterial hypotension were similar in both donor groups. Belzer preservation solution was used more frequently in BD pancreas grafts, and Celsior solution, in ED grafts. Recipient Characteristics
Age, sex distribution, and BMI were also similar between both groups of recipients. Duration of diabetes was significantly lower among the BD than the ED group (21.7 ⫾ 5.5 years vs 24.9 ⫾ 8.5 years, respectively; P ⬍ .05). Heparinization was more frequently used in the BD than the ED one (15.2% vs 3.8%; P ⬍ .05). Portoiliac vein anastomosis technique was more frequently performed in BD patients (P ⬍ .001) and, portocaval vein anastomosis, in the majority of ED patients (P ⬍ .001; Table 1). Thirty-two BD patients (48.5%) versus none in ED group displayed urinary tract infections (UTIs; P ⬍ .001). Sixteen BD patients (24.2%) versus 15 ED subjects (29.4%) developed intra-abdominal infections (P ⫽ NS). The overall rate of reoperations was 33.9% (n ⫽ 40): 34.8% (n ⫽ 23) in the BD versus 32.7% (n ⫽ 17) in the ED cohort (P ⫽ NS). Thirty patients (25.4%) lost their pancreas grafts: 21 patients (31.8%) in the BD versus 9 (17.3%) in the ED group (P ⫽ .055; Table 1). The causes of graft loss were: vascular thrombosis in 15 patients (12 patients in BD and 3 in ED; P ⬍ .05), acute or chronic rejection in seven, pancreatitis in three, duodenal leak and peritonitis in two, abscess in two, and pancreas hemorrhage in one. Graft pancreatectomy was performed in 21 patients: 15 (22.7%) in the BD and 6 (11.5%) in the ED group (P ⫽ .09). Fifteen patients (12.7%) showed acute rejection episodes: 10 (15.2%) in the BD group and 5 (9.8%) in the ED cohort (P ⫽ NS). Overall mortality was 5.08% (n ⫽ 6): one BD patient died due to venous graft thrombosis and respiratory distress; and four ED patients group, due to duodenal leak and peritonitis (n ⫽ 1), necrotizing pancreatitis (n ⫽ 1), aspergillosis (n ⫽ 1), and cerebrovascular disease (n ⫽ 1). Actuarial 5-year patient and graft survivals were similar in both groups: 97.0% and 70.0% in the
2467 Table 1. Donor and Recipient Characteristics and Posttransplant Complications Bladder-D (n ⫽ 66)
Donor variables Age (y) Sex (M/F) BMI (kg/m2) Glycemia (mg/dL) Serum amylase (U/L) Arterial hypotension Belzer solution Celsior solution Cold ischemia time (min) Recipient variables Age (y) Sex (male/female) BMI (kg/m2) Time of diabetes (y) Anticoagulation (IV heparin) Portoiliac vein anastomosis Portocaval vein anastomosis Posttransplant complications Urinary tract infections Intra-abdominal infections Pancreas thrombosis Relaparotomies Pancreas graft loss
Enteric-D (n ⫽ 52)
P Value
26.9 ⫾ 8.8 27.2 ⫾ 8.7 43/23 38/14 23.1 ⫾ 3.0 23.2 ⫾ 2.8 140 ⫾ 39 148 ⫾ 43 182 ⫾ 207 202 ⫾ 174 28 (42.4%) 23 (44.2%) 32 (48.5%) 19 (36.5%) 34 (51.5%) 33 (63.5%) 520 ⫾ 97 527 ⫾ 105
NS NS NS NS NS NS NS NS NS
37.5 ⫾ 6.7 38.4 ⫾ 9.1 34/32 34/18 22.7 ⫾ 3.1 23.6 ⫾ 3.0 21.7 ⫾ 5.5 24.9 ⫾ 8.5 10 (15.2%) 2 (3.8%) 25 (37.8%) 5 (9.6%) 41 (62.1%) 47 (90.4%)
NS NS NS ⬍.05 ⬍.05 ⬍.001 ⬍.001
32 (48.5%) 16 (24.2%) 13 (19.7%) 23 (34.8%) 21 (31.8%)
⬍.001 NS ⬍.05 NS NS
0 (0%) 15 (29.4%) 3 (5.8%) 17 (32.7%) 9 (17.3%)
Abbreviations: BMI, body mass index; IV, intravenous; NS, not significant.
BD versus 91.2%, and 83.6% in the ED group, respectively (P ⫽ NS). Conversion from BD to ED was performed in eight cases (12.1%) due to UTI recurrence, reflux pancreatitis, and duodenal-bladder fistula in one case of an annular pancreas graft. DISCUSSION
Portocaval anastomosis was more significantly used among our ED group and portoiliac anastomosis in the BD cohort. From some years ago, we always performed a portocaval anastomosis and variably BD or ED as the exocrine drainage technique. Pancreas graft thrombosis was more significantly frequent among the BD group despite more frequent use of heparinization in this group. The combination of portocaval and ED can contribute to the lesser rate of vascular thrombosis. The incidence of UTI among BD cases has been reported to be between 63% and 66% and for ED, 20% to 33%.4,5 In our experience, UTIs have only been seen in BD patients with a higher incidence (48.5%). Our rate of intra-abdominal infections was slightly but not significantly higher in the ED group. Relaparotomy was usually required among 28% to 32% of pancreas recipients6,7; the most common causes were intra-abdominal infections, vascular graft thrombosis, anastomotic leak, and hemorrhage; 70% of these patients eventuated in graft pancreatectomy.6 In our series, the overall rate of relaparotomy was 33.9% with similar rates among BD and ED
2468
groups. Pancreas graft loss due to technical failures (thrombosis, infections, pancreatitis, leak, bleeding) has been reported in 13.1% of cases, with 12.7% due to acute or chronic rejection.8 In our experience, most pancreas graft losses were related to technical failures— graft thrombosis, leaks, abscess. The rate of thrombosis as the cause of graft loss was significantly higher among the BD group. Transplantectomy was more frequently performed in the BD group, mainly because of graft thrombosis. A combination of antibodies (monoclonal or polyclonal), tacrolimus, mycophenolate mofetil, and reduced doses of steroids has resulted in a significantly decreased rejection rate, usually between 27% and 28% in recent series.7,9 Our pancreas rejection rate was 12.7% with the same immunosuppressive regimen, it did not show a significant difference between the groups. The conversion rate from BD to ED has been reported between 10% and 35%.10,11 The reasons are usually acidosis (excessive sodium bicarbonate loss), UTI, pancreatitis, and urologic complications,1,2,12 as we have observed with 12.1% of cases in our experience. It has been reported that actuarial 3-year patient and graft survivals were equivalent in both ED and BD groups.5 Our 5-year patient survival was greater among the BD group; conversely, the 5-year pancreas graft survival was higher among the ED group, but the differences were not significant. REFERENCES 1. Sollinger HW, Messing EM, Eckhoff DE, et al: Urological complications in 210 consecutive simultaneous pancreas-kidney transplants with bladder drainage. Ann Surg 218:561, 1993
JIMÉNEZ-ROMERO, MANRIQUE, MENEU ET AL 2. Sindhi R, Stratta RJ, Lowell JA, et al: Experience with enteric conversion after pancreatic transplantation with bladder drainage. J Am Coll Surg 184:281, 1997 3. Douzdjian V, Abecassis MM, Cooper JL, et al: Incidence, management and significance of surgical complications after pancreatic transplantation. Surg Gynecol Obstet 177:451, 1993 4. Pirsch JD, Odorico JS, D’Alessandro AM, et al: Posttransplant infection in enteric versus bladder-drained simultaneous pancreas-kidney transplant recipients. Transplantation 66:1746, 1998 5. Feitosa LC, Dawhara M, Benchaib M, et al: Effect of the surgical technique on long-term outcome of pancreas transplantation. Transpl Int 11:295, 1998 6. Gruessner RWG, Sutherland DER, Troppmann C, et al: The surgical risk of pancreas transplantation in the cyclosporine era: an overview. J Am Coll Surg 185:128, 1997 7. Stratta RJ, Shokoub-Amiri MH, Egidi MF, et al: Long-term experience with simultaneous kidney-pancreas transplantation with portal-enteric drainage and tacrolimus/mycophenolate mofetilbased immunosuppression. Clin Transplant 17(suppl 9):69, 2003 8. Humar A, Ramcharan T, Kandaswamy R, et al: Technical failures after pancreas transplants: why grafts fail and the risk factors—a multivariate analysis. Transplantation 78:1188, 2004 9. Bechstein WO, Malaise J, Saudek F, et al: Efficacy and safety of tacrolimus compared with microemulsion in primary simultaneous pancreas-kidney transplantation: 1-year results of a large multicenter trial. Transplantation 77:1221, 2004 10. West M, Gruessner A, Metrakos P, et al: Conversion from bladder to enteric drainage after pancreaticoduodenal transplantation. Surgery 124:883, 1998 11. Bogetti D, Nazarewski S, Zielinski A, et al: Perioperative treatment with octreotide minimizes technical complications after enteric conversion of bladder-drained pancreas transplants. Clin Transplant 18:137, 2004 12. Marang-van de Mheen PJ, Nijhof HW, Khairoun M, et al: Pancreas-kidney transplantations with primary bladder drainage followed by enteric conversion: graft survival and outcomes. Transplantation 85:517, 2008
B
ED techniques in two groups of pancreas transplantation patients. PATIENTS AND METHODS From March 1995 to September 2008, 118 patients (116 with type 1 diabetes and two with type 2 diabetes) underwent pancreas transplantation: namely, 109 simultaneous pancreas-kidney and nine pancreas after kidney procedures. There were 68 men and 50 women of overall mean age at transplantation of 37.8 ⫾ 7.8 years (range ⫽ 25– 66 years). Recipients were divided into two groups according to the drainage of exocrine pancreatic secretions: (A) BD (n ⫽ 66) and (B) ED (distal ileum; n ⫽ 52). All pancreas graft From the Servicio de Cirugı´a General y Trasplante de Organos Abdominales, Hospital “Doce de Octubre,” Madrid, Spain. Address reprint requests to: Carlos Jiménez-Romero, Hospital “Doce de Octubre,” Servicio de Cirugı´a General y Trasplante de Organos Abdominales, 4a Planta, Ctra Andalucı´a Km 5.4, 28041 Madrid, Spain. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.164
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
2466
Transplantation Proceedings, 41, 2466 –2468 (2009)
BLADDER VERSUS ENTERIC DRAINAGE donors were younger than 45 years of age. Donor characteristics of hyperglycemia, hyperamylasemia, or hemodynamic instability were not considered absolute contraindications. In all patients, the pancreas graft was placed on the right side of the pelvis with an arterial anastomosis (“Y” graft) to the common iliac artery. The immunosuppressive regimen included antithymocyte globulin induction (range ⫽ 6 –12 days), tacrolimus, mycophenolate mofetil (1–2 g/d), and steroids. We analyzed donor and recipient characteristics, as well as posttransplant complications and patient and pancreas graft survivals in both study groups. Differences between means and proportions were assessed by Student t test and chi-square test, respectively. Comparison of qualitative and quantitative variables was performed by analysis of variance. Patient and graft survivals were calculated using the Kaplan-Meier method with survival curves compared by the log-rank test. P ⬍ .05 was considered significant.
RESULTS Donor Characteristics
Mean age, sex distribution, body mass index (BMI), serum glycemia and amylase levels, cold ischemia time, and rate of arterial hypotension were similar in both donor groups. Belzer preservation solution was used more frequently in BD pancreas grafts, and Celsior solution, in ED grafts. Recipient Characteristics
Age, sex distribution, and BMI were also similar between both groups of recipients. Duration of diabetes was significantly lower among the BD than the ED group (21.7 ⫾ 5.5 years vs 24.9 ⫾ 8.5 years, respectively; P ⬍ .05). Heparinization was more frequently used in the BD than the ED one (15.2% vs 3.8%; P ⬍ .05). Portoiliac vein anastomosis technique was more frequently performed in BD patients (P ⬍ .001) and, portocaval vein anastomosis, in the majority of ED patients (P ⬍ .001; Table 1). Thirty-two BD patients (48.5%) versus none in ED group displayed urinary tract infections (UTIs; P ⬍ .001). Sixteen BD patients (24.2%) versus 15 ED subjects (29.4%) developed intra-abdominal infections (P ⫽ NS). The overall rate of reoperations was 33.9% (n ⫽ 40): 34.8% (n ⫽ 23) in the BD versus 32.7% (n ⫽ 17) in the ED cohort (P ⫽ NS). Thirty patients (25.4%) lost their pancreas grafts: 21 patients (31.8%) in the BD versus 9 (17.3%) in the ED group (P ⫽ .055; Table 1). The causes of graft loss were: vascular thrombosis in 15 patients (12 patients in BD and 3 in ED; P ⬍ .05), acute or chronic rejection in seven, pancreatitis in three, duodenal leak and peritonitis in two, abscess in two, and pancreas hemorrhage in one. Graft pancreatectomy was performed in 21 patients: 15 (22.7%) in the BD and 6 (11.5%) in the ED group (P ⫽ .09). Fifteen patients (12.7%) showed acute rejection episodes: 10 (15.2%) in the BD group and 5 (9.8%) in the ED cohort (P ⫽ NS). Overall mortality was 5.08% (n ⫽ 6): one BD patient died due to venous graft thrombosis and respiratory distress; and four ED patients group, due to duodenal leak and peritonitis (n ⫽ 1), necrotizing pancreatitis (n ⫽ 1), aspergillosis (n ⫽ 1), and cerebrovascular disease (n ⫽ 1). Actuarial 5-year patient and graft survivals were similar in both groups: 97.0% and 70.0% in the
2467 Table 1. Donor and Recipient Characteristics and Posttransplant Complications Bladder-D (n ⫽ 66)
Donor variables Age (y) Sex (M/F) BMI (kg/m2) Glycemia (mg/dL) Serum amylase (U/L) Arterial hypotension Belzer solution Celsior solution Cold ischemia time (min) Recipient variables Age (y) Sex (male/female) BMI (kg/m2) Time of diabetes (y) Anticoagulation (IV heparin) Portoiliac vein anastomosis Portocaval vein anastomosis Posttransplant complications Urinary tract infections Intra-abdominal infections Pancreas thrombosis Relaparotomies Pancreas graft loss
Enteric-D (n ⫽ 52)
P Value
26.9 ⫾ 8.8 27.2 ⫾ 8.7 43/23 38/14 23.1 ⫾ 3.0 23.2 ⫾ 2.8 140 ⫾ 39 148 ⫾ 43 182 ⫾ 207 202 ⫾ 174 28 (42.4%) 23 (44.2%) 32 (48.5%) 19 (36.5%) 34 (51.5%) 33 (63.5%) 520 ⫾ 97 527 ⫾ 105
NS NS NS NS NS NS NS NS NS
37.5 ⫾ 6.7 38.4 ⫾ 9.1 34/32 34/18 22.7 ⫾ 3.1 23.6 ⫾ 3.0 21.7 ⫾ 5.5 24.9 ⫾ 8.5 10 (15.2%) 2 (3.8%) 25 (37.8%) 5 (9.6%) 41 (62.1%) 47 (90.4%)
NS NS NS ⬍.05 ⬍.05 ⬍.001 ⬍.001
32 (48.5%) 16 (24.2%) 13 (19.7%) 23 (34.8%) 21 (31.8%)
⬍.001 NS ⬍.05 NS NS
0 (0%) 15 (29.4%) 3 (5.8%) 17 (32.7%) 9 (17.3%)
Abbreviations: BMI, body mass index; IV, intravenous; NS, not significant.
BD versus 91.2%, and 83.6% in the ED group, respectively (P ⫽ NS). Conversion from BD to ED was performed in eight cases (12.1%) due to UTI recurrence, reflux pancreatitis, and duodenal-bladder fistula in one case of an annular pancreas graft. DISCUSSION
Portocaval anastomosis was more significantly used among our ED group and portoiliac anastomosis in the BD cohort. From some years ago, we always performed a portocaval anastomosis and variably BD or ED as the exocrine drainage technique. Pancreas graft thrombosis was more significantly frequent among the BD group despite more frequent use of heparinization in this group. The combination of portocaval and ED can contribute to the lesser rate of vascular thrombosis. The incidence of UTI among BD cases has been reported to be between 63% and 66% and for ED, 20% to 33%.4,5 In our experience, UTIs have only been seen in BD patients with a higher incidence (48.5%). Our rate of intra-abdominal infections was slightly but not significantly higher in the ED group. Relaparotomy was usually required among 28% to 32% of pancreas recipients6,7; the most common causes were intra-abdominal infections, vascular graft thrombosis, anastomotic leak, and hemorrhage; 70% of these patients eventuated in graft pancreatectomy.6 In our series, the overall rate of relaparotomy was 33.9% with similar rates among BD and ED
2468
groups. Pancreas graft loss due to technical failures (thrombosis, infections, pancreatitis, leak, bleeding) has been reported in 13.1% of cases, with 12.7% due to acute or chronic rejection.8 In our experience, most pancreas graft losses were related to technical failures— graft thrombosis, leaks, abscess. The rate of thrombosis as the cause of graft loss was significantly higher among the BD group. Transplantectomy was more frequently performed in the BD group, mainly because of graft thrombosis. A combination of antibodies (monoclonal or polyclonal), tacrolimus, mycophenolate mofetil, and reduced doses of steroids has resulted in a significantly decreased rejection rate, usually between 27% and 28% in recent series.7,9 Our pancreas rejection rate was 12.7% with the same immunosuppressive regimen, it did not show a significant difference between the groups. The conversion rate from BD to ED has been reported between 10% and 35%.10,11 The reasons are usually acidosis (excessive sodium bicarbonate loss), UTI, pancreatitis, and urologic complications,1,2,12 as we have observed with 12.1% of cases in our experience. It has been reported that actuarial 3-year patient and graft survivals were equivalent in both ED and BD groups.5 Our 5-year patient survival was greater among the BD group; conversely, the 5-year pancreas graft survival was higher among the ED group, but the differences were not significant. REFERENCES 1. Sollinger HW, Messing EM, Eckhoff DE, et al: Urological complications in 210 consecutive simultaneous pancreas-kidney transplants with bladder drainage. Ann Surg 218:561, 1993
JIMÉNEZ-ROMERO, MANRIQUE, MENEU ET AL 2. Sindhi R, Stratta RJ, Lowell JA, et al: Experience with enteric conversion after pancreatic transplantation with bladder drainage. J Am Coll Surg 184:281, 1997 3. Douzdjian V, Abecassis MM, Cooper JL, et al: Incidence, management and significance of surgical complications after pancreatic transplantation. Surg Gynecol Obstet 177:451, 1993 4. Pirsch JD, Odorico JS, D’Alessandro AM, et al: Posttransplant infection in enteric versus bladder-drained simultaneous pancreas-kidney transplant recipients. Transplantation 66:1746, 1998 5. Feitosa LC, Dawhara M, Benchaib M, et al: Effect of the surgical technique on long-term outcome of pancreas transplantation. Transpl Int 11:295, 1998 6. Gruessner RWG, Sutherland DER, Troppmann C, et al: The surgical risk of pancreas transplantation in the cyclosporine era: an overview. J Am Coll Surg 185:128, 1997 7. Stratta RJ, Shokoub-Amiri MH, Egidi MF, et al: Long-term experience with simultaneous kidney-pancreas transplantation with portal-enteric drainage and tacrolimus/mycophenolate mofetilbased immunosuppression. Clin Transplant 17(suppl 9):69, 2003 8. Humar A, Ramcharan T, Kandaswamy R, et al: Technical failures after pancreas transplants: why grafts fail and the risk factors—a multivariate analysis. Transplantation 78:1188, 2004 9. Bechstein WO, Malaise J, Saudek F, et al: Efficacy and safety of tacrolimus compared with microemulsion in primary simultaneous pancreas-kidney transplantation: 1-year results of a large multicenter trial. Transplantation 77:1221, 2004 10. West M, Gruessner A, Metrakos P, et al: Conversion from bladder to enteric drainage after pancreaticoduodenal transplantation. Surgery 124:883, 1998 11. Bogetti D, Nazarewski S, Zielinski A, et al: Perioperative treatment with octreotide minimizes technical complications after enteric conversion of bladder-drained pancreas transplants. Clin Transplant 18:137, 2004 12. Marang-van de Mheen PJ, Nijhof HW, Khairoun M, et al: Pancreas-kidney transplantations with primary bladder drainage followed by enteric conversion: graft survival and outcomes. Transplantation 85:517, 2008