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Role of Sonography in Pancreatic Transplantation¹

¹ From the Department of Radiology, Northwestern University Medical School, 676 N St Clair St, Suite 800, Chicago, IL 60611 (P.N., C.H., R.M.M.); Department of Radiology, Methodist Hospital, Baylor College of Medicine, Houston, Tex (R.S.A.); Departments of Radiology (P.N., P.C.C.) and Pathology (J.H.C.), University of Texas Medical School, Houston; and Department of Surgery, Wayne State University School of Medicine, Detroit, Mich (S.A.G.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received November 13, 2002; revision requested February 11, 2003, and received March 24; accepted April 4. Address correspondence to P.N. (e-mail: p-nikolaidis@northwestern.edu).

View larger version (99K): [in a new window]   Figure 1.  Drawing shows the anatomy of PAK transplantation, with bladder drainage and detailed depiction of the aortic patch containing the celiac (black arrow), splenic (sp), and superior mesenteric (*) arteries attached to the recipient common iliac artery. The donor portal vein is attached to the external iliac vein (white arrows). Note the side-to-side anastomosis between the duodenum (D), which is oversewn on both ends, and the bladder. A left iliac fossa renal transplant is also shown.

View larger version (99K): [in a new window]   Figure 2.  Diagram illustrates the portal-enteric technique for pancreatic transplantation. Vascular reconstruction involves connecting a donor iliac arterial Y-graft, composed of the internal and external branches of the donor common iliac artery, to the donor splenic (sp) and superior mesenteric (sm) arteries. The common iliac portion of the Y-graft is then anastomosed to the recipient common or external iliac artery. Venous drainage goes into the superior mesenteric vein (S). Note the donor duodenum (D), which is oversewn at both ends, with a side-to-side anastomosis to the recipient Roux-en-Y loop.

View larger version (122K): [in a new window]   Figure 3.  Gray-scale sonogram shows the anatomy of the transplanted pancreas body (B) and tail (T). The splenic artery (S) is located just posteriorly.

View larger version (132K): [in a new window]   Figure 4.  Gray-scale sonogram depicts the anatomy of the duodenopancreatic graft and its relationship to the pancreas. BL = bladder, D = duodenum, P = pancreas, with cursors delineating the pancreatic head.

View larger version (123K): [in a new window]   Figure 5a.  (a) Gray-scale sonogram of a PTA transplant reveals a heterogeneous appearance of the pancreatic parenchyma (arrows). Increased echogenicity of the pancreatic parenchyma renders the transplant isoechoic relative to the adjacent peripancreatic soft tissues. Because the pancreas lacks a defining capsule, the borders of the graft become indistinct, particularly in cases of acute graft rejection and pancreatitis. (b) Gray-scale sonogram of the pancreatic transplant in another patient demonstrates that sonographic delineation of the transplant is superior when it is outlined by fluid.

View larger version (105K): [in a new window]   Figure 5b.  (a) Gray-scale sonogram of a PTA transplant reveals a heterogeneous appearance of the pancreatic parenchyma (arrows). Increased echogenicity of the pancreatic parenchyma renders the transplant isoechoic relative to the adjacent peripancreatic soft tissues. Because the pancreas lacks a defining capsule, the borders of the graft become indistinct, particularly in cases of acute graft rejection and pancreatitis. (b) Gray-scale sonogram of the pancreatic transplant in another patient demonstrates that sonographic delineation of the transplant is superior when it is outlined by fluid.

View larger version (144K): [in a new window]   Figure 6a.  (a) Color flow sonogram demonstrates a portion of the pancreatic transplant (P) and the patent splenic artery and vein, seen on its undersurface. (b) Power flow image of another patient demonstrates normal intraparenchymal flow within the pancreatic transplant.

View larger version (137K): [in a new window]   Figure 6b.  (a) Color flow sonogram demonstrates a portion of the pancreatic transplant (P) and the patent splenic artery and vein, seen on its undersurface. (b) Power flow image of another patient demonstrates normal intraparenchymal flow within the pancreatic transplant.

View larger version (119K): [in a new window]   Figure 7.  Ascites in a patient who underwent SPK transplantation. Power flow image of the pancreatic transplant reveals a large anechoic fluid collection (FL) within the peritoneal cavity. An exocrine leak can precipitate ascites. The common iliac artery (a) and the Y-graft (arrow) are also shown.

View larger version (145K): [in a new window]   Figure 8.  Duodenovesicular anastomotic leak in a patient who underwent SPK transplantation. Gray-scale sonogram reveals a small amount of anechoic fluid (cursors) anterior to the pancreatic transplant (arrows).

View larger version (116K): [in a new window]   Figure 9a.  Pancreatic necrosis in a patient who recently underwent pancreatic transplantation and who presented with fever, leukocytosis, and severe right lower quadrant tenderness. (a) Gray-scale sonogram shows multiple echogenic foci (arrow) within the substance of the pancreatic transplant, findings compatible with foci of intraparenchymal air. (b) Subsequent CT scan obtained later that day helps confirm the presence of intrapancreatic air (arrow). At surgery, the necrotic transplant was draped with purulent material.

View larger version (99K): [in a new window]   Figure 9b.  Pancreatic necrosis in a patient who recently underwent pancreatic transplantation and who presented with fever, leukocytosis, and severe right lower quadrant tenderness. (a) Gray-scale sonogram shows multiple echogenic foci (arrow) within the substance of the pancreatic transplant, findings compatible with foci of intraparenchymal air. (b) Subsequent CT scan obtained later that day helps confirm the presence of intrapancreatic air (arrow). At surgery, the necrotic transplant was draped with purulent material.

View larger version (155K): [in a new window]   Figure 10.  Acute graft rejection in a patient with a PTA transplant. Power flow image shows nonspecific heterogeneity of the pancreatic graft parenchyma and graft swelling. Changes within the parenchyma are subtle. A small amount of peripancreatic fluid is seen anterior to the graft (arrow). Biopsy helped confirm acute rejection. Similar sonographic findings may be seen with graft pancreatitis.

View larger version (123K): [in a new window]   Figure 11.  Graft pancreatitis. Gray-scale sonogram reveals nonspecific enlargement and heterogeneity of the head of the transplanted pancreas (arrows). The patient’s serum amylase and lipase levels were markedly elevated. Findings from subsequent exploratory laparotomy confirmed the clinical diagnosis of pancreatitis.

View larger version (124K): [in a new window]   Figure 12a.  Pancreatitis in another patient with an amylase level exceeding 900. (a) Gray-scale sonogram reveals a hypoechoic pancreas (arrows) with fluid surrounding the transplant. (b) CT scan obtained the same day better delineates the extent of the large peripancreatic fluid collection. The mildly enhancing pancreatic transplant (P) is difficult to discern.

View larger version (134K): [in a new window]   Figure 12b.  Pancreatitis in another patient with an amylase level exceeding 900. (a) Gray-scale sonogram reveals a hypoechoic pancreas (arrows) with fluid surrounding the transplant. (b) CT scan obtained the same day better delineates the extent of the large peripancreatic fluid collection. The mildly enhancing pancreatic transplant (P) is difficult to discern.

View larger version (52K): [in a new window]   Figure 13.  Normal vascularity. Power flow sonogram of the pancreatic graft shows normal vascularity. Note how easy it is to discern the pancreatic transplant when it is surrounded by fluid.

View larger version (142K): [in a new window]   Figure 14a.  Pseudoaneurysm. (a) Color Doppler flow image demonstrates the classic swirling pattern in a large pseudoaneurysm adjacent to a pancreatic transplant. The supplying artery is the donor splenic artery (red) with the splenic vein (blue) adjacent to it. (b) Three-dimensional CT angiogram depicts the pseudoaneurysm. The white curved line is the duodenal stump suture line (arrow). The kidney transplant (K) is located posterior to it, whereas the pancreatic transplant (P) is seen as the faint green structure inferior to the pseudoaneurysm. (Case courtesy of Myron A. Pozniak, University of Wisconsin Hospital, Madison, Wis.)

View larger version (137K): [in a new window]   Figure 14b.  Pseudoaneurysm. (a) Color Doppler flow image demonstrates the classic swirling pattern in a large pseudoaneurysm adjacent to a pancreatic transplant. The supplying artery is the donor splenic artery (red) with the splenic vein (blue) adjacent to it. (b) Three-dimensional CT angiogram depicts the pseudoaneurysm. The white curved line is the duodenal stump suture line (arrow). The kidney transplant (K) is located posterior to it, whereas the pancreatic transplant (P) is seen as the faint green structure inferior to the pseudoaneurysm. (Case courtesy of Myron A. Pozniak, University of Wisconsin Hospital, Madison, Wis.)

View larger version (44K): [in a new window]   Figure 15.  Normal resistive index measurement. Duplex color Doppler flow imaging is useful in assessing the intraparenchymal arterial pressures as an indirect measure to detect complications such as vascular thrombosis, acute graft rejection, and pancreatitis. The measurement can be obtained from the intraparenchymal arterial vasculature (head, body, tail), or the extraparenchymal arterial vasculature (Y-graft). However, these measurements have not proved to be sensitive or specific in diagnosing certain complications.

View larger version (109K): [in a new window]   Figure 16.  Percutaneous biopsy. Gray-scale sonogram shows how sonographic guidance is used for core needle biopsy of the pancreatic body or tail (arrowheads). N = needle.

View larger version (160K): [in a new window]   Figure 17a.  Acute graft rejection in a patient with a PTA transplant and subtle sonographic findings who underwent percutaneous biopsy. (a) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) of a histologic specimen shows the focus of acinar inflammation and ductal inflammatory destruction by lymphocytes, characteristic of rejection (arrow). (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) of another histologic specimen shows destruction of acinar cells by lymphocytes (arrow). The degree of infiltration is compatible with grade 4 moderate rejection.

View larger version (155K): [in a new window]   Figure 17b.  Acute graft rejection in a patient with a PTA transplant and subtle sonographic findings who underwent percutaneous biopsy. (a) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) of a histologic specimen shows the focus of acinar inflammation and ductal inflammatory destruction by lymphocytes, characteristic of rejection (arrow). (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) of another histologic specimen shows destruction of acinar cells by lymphocytes (arrow). The degree of infiltration is compatible with grade 4 moderate rejection.