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Spectrum of Imaging Findings After Intestinal, Liver-Intestinal, or Multivisceral Transplantation: Part 1, Posttransplantation Anatomy

¹ Department of Pediatrics, Leopold-Franzens University, Anichstrasse 35, Innsbruck A-6020, Austria.
² Department of Radiology, Leopold-Franzens University, Innsbruck, Austria.
³ Department of General Surgery and Transplantation Surgery, Leopold-Franzens University, Innsbruck, Austria.

View larger version (100K): [in a new window]   Fig. 1A. —Schematic illustrations of isolated intestinal transplantation. Ao = abdominal aorta, CIA = common iliac artery, d = donor, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, TI = temporary ileostomy, single arrow = duodenojejunal anastomosis, double arrows = ileocolonic anastomosis, open arrowhead = superior mesenteric vein stump, solid arrowhead = venous extension graft, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intestinal graft after explantation and ex situ preparation on back-table.

View larger version (93K): [in a new window]   Fig. 1B. —Schematic illustrations of isolated intestinal transplantation. Ao = abdominal aorta, CIA = common iliac artery, d = donor, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, TI = temporary ileostomy, single arrow = duodenojejunal anastomosis, double arrows = ileocolonic anastomosis, open arrowhead = superior mesenteric vein stump, solid arrowhead = venous extension graft, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after heterotopic intestinal transplantation. End-to-side anastomosis of recipient common iliac artery to donor superior mesenteric artery and donor superior mesenteric vein to recipient inferior vena cava are also depicted.

View larger version (87K): [in a new window]   Fig. 1C. —Schematic illustrations of isolated intestinal transplantation. Ao = abdominal aorta, CIA = common iliac artery, d = donor, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, TI = temporary ileostomy, single arrow = duodenojejunal anastomosis, double arrows = ileocolonic anastomosis, open arrowhead = superior mesenteric vein stump, solid arrowhead = venous extension graft, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after orthotopic intestinal transplantation. End-to-side anastomosis of recipient infrarenal abdominal aorta to donor superior mesenteric artery and donor superior mesenteric vein to recipient superior mesenteric vein stump utilizing venous extension graft are depicted.

View larger version (74K): [in a new window]   Fig. 7A. —Schematic illustrations of multivisceral transplantation. d = donor, L = liver, P = pancreas, r = recipient, ST = stomach, TI = temporary ileostomy, single black arrow = gastrogastric anastomosis, white arrows = cavocaval anastomosis, double black arrows = ileocolonic anastomosis, open arrowheads = aortic segment together with celiac trunk and superior mesenteric artery, solid single arrowheads = inferior vena cava segment together with hepatic veins, solid double arrowheads = aortoaortic anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows multivisceral graft on back-table after explantation.

View larger version (75K): [in a new window]   Fig. 7B. —Schematic illustrations of multivisceral transplantation. d = donor, L = liver, P = pancreas, r = recipient, ST = stomach, TI = temporary ileostomy, single black arrow = gastrogastric anastomosis, white arrows = cavocaval anastomosis, double black arrows = ileocolonic anastomosis, open arrowheads = aortic segment together with celiac trunk and superior mesenteric artery, solid single arrowheads = inferior vena cava segment together with hepatic veins, solid double arrowheads = aortoaortic anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after implantation.

View larger version (94K): [in a new window]   Fig. 2A. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with only oral contrast material (A) and with oral and IV contrast material (B) show normal wall, mucosal folds, and contrast enhancement of intestinal graft.

View larger version (85K): [in a new window]   Fig. 2B. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with only oral contrast material (A) and with oral and IV contrast material (B) show normal wall, mucosal folds, and contrast enhancement of intestinal graft.

View larger version (103K): [in a new window]   Fig. 2C. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with oral and IV contrast application at level of arterial anastomosis (C) and at level of venous anastomosis (D) show donor superior mesenteric artery arising from recipient infrarenal aorta and donor superior mesenteric vein draining in recipient inferior vena cava.

View larger version (99K): [in a new window]   Fig. 2D. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowheads = donor lymph node. Images obtained with oral and IV contrast application at level of arterial anastomosis (C) and at level of venous anastomosis (D) show donor superior mesenteric artery arising from recipient infrarenal aorta and donor superior mesenteric vein draining in recipient inferior vena cava.

View larger version (112K): [in a new window]   Fig. 2E. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen. Selective catheter angiogram obtained during dominant arterial phase shows arterial anastomosis of donor superior mesenteric artery to recipient infrarenal aorta.

View larger version (131K): [in a new window]   Fig. 2F. —MDCT scans obtained 14 months after heterotopic intestinal transplantation in 3-year-old girl with short-bowel syndrome. Ao = abdominal aorta, d = donor, IMA = inferior mesenteric artery, IVC = inferior vena cava, L = liver, r = recipient, S = spleen, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, asterisks = intestinal graft lumen. Selective catheter angiogram obtained during dominant venous phase displays venous anastomosis of donor superior mesenteric vein to recipient inferior vena cava.

View larger version (107K): [in a new window]   Fig. 3A. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric vein draining in recipient portal venous confluence.

View larger version (107K): [in a new window]   Fig. 3B. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric vein draining in recipient portal venous confluence.

View larger version (103K): [in a new window]   Fig. 3C. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric artery arising from recipient infrarenal aorta.

View larger version (103K): [in a new window]   Fig. 3D. —Contrast-enhanced MDCT scans of 39-year-old man with normal graft function 14 months after orthotopic intestinal transplantation because of short-bowel syndrome. Ao = abdominal aorta, d = donor, GB = gallbladder, IVC = inferior vena cava, r = recipient, SV = splenic vein, ST = stomach, SMA = superior mesenteric artery stump, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, white asterisk = loculated fluid, arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node, white arrowheads = hyperdense staple line. Images show donor superior mesenteric artery arising from recipient infrarenal aorta.

View larger version (97K): [in a new window]   Fig. 4A. —Contrast-enhanced MDCT scans obtained 4 months after intestinal transplantation in 5-year-old girl with short-bowel syndrome. Ao = abdominal aorta, C = colon, CIA = common iliac artery, d = donor, D = duodenum, I = ileum, IMA = inferior mesenteric artery, IVC = inferior vena cava, J = jejunum, r = recipient, SMV = superior mesenteric vein, white asterisks = intestinal graft lumen, black arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node. Images show proximal intestinal end-to-end anastomosis (between white arrowheads, A) between recipient duodenum and donor jejunum (A) and distal intestinal end-to-end anastomosis (between white arrows, B) marked by hyperdense staple line between donor ileum and recipient ascending colon (B).

View larger version (92K): [in a new window]   Fig. 4B. —Contrast-enhanced MDCT scans obtained 4 months after intestinal transplantation in 5-year-old girl with short-bowel syndrome. Ao = abdominal aorta, C = colon, CIA = common iliac artery, d = donor, D = duodenum, I = ileum, IMA = inferior mesenteric artery, IVC = inferior vena cava, J = jejunum, r = recipient, SMV = superior mesenteric vein, white asterisks = intestinal graft lumen, black arrows = subsegmental arteries and veins in mesenteric fat of intestinal graft, black arrowheads = donor lymph node. Images show proximal intestinal end-to-end anastomosis (between white arrowheads, A) between recipient duodenum and donor jejunum (A) and distal intestinal end-to-end anastomosis (between white arrows, B) marked by hyperdense staple line between donor ileum and recipient ascending colon (B).

View larger version (131K): [in a new window]   Fig. 5. —Upper gastrointestinal study with water-soluble contrast material obtained 4 weeks after intestinal transplantation in 39-year-old man with short-bowel syndrome. Image shows proximal intestinal side-to-end anastomosis (between arrows) between recipient duodenum and donor jejunum. d = donor, D = duodenum, J = jejunum, r = recipient, ST = stomach, asterisk = recipient duodenal stump, between arrows = proximal intestinal anastomosis, arrowheads = gastric tube.

View larger version (122K): [in a new window]   Fig. 6. —Retrograde intestinal enema study obtained 3 months after intestinal transplantation in 59-year-old man with short-bowel syndrome shows blocked Foley catheter (open arrowhead) within isolated donor intestinal loop (asterisk) and distal intestinal end-to-side anastomosis (between arrows) between donor ileum and recipient rectum. d = donor, I = ileum, J = jejunum, r = recipient, R = rectum, solid arrowhead = intestinal tube.

View larger version (106K): [in a new window]   Fig. 8A. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (119K): [in a new window]   Fig. 8B. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (117K): [in a new window]   Fig. 8C. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (120K): [in a new window]   Fig. 8D. —Contrast-enhanced MDCT scans obtained during dominant arterial phase and 5 weeks after multivisceral transplantation in 61-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = abdominal aorta, AoC = aortic conduit, C = colon, CHA = common hepatic artery, CTr = celiac trunk, d = donor, IVC = inferior vena cava, LRV = left renal vein, L = liver, P = pancreas, PV = portal vein, r = recipient, SA = splenic artery, ST = stomach, SMA = superior mesenteric artery, SMV = superior mesenteric vein, black asterisks = intestinal graft lumen, arrow = subsegmental arteries and veins in mesenteric fat of intestinal graft, arrowhead = renal cyst. Images show normal anatomy at level of arterial anastomosis (A), origin of celiac trunk (B), origin of superior mesenteric artery (C), and bifurcation of celiac trunk (D).

View larger version (107K): [in a new window]   Fig. 9A. —Contrast-enhanced helical CT scans obtained 7 days after multivisceral transplantation with piggyback technique in 67-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = aorta, d = donor, L = liver, r = recipient, ST = stomach, white asterisk = ascites, solid single arrow = donor inferior vena cava, open arrows = liver vein, solid double arrows = recipient inferior vena cava with hyperdense staple line, black arrowhead = gastric tube, solid arrowhead = subphrenic drain, open arrowhead = staple line of donor caval stump. Images obtained at level of hepatic veins show side-by-side location of donor and recipient inferior vena cava (A) and stapled caval stump caudally (B).

View larger version (103K): [in a new window]   Fig. 9B. —Contrast-enhanced helical CT scans obtained 7 days after multivisceral transplantation with piggyback technique in 67-year-old man with liver cirrhosis, hepatocellular carcinoma, and portomesenteric thrombosis. Ao = aorta, d = donor, L = liver, r = recipient, ST = stomach, white asterisk = ascites, solid single arrow = donor inferior vena cava, open arrows = liver vein, solid double arrows = recipient inferior vena cava with hyperdense staple line, black arrowhead = gastric tube, solid arrowhead = subphrenic drain, open arrowhead = staple line of donor caval stump. Images obtained at level of hepatic veins show side-by-side location of donor and recipient inferior vena cava (A) and stapled caval stump caudally (B).

View larger version (130K): [in a new window]   Fig. 10. —Upper gastrointestinal study with water-soluble contrast material obtained 5 years after multivisceral transplantation in 41-year-old woman with Gardner's syndrome and intraabdominal desmoid tumor. Image shows normal postoperative anatomy after end-to-end gastrogastrostomy with normal intestinal contrast passage. Exact position of end-to-end gastrogastrostomy is not discernible. d = donor, r = recipient, ST = stomach, asterisks = intestinal graft, arrowheads = urethral drainage tube.

View larger version (79K): [in a new window]   Fig. 11A. —Schematic illustrations of liver-intestinal transplantation. CBD = common bile duct, CHA = common hepatic artery, CTr = celiac trunk, d = donor, D = duodenum, IMV = inferior mesenteric vein, IVC = inferior vena cava, LHV = left hepatic vein, LLHA = left lateral hepatic artery, LLHD = left lateral hepatic duct, P = pancreas, PV = portal vein, r = recipient, S = spleen, SA = splenic artery, SMA = superior mesenteric artery, SMV = superior mesenteric vein, ST = stomach, SV = splenic vein, TI = temporary ileostomy, single arrows = duodenoduodenal anastomosis, double arrows = ileocolonic anastomosis, black arrowhead = hepatocaval anastomosis, white arrowhead = portocaval anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration of intraoperative appearance of recipient site after removal of diseased liver in patient with short-bowel syndrome shows end-to-side anastomosis between portal vein and inferior vena cava.

View larger version (81K): [in a new window]   Fig. 11B. —Schematic illustrations of liver-intestinal transplantation. CBD = common bile duct, CHA = common hepatic artery, CTr = celiac trunk, d = donor, D = duodenum, IMV = inferior mesenteric vein, IVC = inferior vena cava, LHV = left hepatic vein, LLHA = left lateral hepatic artery, LLHD = left lateral hepatic duct, P = pancreas, PV = portal vein, r = recipient, S = spleen, SA = splenic artery, SMA = superior mesenteric artery, SMV = superior mesenteric vein, ST = stomach, SV = splenic vein, TI = temporary ileostomy, single arrows = duodenoduodenal anastomosis, double arrows = ileocolonic anastomosis, black arrowhead = hepatocaval anastomosis, white arrowhead = portocaval anastomosis, black asterisk = intestinal graft, white asterisk = residual recipient colon. Illustration shows intraoperative appearance of recipient site after implantation of size-reduced liver-intestinal graft using extended right hemihepatectomy and distal segmental small-bowel resection.

View larger version (130K): [in a new window]   Fig. 12A. —High-resolution sonograms obtained 3 months after liver-intestinal transplantation in 2-year-old girl with short-bowel syndrome. Ao = aorta, d = donor, L = liver, r = recipient, asterisk = intestinal graft. Axial image displays side-to-end arterial anastomosis (between arrowheads) between recipient abdominal aorta and donor aortic conduit (arrows).

View larger version (88K): [in a new window]   Fig. 12B. —High-resolution sonograms obtained 3 months after liver-intestinal transplantation in 2-year-old girl with short-bowel syndrome. Ao = aorta, d = donor, L = liver, r = recipient, asterisk = intestinal graft. Oblique image shows normal anatomy of portal vein (double arrows) and hepatic artery (single arrow).

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