AJR 2004; 182:911-917
© American Roentgen Ray Society
Spectrum of Imaging Findings After Pancreas Transplantation with Enteric Exocrine Drainage: Part 1, Posttransplantation Anatomy
Martin C. Freund1,
Wolfgang Steurer2,
Eva M. Gassner1,
Karin M. Unsinn1,
Michael Rieger1,
Alfred Koenigsrainer2,
Raimund Margreiter2 and
Werner R. Jaschke1
1 Department of Radiology, Leopold-Franzens University, Anichstrasse 35,
Innsbruck A-6020, Austria.
2 Department of General Surgery and Transplant Surgery, Leopold-Franzens
University, Innsbruck A-6020, Austria.
Received May 21, 2003;
accepted after revision July 24, 2003.
Address correspondence to M. C. Freund
(martin.freund{at}uibk.ac.at).
Introduction
Successful pancreas transplantation is currently the only known therapy
that establishes an insulin-independent euglycemic state with normalization of
glycosylated hemoglobin levels. Insulin-secreting cells are part of the
pancreatic islets, which are predominantly located in the tail [l]. The first
human pancreas transplantation was performed at the University of Minnesota in
1966 [2]. Since then, pancreas
graft survival has improved consistently, especially in the last decade,
thanks to refined surgical techniques and the introduction of better
immunosuppressive regimens, including administration of tacrolimus and
mycophenolate mofetil, which have decreased technical and immunologic failure
rates. In total, over 90% of pancreas transplantations are performed as
simultaneous pancreas–kidney transplantation from the same donor, with
the remaining cases classified as sequential pancreas after previous kidney
transplantation and rarely as pancreas transplantation alone. Today the
International Pancreas Transplant Registry reports a 1-year patient survival
rate of greater than 95% and a 1-year pancreas graft survival rate of greater
than 80% for simultaneous pancreas–kidney transplantation and of nearly
80% for pancreas after previous kidney transplantation and pancreas
transplantation alone [3].
Although most transplantation centers formerly used exocrine bladder drainage
to divert pancreatic juice, an increasing proportion of simultaneous
pancreas–kidney transplantations is being performed with the more
physiologic enteric drainage and either systemic or portal endocrine
drainage.
Knowledge of the transplantation procedure and postoperative imaging
anatomy of the pancreas allograft is a basic requirement for radiologists.
Early diagnosis of organ-related complications after pancreas transplantation
is essential for short- and long-term results
[4,
5]. For these reasons, this
pictorial essay schematically illustrates the intraoperative appearance during
the most important steps of the pancreas transplantation procedure performed
in patients with standard vascular anatomy (i.e., organ procurement,
back-table reconstruction, and pancreas implantation [Fig.
1A,
1B,
1C,
1D]). This article is
supplemented by examples of typical anatomy as shown on several imaging
techniques, including sonography, CT, MRI, and angiography.
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Fig. 1A. —Schematic illustrations of transplantation procedure for
whole cadaveric pancreatic graft with enteric exocrine drainage. d = donor's,
r = right, CIA = common iliac artery, CIV = common iliac vein, CTR = celiac
trunk, D = duodenum, EIA = external iliac artery, GDA = gastroduodenal artery,
IIA = internal iliac artery, IMV = inferior mesenteric vein, IVC = inferior
vena cava, PG = pancreatic graft, PV = portal vein, SA = splenic artery, SMA =
superior mesenteric artery, SMV = superior mesenteric vein, SV = splenic vein.
Drawing shows intraoperative appearance at end of pancreas procurement before
splenectomy but after dissection of gastroduodenal artery, splenic artery,
superior and inferior mesenteric veins, superior mesenteric artery at line of
mesenteric root, and proximal and distal duodenum. Dissected common bile duct
is not shown because of superposition of donor's pancreatic head and
duodenum.
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Fig. 1B. —Schematic illustrations of transplantation procedure for
whole cadaveric pancreatic graft with enteric exocrine drainage. d = donor's,
r = right, CIA = common iliac artery, CIV = common iliac vein, CTR = celiac
trunk, D = duodenum, EIA = external iliac artery, GDA = gastroduodenal artery,
IIA = internal iliac artery, IMV = inferior mesenteric vein, IVC = inferior
vena cava, PG = pancreatic graft, PV = portal vein, SA = splenic artery, SMA =
superior mesenteric artery, SMV = superior mesenteric vein, SV = splenic vein.
Drawing shows back-table procedure with display of pancreatic graft from
behind and emphasis on arterial reconstruction. End-to-end anastomosis of
donor's external iliac artery to donor's superior mesenteric artery and
donor's internal iliac artery to donor's splenic artery is performed; donor's
common iliac artery serves as common arterial conduit of pancreatic graft.
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Fig. 1C. —Schematic illustrations of transplantation procedure for
whole cadaveric pancreatic graft with enteric exocrine drainage. d = donor's,
r = right, CIA = common iliac artery, CIV = common iliac vein, CTR = celiac
trunk, D = duodenum, EIA = external iliac artery, GDA = gastroduodenal artery,
IIA = internal iliac artery, IMV = inferior mesenteric vein, IVC = inferior
vena cava, PG = pancreatic graft, PV = portal vein, SA = splenic artery, SMA =
superior mesenteric artery, SMV = superior mesenteric vein, SV = splenic vein.
Drawing shows magnified intraoperative appearance after revascularization.
End-to-side anastomosis is used to connect donor's portal vein to recipient's
right common iliac vein and donor's arterial conduit to recipient's right
common iliac artery. Surgical drapings cover recipient's intestine.
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Fig. 1D. —Schematic illustrations of transplantation procedure for
whole cadaveric pancreatic graft with enteric exocrine drainage. d = donor's,
r = right, CIA = common iliac artery, CIV = common iliac vein, CTR = celiac
trunk, D = duodenum, EIA = external iliac artery, GDA = gastroduodenal artery,
IIA = internal iliac artery, IMV = inferior mesenteric vein, IVC = inferior
vena cava, PG = pancreatic graft, PV = portal vein, SA = splenic artery, SMA =
superior mesenteric artery, SMV = superior mesenteric vein, SV = splenic vein.
Drawing illustrates intraoperative appearance at end of transplantation
procedure. Pancreatic graft is placed intraperitoneally in pelvis in cephalad
orientation with side-to-side duodenojejunostomy (arrows) connecting
donor's duodenal segment to recipient's upper jejunum; donor's duodenum is
closed on both ends using sutures (arrowheads) or staples.
Recipient's native pancreas in upper abdomen is left untouched.
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Organ Procurement
The growing organ shortage and the establishment of pancreas
transplantation caused multiorgan procurement including liver and whole
pancreas from the same donor to become standard. This requires either en bloc
retrieval of liver and pancreas followed by back-table separation
[6] or separate procurement of
the liver before the pancreas
[7]. For procurement of the
donor's pancreas (Fig. 1A) and
a duodenal segment, various vascular structures must be ligated and transected
in an ordered temporal and spatial sequence. These are the proximal
gastroduodenal artery; proximal splenic artery; proximal portal vein; superior
and inferior mesenteric veins at the mesenteric root and lower rim of the
pancreas, respectively; proximal superior mesenteric artery distal to the
origin of the inferior pancreaticoduodenal artery, including the proximal
vascular root of the mesentery; and the splenic vascular pedicle at the
pancreatic tail. Also, the distal common bile duct is ligated and transected,
the duodenum is stapled and transected distal to the pylorus and at the third
segment, and the spleen is excised. Additionally, the donor's iliac artery
bifurcation is procured for reconstruction of the arterial conduit.
Back-Table Reconstruction
The procured pancreatic graft, attached to a small portion of the duodenum
containing the ampulla of Vater, is then further prepared in lactated Ringer's
solution at 4°C under sterile conditions at the back table
[8]
(Fig. 1B). Minimal requirements
for successful arterial reconstruction of the pancreatic graft are a
full-length splenic artery and a proximal superior mesenteric artery,
including the inferior pancreaticoduodenal artery. Arterial reconstruction is
performed with the donor's iliac artery bifurcation. The donor's external
iliac artery is anastomosed in an end-to-end fashion to the donor's proximal
superior mesenteric artery, and the donor's internal iliac artery, to the
donor's splenic artery. The donor's common iliac artery serves as a common
arterial conduit for the donor's pancreas and connects two formerly unrelated
arterial territories (i.e., mesenteric and splenic). Moreover, excess tissue,
especially fat, is carefully removed from the pancreatic borders without
injuring the parenchyma and vessels. The distal portion of the duodenum is
kept sufficiently long until the side-to-side duodenojejunostomy is completed
in the recipient.
Pancreas Transplantation
A midline abdominal incision is used for intraperitoneal placement. The
donor's pancreas is placed laterally in the pelvis with the duodenal segment
facing either preferentially cephalad for enteric exocrine diversion or
sometimes caudad for bladder drainage. Whenever possible, the graft is
revascularized in an end-to-side fashion, connecting the donor's portal vein
to the recipient's right common iliac vein or distal inferior vena cava and
the donor's arterial conduit to the recipient's right common iliac artery
(Fig. 1C). The side-to-side
duodenojejunostomy connects the donor's duodenal segment to the recipient's
upper jejunum, approximately 30–40 cm distal to the ligament of Treitz,
using a circular stapler for a circular, radiopaque suture line
(Fig. 1D). The second portion
of the duodenum is then shortened in situ to its final length of approximately
10 cm and closed distally with a stapling device. Modifications to this
approach include portal rather than systemic venous drainage of the endocrine
pancreas and bladder rather than enteric diversion of the pancreatic juice.
For portal drainage, the graft is placed parapancreatic, and an end-to-side
anastomosis is performed to join the donor's portal vein to the recipient's
infrapancreatic superior mesenteric vein and the donor's arterial conduit to
the recipient's proximal common iliac artery. With this approach, exocrine
diversion is completed by end-to-end anastomosis of the donor's distal
duodenum with a Roux-en-Y loop.
For exocrine bladder drainage, the pancreas graft with the duodenal segment
faces caudad with subsequent side-to-side duodenocystostomy. The recipient's
native pancreas is left untouched. Figures
2A,
2B,
2C,
2D,
3A,
3B,
4A,
4B,
5A,
5B,
5C,
6A,
6B,
7,
8,
9A,
9B,
9C,
9D,
10A,
10B illustrate the normal
postoperative imaging anatomy after pancreas transplantation with systemic
venous and exocrine enteric drainage using sonography, CT, MRI, angiography,
and small-bowel followthrough examination. All imaged patients underwent
pancreas transplantation for long-standing type 1 diabetes mellitus.
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Fig. 2A. —33-year-old man with history of two separate pancreas
transplantations at different times. d = donor's, r = right, l = left, CIA =
common iliac artery, CIVB = common iliac vein bifurcation, DPA = dorsal
pancreatic artery, EIA = external iliac artery, IIA = internal iliac artery,
IMA = inferior mesenteric artery, SA = splenic artery, SMA = superior
mesenteric artery, asterisk = renal graft. Contrast-enhanced helical CT scans
were obtained 36 months after initial simultaneous pancreas–kidney
transplantation with normal pancreatic graft function at time of examination.
Dominant arterial phase image obtained at line of arterial anastomosis
(A) and cephalad (B) and caudad (C) to arterial
anastomosis displays normal posttransplantation arterial anatomy, homogeneous
enhancement of pancreatic graft (arrow), and donor's normal duodenum
(black arrowhead, A and B) with hyperdense staple line
(white arrowhead, B).
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Fig. 2B. —33-year-old man with history of two separate pancreas
transplantations at different times. d = donor's, r = right, l = left, CIA =
common iliac artery, CIVB = common iliac vein bifurcation, DPA = dorsal
pancreatic artery, EIA = external iliac artery, IIA = internal iliac artery,
IMA = inferior mesenteric artery, SA = splenic artery, SMA = superior
mesenteric artery, asterisk = renal graft. Contrast-enhanced helical CT scans
were obtained 36 months after initial simultaneous pancreas–kidney
transplantation with normal pancreatic graft function at time of examination.
Dominant arterial phase image obtained at line of arterial anastomosis
(A) and cephalad (B) and caudad (C) to arterial
anastomosis displays normal posttransplantation arterial anatomy, homogeneous
enhancement of pancreatic graft (arrow), and donor's normal duodenum
(black arrowhead, A and B) with hyperdense staple line
(white arrowhead, B).
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Fig. 2C. —33-year-old man with history of two separate pancreas
transplantations at different times. d = donor's, r = right, l = left, CIA =
common iliac artery, CIVB = common iliac vein bifurcation, DPA = dorsal
pancreatic artery, EIA = external iliac artery, IIA = internal iliac artery,
IMA = inferior mesenteric artery, SA = splenic artery, SMA = superior
mesenteric artery, asterisk = renal graft. Contrast-enhanced helical CT scans
were obtained 36 months after initial simultaneous pancreas–kidney
transplantation with normal pancreatic graft function at time of examination.
Dominant arterial phase image obtained at line of arterial anastomosis
(A) and cephalad (B) and caudad (C) to arterial
anastomosis displays normal posttransplantation arterial anatomy, homogeneous
enhancement of pancreatic graft (arrow), and donor's normal duodenum
(black arrowhead, A and B) with hyperdense staple line
(white arrowhead, B).
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Fig. 2D. —33-year-old man with history of two separate pancreas
transplantations at different times. d = donor's, r = right, l = left, CIA =
common iliac artery, CIVB = common iliac vein bifurcation, DPA = dorsal
pancreatic artery, EIA external iliac artery, IIA = internal iliac artery, IMA
= inferior mesenteric artery, SA = splenic artery, SMA = superior mesenteric
artery, asterisk = renal graft. Three-dimensional volume-rendering image of
contrast-enhanced MDCT during dominant arterial phase, obtained 5 days after
sequential pancreas-after-kidney retransplantation after vascular failure and
pancreatectomy of initial pancreatic graft, shows normal posttransplantation
arterial anatomy, residual arterial conduit (RAC) after pancreatectomy of
initial pancreatic graft, hyperdense staple line (single arrowheads)
of donor's duodenum, and hyperdense circular staple line (double
arrowheads) of duodenojejunostomy (intestinal wall structures and grafted
pancreatic parenchyma are not seen because of applied electronic
thresholds).
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Fig. 3A. —53-year-old man after simultaneous pancreas–kidney
transplantation. d = donor's, r = right, CIA = common iliac artery, EIA =
external iliac artery, IIA = internal iliac artery, IPDA = inferior
pancreaticoduodenal artery, RA = renal artery, RV = renal vein, SA = splenic
artery, SMA = superior mesenteric artery. Angiogram obtained 31 months after
operation shows normal posttransplantation arterial anatomy with right-sided
pancreatic and left-sided renal graft.
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Fig. 3B. —53-year-old man after simultaneous pancreas–kidney
transplantation. d = donor's, r = right, CIA = common iliac artery, EIA =
external iliac artery, IIA = internal iliac artery, IPDA = inferior
pancreaticoduodenal artery, RA = renal artery, RV = renal vein, SA = splenic
artery, SMA = superior mesenteric artery. Maximum-intensity-projection
reconstruction of contrast-enhanced MR image obtained 47 months after
operation shows normal posttransplantation arterial anatomy.
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Fig. 4A. —39-year-old woman 56 months after simultaneous
pancreas–kidney transplantation. Arterial revascularization of
pancreatic graft was performed with donor's arterial conduit to recipient's
infrarenal aorta and right-sided renal transplantation because of advanced
calcifying arthrosclerosis. d = donor's, CTR = celiac trunk, RA = renal
artery, SMA = superior mesenteric artery. Lateral view of
maximum-intensity-projection reconstruction of contrast-enhanced MR image
shows normal enhancement of donor's arterial conduit (between arrow
and arrowhead) and originating donor's superior mesenteric
artery.
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Fig. 4B. —39-year-old woman 56 months after simultaneous
pancreas–kidney transplantation. Arterial revascularization of
pancreatic graft was performed with donor's arterial conduit to recipient's
infrarenal aorta and right-sided renal transplantation because of advanced
calcifying arthrosclerosis. d = donor's, CTR = celiac trunk, RA = renal
artery, SMA = superior mesenteric artery. Frontal view of
maximum-intensity-projection reconstruction of contrast-enhanced MR image
shows additional high-grade stenosis of right common iliac artery
(arrow) and serpentine arterial collateral (arrowhead)
between median sacral artery and internal iliac artery territory.
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Fig. 5A. —40-year-old man 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, CIV = common iliac vein, EIA = external iliac artery, IIA
= internal iliac artery, black arrow = pancreatic graft, PV = portal vein, SMV
= superior mesenteric vein, SV = splenic vein, asterisk = renal graft.
Contrast-enhanced MDCT scans obtained during dominant parenchymal phase at
level of venous anastomosis (A) and cephalad (B) and caudad
(C) to venous anastomosis show normal posttransplantation venous
anatomy, homogeneous enhancement of pancreatic graft, donor's normal duodenum
with hyperdense staple line (black arrowhead, A), hyperdense
mesenteric staple line (white arrowhead, A), and intermediate
density of donor's mesenteric fat (white arrow, B) at level of
superior mesenteric vein.
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Fig. 5B. —40-year-old man 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, CIV = common iliac vein, EIA = external iliac artery, IIA
= internal iliac artery, black arrow = pancreatic graft, PV = portal vein, SMV
= superior mesenteric vein, SV = splenic vein, asterisk = renal graft.
Contrast-enhanced MDCT scans obtained during dominant parenchymal phase at
level of venous anastomosis (A) and cephalad (B) and caudad
(C) to venous anastomosis show normal posttransplantation venous
anatomy, homogeneous enhancement of pancreatic graft, donor's normal duodenum
with hyperdense staple line (black arrowhead, A), hyperdense
mesenteric staple line (white arrowhead, A), and intermediate
density of donor's mesenteric fat (white arrow, B) at level of
superior mesenteric vein.
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Fig. 5C. —40-year-old man 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, CIV = common iliac vein, EIA = external iliac artery, IIA
= internal iliac artery, black arrow = pancreatic graft, PV = portal vein, SMV
= superior mesenteric vein, SV = splenic vein, asterisk = renal graft.
Contrast-enhanced MDCT scans obtained during dominant parenchymal phase at
level of venous anastomosis (A) and cephalad (B) and caudad
(C) to venous anastomosis show normal posttransplantation venous
anatomy, homogeneous enhancement of pancreatic graft, donor's normal duodenum
with hyperdense staple line (black arrowhead, A), hyperdense
mesenteric staple line (white arrowhead, A), and intermediate
density of donor's mesenteric fat (white arrow, B) at level of
superior mesenteric vein.
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Fig. 6A. —58-year-old man 9 days after sequential pancreas-after-kidney
transplantation. Contrast-enhanced MDCT scan shows normal side-to-side
duodenojejunostomy with hyperdense, circular staple line (double
arrows), donor's duodenum (single arrowhead), recipient's
jejunum (double arrowheads), and ascites (asterisks).
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Fig. 6B. —58-year-old man 9 days after sequential pancreas-after-kidney
transplantation. Contrast-enhanced MDCT scan obtained 5 cm caudad to
duodenojejunostomy shows donor's duodenum closed proximally (black
arrowhead) and distally (white arrowhead) with hyperdense staple
line, hyperdense mesenteric staple line (double arrowheads),
pancreatic graft (arrow), renal graft (black asterisk), and
ascites (white asterisk).
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Fig. 7. —42-year-old man 7 days after simultaneous
pancreas–kidney transplantation. Small-bowel follow-through examination
with water-soluble contrast material shows duodenojejunostomy (single
arrow) and partly contrasted donor's duodenum (arrowheads).
Contrast-filled small-bowel loops and partially air-filled descending colon
indirectly outline pancreas graft. Note radiopaque cutaneous staples
(double arrows) resulting from median laparotomy.
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Fig. 8. —18-year-old man 15 days after simultaneous
pancreas–kidney transplantation. Coronal T2-weighted turbo spin-echo MR
image shows normal pancreatic graft (arrows) in pelvis. Asterisk =
renal graft.
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Fig. 9A. —25-year-old woman 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, EIA = external iliac artery, IIA = internal iliac artery,
SA = splenic artery, SV = splenic vein. MR image with fat-suppressed
T1-weighted gradient-echo sequences without contrast enhancement (A)
and with contrast enhancement obtained during dominant arterial phase
(B) and dominant parenchymal phase (C) show normal vascular
anatomy, homogeneous parenchymal enhancement of pancreatic graft
(arrow), and major pancreatic duct (arrowhead). Asterisk =
renal graft.
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Fig. 9B. —25-year-old woman 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, EIA = external iliac artery, IIA = internal iliac artery,
SA = splenic artery, SV = splenic vein. MR image with fat-suppressed
T1-weighted gradient-echo sequences without contrast enhancement (A)
and with contrast enhancement obtained during dominant arterial phase
(B) and dominant parenchymal phase (C) show normal vascular
anatomy, homogeneous parenchymal enhancement of pancreatic graft
(arrow), and major pancreatic duct (arrowhead). Asterisk =
renal graft.
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Fig. 9C. —25-year-old woman 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, EIA = external iliac artery, IIA = internal iliac artery,
SA = splenic artery, SV = splenic vein. MR image with fat-suppressed
T1-weighted gradient-echo sequences without contrast enhancement (A)
and with contrast enhancement obtained during dominant arterial phase
(B) and dominant parenchymal phase (C) show normal vascular
anatomy, homogeneous parenchymal enhancement of pancreatic graft
(arrow), and major pancreatic duct (arrowhead). Asterisk =
renal graft.
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Fig. 9D. —25-year-old woman 14 days after simultaneous
pancreas–kidney transplantation. d = donor's, r = right, l = left, CIA =
common iliac artery, EIA = external iliac artery, IIA = internal iliac artery,
SA = splenic artery, SV = splenic vein. MR pancreatogram shows vertically
oriented major pancreatic duct (arrows), donor's duodenum (between
single arrowhead and double arrowheads), and ascites
(asterisk) in pelvis.
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Fig. 10A. —40-year-old woman 63 months after simultaneous
pancreas–kidney transplantation. High-resolution sonogram (longitudinal
section) displays normal hypoechogenic parenchyma of pancreatic graft (between
arrows and arrowheads).
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Fig. 10B. —40-year-old woman 63 months after simultaneous
pancreas–kidney transplantation. Color-coded sonogram (longitudinal
section) shows normal arterial and venous anatomy to better advantage. d =
donor's, DPA = dorsal pancreatic artery, SV = splenic vein, SA = splenic
artery.
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Introduction
Organ Procurement
