AJR 2004; 182:919-925
© American Roentgen Ray Society
Spectrum of Imaging Findings After Pancreas Transplantation with Enteric Exocrine Drainage: Part 2, Posttransplantation Complications
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
Pancreas transplantation has emerged as an effective treatment for patients
with long-standing type 1 diabetes mellitus resulting in an
insulin-independent euglycemic state and normalization of glycosylated
hemoglobin levels. In most cases, pancreas transplantation is performed at the
same time as kidney transplantation from the same donor as simultaneous
pancreas–kidney transplantation in patients with coexisting end-stage
diabetic nephropathy, less frequently as sequential pancreas-after-kidney
transplantation or pancreas transplantation alone. Various transplantation
procedures exist, including transplantation of a whole pancreatic graft with a
duodenal segment and enteric exocrine drainage via a duodenojejunostomy and
systemic venous endocrine drainage via vascular anastomoses to the iliac
vessels. In all modifications of pancreas transplantation, the recipient's own
pancreas is left untouched.
Knowledge of the transplantation procedure and postoperative imaging
anatomy of the pancreas allograft are basic requirements for radiologists.
Graft survival, among other factors, corresponds to early diagnosis and
therapy for specific graft-related complications including thrombosis, leakage
of enteric anastomosis, hematoma, abscess, pancreatitis, pseudocyst formation,
rejection, and posttransplantation lymphoproliferative disorder.
This pictorial essay uses various imaging techniques to show the imaging
spectrum of diseases after pancreas transplantation with systemic venous
endocrine and enteric exocrine drainage.
Imaging Techniques
Various imaging techniques are routinely used to detect early and late
posttransplantation complications. In contrast to imaging of other solid organ
transplants—for instance, liver and kidney—imaging of the pancreas
allograft with sonography and color-coded sonography is hampered by
superposition of intestinal gas. This results from the heterotopic position of
the graft in the right pelvis adjacent to the iliac vessels and surrounded by
air-filled intestinal loops. For this reason, complete evaluation of the
vascular and enteric anastomoses as well as the parenchyma of the pancreatic
graft can be best accomplished by contrast-enhanced helical CT
[1]. Additionally,
contrast-enhanced MDCT enables 3D reconstruction of the vascular anatomy with
respect to neighboring anatomic structures. MRI without contrast application
[2], with static
[3], and especially with
dynamic [4] contrast
enhancement enables better evaluation of the pancreatic parenchymal graft.
However, MR angiography is inferior to CT angiography because of its limited
spatial resolution. Moreover, evaluation of the enteric anastomosis on MRI is
difficult. Additionally, renal function also determines the selection of an
appropriate cross-sectional imaging technique after simultaneous
pancreas–kidney transplantation. In cases of decreased renal function,
contrast-enhanced MRI and unenhanced CT represent the preferred examination to
preserve the renal graft. MR pancreatography is a complementary examination
for detection of duct abnormalities. Catheter angiography is used to confirm
vascular complications while permitting immediate endovascular therapy. Other
imaging-guided interventions are used to percutaneously treat localized fluid
collections, such as seromas, hematomas, and abscesses. Occasionally,
small-bowel follow-up studies are performed to detect complications of the
enteral anastomosis.
Imaged Abnormalities
The following complications after pancreas transplantation with enteric
anatomosis can be observed: vascular graft complications, including rejection;
pancreatic graft complications, including infection; and other
transplantation-associated complications.
Vascular Graft Complications Including Rejection
The most serious vascular complication is venous and arterial graft
thrombosis and results in pancreatic graft necrosis and pancreatectomy in most
cases. Typically, contrast-enhanced CT displays an intraluminal filling defect
in the larger graft veins (Fig.
1A,
1B). Arterial thrombosis
results in complete occlusion of the vessel with nonenhancement of the
parenchymal graft indicating graft necrosis (Fig.
2A,
2B). Further progression can
result in an emphysematous transformation of the pancreatic graft; in a
patient without clinical signs of local infection or sepsis, this is described
as an innocuous gas collection in the pancreatic graft
[5]. Imaging-guided biopsy
represents the only definite test to distinguish an infected from noninfected
pancreatic graft with gas collection (Fig.
3). Risk factors for early graft loss due to arterial occlusion
after pancreas transplantation are mainly posed by technical complications
involving back-table preparation or the vascular anastomosis in the recipient.
In the later course, graft loss due to arterial occlusion represents the end
point of graft rejection due to alloimmune vasculitis, resulting in occlusion
of small vessels, progressing to larger vessels, and finally involving the
donor's anastomosed greater vessels
[4]. For this reason, dynamic
contrast-enhanced MRI appears to be a promising means of assessing parenchymal
enhancement to detect early changes of vascular rejection
[4]; other MRI protocols or
other imaging techniques, including sonography, color-coded sonography, and
contrast-enhanced CT, did not meet expectations. However, considering the
absence of reliable clinical markers and the persistent uncertainty regarding
imaging examinations, imaging-guided biopsy of the pancreatic graft
(Fig. 4) still represents the
gold standard for the diagnosis of graft rejection
[6].
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Fig. 1A. —43-year-old woman with abdominal discomfort 12 days after
simultaneous pancreas–kidney transplantation. Contrast-enhanced MDCT
scans show acute thrombosis of superior mesenteric vein (arrowheads)
and splenic vein (arrowhead) but homogeneous contrast enhancement of
pancreatic graft (arrow, B) with donor's duodenum
(arrows, A) and renal graft (asterisk). d = donor's,
r = right, l = left, CIA = common iliac artery, CIV = common iliac vein, SA =
splenic artery, IPDA = inferior pancreaticoduodenal artery, SMA = superior
mesenteric artery.
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Fig. 1B. —43-year-old woman with abdominal discomfort 12 days after
simultaneous pancreas–kidney transplantation. Contrast-enhanced MDCT
scans show acute thrombosis of superior mesenteric vein (arrowheads)
and splenic vein (arrowhead) but homogeneous contrast enhancement of
pancreatic graft (arrow, B) with donor's duodenum
(arrows, A) and renal graft (asterisk). d = donor's,
r = right, l = left, CIA = common iliac artery, CIV = common iliac vein, SA =
splenic artery, IPDA = inferior pancreaticoduodenal artery, SMA = superior
mesenteric artery.
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Fig. 2A. —36-year-old woman 8 months after pancreas transplantation
alone with newly developed hyperglycemia, graft necrosis, and subsequent graft
pancreatectomy. Contrast-enhanced MDCT scan obtained during dominant arterial
phase shows enhancement of donor's arterial conduit (arrowhead) but
nonvisualization of graft arteries and nonenhancement of pancreas graft
(arrow) indicating arterial occlusion and absent parenchymal
perfusion. r = right, l = left, CIA = common iliac artery.
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Fig. 2B. —36-year-old woman 8 months after pancreas transplantation
alone with newly developed hyperglycemia, graft necrosis, and subsequent graft
pancreatectomy. Angiogram verifying CT findings shows residual enhancement of
donor's arterial conduit (arrowhead) but nonvisualization of graft
arteries and absent parenchymal enhancement of pancreatic graft.
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Fig. 3. —44-year-old man 9 months after simultaneous
pancreas–kidney transplantation with graft necrosis but without local
infection or sepsis and subsequent graft extirpation. Contrast-enhanced MDCT
scan shows absent parenchymal enhancement and emphysematous transformation of
pancreatic graft (arrows) consistent with innocuous gas collection.
Note renal graft (black asterisk) and ascites (white
asterisk).
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Fig. 4. —33-year-old man 20 months after simultaneous
pancreas–kidney transplantation with pancreatic graft dysfunction and
acute rejection verified by histopathologic examination. Helical CT scan is
used for image-guided percutaneous biopsy (double arrows) of
pancreatic graft (single arrows) adjacent to contrast
medium–filled small bowel (arrowhead) and renal graft
(asterisk).
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Pancreatic Graft Complications Including Infection
Complications of the pancreatic graft itself are an important cause of
morbidity in the early posttransplantation period. These complications include
pancreatitis; pseudocyst formation, including expansion; infection with
abscess formation; pseudoaneurysm formation; leakage of the enteric
anastomosis or duodenal stump; and small-bowel obstruction. Self-limited
edematous pancreatitis (Fig.
5A,
5B) occurs preferentially in
the early posttransplantation period because of reperfusion injury and
typically involves the entire graft. Focal edematous swelling of the donor's
remaining mesenteric fat attached to the superior mesenteric arterial stump
should not be misdiagnosed as focal edematous pancreatitis
(Fig. 6); presumably this
condition results from ligation of the donor's lymphatic vessels. Necrotizing
pancreatitis is the most severe form of pancreatitis
(Fig. 7) and necessitates
graft pancreatectomy. Pseudocyst formation develops later in the clinical
course after onset of graft pancreatitis and can occur in various sizes,
contours, and septa inside or outside the pancreatic graft. Sonography is the
imaging technique of choice for large pseudocysts
(Fig. 8), whereas complex
pseudocysts (Fig. 9), infected
pseudocysts (Fig. 10A), and
percutaneous catheter drainage of pseudocysts
(Fig. 10B) are best imaged on
contrast-enhanced CT [7].
Infection of pseudocysts after pancreas transplantation is a frequent
occurrence and can cause pseudoaneurysm formation in arteries (Fig.
11A,
11B,
11C,
11D) and veins
[8]. Finally, fistula formation
can result from pancreatitis with communication to the skin
(Fig. 10C) or peritoneal
cavity (Fig. 12), and sinus
tract formation can involve the retroperitoneum (Figs.
12 and
13A,
13B) and gut (Fig.
13A,
13B).
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Fig. 5A. —40-year-old man 16 days after simultaneous
pancreas–kidney transplantation and graft pancreatitis. Donor's duodenum
(arrowhead), renal graft (black asterisk), and perirenal
fluid (white asterisk) are seen. Contrast-enhanced MDCT scan shows
homogeneous contrast enhancement of pancreatic graft (arrows).
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Fig. 5B. —40-year-old man 16 days after simultaneous
pancreas–kidney transplantation and graft pancreatitis. Donor's duodenum
(arrowhead), renal graft (black asterisk), and perirenal
fluid (white asterisk) are seen. Contrast-enhanced MDCT scan obtained
5 days after initial CT shows inhomogeneous contrast enhancement and
increasing size of pancreatic graft (arrows) indicating edematous
pancreatitis.
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Fig. 6. —51-year-old man 4 weeks after simultaneous
pancreas–kidney transplantation. Contrast-enhanced MDCT scan shows
edematous swelling of donor's remaining mesenteric fat (double
arrows) and lymph nodes (white asterisks) attached to
unremarkable, homogeneous contrast-enhancing pancreatic graft (single
arrow). Condition presumably results from ligation of donor's lymphatic
vessels. CT also shows normal enhancement of donor's (d) vessels including
superior mesenteric artery (SMA), external iliac artery (EIA), splenic artery
(SA), and renal graft (black asterisk).
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Fig. 7. —38-year-old man 5 weeks after simultaneous
pancreas–kidney transplantation with necrotizing graft pancreatitis and
subsequent graft extirpation. Contrast-enhanced helical CT scan displays
remnants of contrast-enhanced pancreatic graft (arrow) surrounded by
fluid and thin-walled membrane (arrowheads) representing pseudocyst
formation due to necrotizing pancreatitis. Ascites (white asterisk)
and renal graft (black asterisk) are also seen.
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Fig. 8. —54-year-old man 5 months after simultaneous
pancreas–kidney transplantation with graft pancreatitis and pseudocyst
formation. Sonogram shows large, partly septated cyst (white
asterisk) adjacent to pancreatic graft (not shown) consistent with
peripancreatic pseudocyst.
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Fig. 9. —34-year-old woman 5 months after simultaneous
pancreas–kidney transplantation with exudative pancreatitis and
pseudocyst formation. Contrast-enhanced helical CT scan displays homogeneous
enhancement of small pancreatic graft (arrow) surrounded by
thin-walled peripancreatic pseudocyst (arrowheads) and various
intraabdominal pseudocysts (white asterisks). Note renal graft
(black asterisk). d = donor's, SMA = superior mesenteric artery, SMV
= superior mesenteric vein, CIA = common iliac artery.
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Fig. 10A. —27-year-old man 4 weeks after simultaneous
pancreas–kidney transplantation with infected peripancreatic pseudocyst
requiring percutaneous drainage and subsequent development of
pancreatocutaneous fistula. Contrast-enhanced helical CT scan shows
homogeneous contrast enhancement of pancreatic graft (arrow)
surrounded by septate, peripancreatic fluid collection (white
asterisks) combined with air–fluid level (white
arrowheads) and thin, contrast-enhanced wall (black arrowheads)
consistent with infected pseudocyst. Note renal graft (black
asterisk).
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Fig. 10B. —27-year-old man 4 weeks after simultaneous
pancreas–kidney transplantation with infected peripancreatic pseudocyst
requiring percutaneous drainage and subsequent development of
pancreatocutaneous fistula. Contrast-enhanced helical CT scan obtained during
performance of subsequent CT-guided percutaneous drainage with pigtail
catheter (double arrows) for treatment of infected peripancreatic
pseudocyst shows pancreatic graft (single arrow) and renal graft
(asterisk).
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Fig. 11A. —50-year-old man 18 days after simultaneous
pancreas–kidney transplantation and 5 days after pancreatic graft
extirpation due to infected graft pancreatitis with localized retroperitoneal
and intraabdominal abscesses and subsequent surgical arterial repair of
symptomatic mycotic pseudoaneurysm. Contrast-enhanced helical CT shows
residual donor's arterial conduit (arrow) after pancreatic graft
extirpation surrounded by small fluid collection with thin-walled
contrast-enhanced membrane (arrowhead). Also residual fluid
collection (white asterisk) in perirenal location is seen. Note renal
graft (black asterisk). r = right, l = left, CIA = common iliac
artery, CIV = common iliac vein.
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Fig. 11B. —50-year-old man 18 days after simultaneous
pancreas–kidney transplantation and 5 days after pancreatic graft
extirpation due to infected graft pancreatitis with localized retroperitoneal
and intraabdominal abscesses and subsequent surgical arterial repair of
symptomatic mycotic pseudoaneurysm. Contrast-enhanced MDCT scan with dominant
late parenchymal phase obtained 9 days after initial CT shows donor's residual
arterial conduit (arrow) and newly developed emphysematous
transformation (arrowhead) of adjacent fluid collection, indicating
recurrent abscess. Decrease in fluid (white asterisk) adjacent to
renal graft (black asterisk) is noted.
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Fig. 11C. —50-year-old man 18 days after simultaneous
pancreas–kidney transplantation and 5 days after pancreatic graft
extirpation due to infected graft pancreatitis with localized retroperitoneal
and intraabdominal abscesses and subsequent surgical arterial repair of
symptomatic mycotic pseudoaneurysm. Contrast-enhanced MDCT scans obtained 12
days after initial CT show newly developed mycotic pseudoaneurysm (double
arrows) originating from donor's arterial conduit (arrow,
C) and recently developed large retroperitoneal hematoma
(arrowheads). Note renal graft (black asterisk).
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Fig. 11D. —50-year-old man 18 days after simultaneous
pancreas–kidney transplantation and 5 days after pancreatic graft
extirpation due to infected graft pancreatitis with localized retroperitoneal
and intraabdominal abscesses and subsequent surgical arterial repair of
symptomatic mycotic pseudoaneurysm. Contrast-enhanced MDCT scans obtained 12
days after initial CT show newly developed mycotic pseudoaneurysm (double
arrows) originating from donor's arterial conduit (arrow,
C) and recently developed large retroperitoneal hematoma
(arrowheads). Note renal graft (black asterisk).
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Fig. 10C. —27-year-old man 4 weeks after simultaneous
pancreas–kidney transplantation with infected peripancreatic pseudocyst
requiring percutaneous drainage and subsequent development of
pancreatocutaneous fistula. Contrast-enhanced helical CT scan obtained 10
weeks after initial CT-guided percutaneous drainage and ultimate operative
débridement of recurrently infected pseudocyst shows
pancreatic–cutaneous fistula (arrowheads) originating from
pancreatic graft (arrow). Note renal graft (asterisk).
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Fig. 12. —29-year-old man 3 weeks after simultaneous
pancreas–kidney transplantation with infected peripancreatic pseudocyst
and complex pancreatic cutaneous fistula. Drainage catheter (double
arrows) was placed through cutaneous fistula opening, and sinogram
displays large central cavity (single arrow) with communication to
peritoneal cavity (black arrowheads) and sinus tracts (white
arrowheads) in retroperitoneal location.
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Fig. 13A. —43-year-old man 10 weeks after simultaneous
pancreas–kidney transplantation complicated by pancreatitis, infection
of peripancreatic pseudocyst, and subsequent surgical débridement and
drainage tube placement. Spot film image obtained during small-bowel
follow-through examination shows contrast-filled small-bowel loops (SB), cecum
(arrowheads), and two partly contrast-filled sinus tracts
(arrows) opening to cecum.
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Fig. 13B. —43-year-old man 10 weeks after simultaneous
pancreas–kidney transplantation complicated by pancreatitis, infection
of peripancreatic pseudocyst, and subsequent surgical débridement and
drainage tube placement. Contrast-enhanced helical CT scan confirms
retroperitoneal location of partly contrast-filled sinus tracts (white
arrows) adjacent to cecum (arrowheads) and pancreatic graft
(black arrow), indicating previously existing pancreatocolic fistula.
Note renal graft (asterisk).
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Enteric complications manifest either as leakage of the duodenojejunostomy
or duodenal stump with ensuing abscess and peritonitis or sometimes as
volvulus of the small bowel around the longitudinal axis of the graft (Fig.
14A,
14B).
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Fig. 14A. —39-year-old woman 14 days after simultaneous
pancreas–kidney transplantation with clinical signs of upper intestinal
obstruction due to intermittent small-bowel volvulus and subsequent surgical
reduction. Contrast-enhanced MDCT scan shows prestenotic, dilated,
fluid-filled loops of small bowel (white asterisks), twisted segment
of small bowel (between single white arrow and white
arrowhead) consisting of collapsed loop of small intestine located
adjacent to donor's duodenum (double black arrows) with hyperdense
staple line (black arrowhead), and poststenotic, nondilated colon
(black asterisks) filled with intraluminal contrast material from
prior unremarkable small-bowel follow-through examination.
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Fig. 14B. —39-year-old woman 14 days after simultaneous
pancreas–kidney transplantation with clinical signs of upper intestinal
obstruction due to intermittent small-bowel volvulus and subsequent surgical
reduction. Upright abdominal radiograph obtained after repeated small-bowel
follow-through examination with water-soluble contrast material verifies
mechanical small-bowel obstruction at level of presumed location of head of
pancreatic graft (between arrow and arrowhead) with
dilatation and abnormal air–fluid levels of partly contrast-filled,
prestenotic, small intestinal loops (asterisks), including
stomach.
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Other Transplantation-Associated Complications
Pseudothrombosis of the iliac vein
(Fig. 15) has been described
after simultaneous pancreas–kidney transplantation with bilateral
revascularization to the respective iliac vessels
[9]. Pseudothrombosis results
from delayed venous opacification of the iliac vein ipsilateral to the
pancreatic graft as compared with the contralateral side of the renal graft.
This phenomenon results from longer transit time and reduced blood flow to the
pancreas as compared with the kidney. Pseudothrombosis can also involve the
ipsilateral iliac vein below the vascular anastomoses of the pancreatic graft
because of more peripheral implantation of the renal graft on the
contralateral side and longer transit time of the lower extremity as compared
with the renal graft. Posttransplantation lymphoproliferative disorder is a
serious but rare complication of pancreas transplantation. It manifests
predominantly as a diffuse enlargement of the pancreatic graft, which is
indistinguishable from acute pancreatitis for imaging techniques, or rarely as
intra- or extraallograft focal masses, lymphadenopathy, or organomegaly
[10].
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Fig. 15. —54-year-old man 9 months after simultaneous
pancreas–kidney transplantation. Contrast-enhanced MDCT scan shows
pseudothrombosis (double arrows) of right external iliac vein (EIV)
as compared with left side. This is due to delayed venous opacification on
right side resulting from longer transit time and reduced blood flow of
right-sided pancreatic graft (single arrow) as compared with
left-sided renal graft as well as more peripheral implantation of renal graft
and longer transit time of the lower extremity as compared with renal graft.
Homogeneous contrast enhancement of pancreatic graft and ascites (white
asterisks) is seen. r = right, l = left, d = donor's, EIA = external
iliac artery, SA = splenic artery, SV = splenic vein.
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Introduction
Imaging Techniques
