David Ting, MS IV
Gillian Lieberman, MD
Radiographic Perioperative
Evaluation of Pancreatic Transplant
David Ting, Harvard Medical School Year IV
Gillian Lieberman, MD
July 2004
David Ting, MS IV
Gillian Lieberman, MD
2
Patient Presentation
•
41 y.o. female with Type I diabetes mellitus for 24
years
–
Difficulty controlling glucose levels
–
Frequent and severe episodes of metabolic
complications (i.e. DKA)
–
Peripheral neuropathy
–
Chronic renal failure (diabetic nephropathy) requiring
dialysis
David Ting, MS IV
Gillian Lieberman, MD
3
Treatment Options
•
Optimize insulin control
–
Alter type of insulin regimen used
–
Insulin pump for improved insulin dose control
•
Treat/prevent secondary complications
–
Nephropathy: Strict BP control (ACEI); dialysis
–
Retinopathy: Photocoagulation
–
Neuropathy: Pain management
•
PANCREAS TRANSPLANT
David Ting, MS IV
Gillian Lieberman, MD
4
Selection Criteria at BIDMC
• Anyone with uncontrolled or poorly controlled
Type I diabetes and at least one of the
following:
– HbA1C persistently >7%
– Proliferative retinopathy
– Diabetic Nephropathy diagnosed by biopsy or
proteinuria
– Autonomic or peripheral neuropathy
– Frequent and severe metabolic crises resulting in
hospitalization
David Ting, MS IV
Gillian Lieberman, MD
5
BIDMC Contraindications
• Age must be between 13 and 65
• BMI > 35
• Type 2 diabetes mellitus
• CV disease
– Recent MI
– Significant CAD
– CHF
– Severe peripheral vascular disease with ischemia of at least
one limb
• Cancer diagnosis within 5 years
• Possible difficulty with compliance to rigorous post
operative medication regime
David Ting, MS IV
Gillian Lieberman, MD
6
How common is this procedure?
•
The first clinical pancreas transplant was
done with a simultaneous kidney transplant
at the University of Minnesota on 12/16/66.
•
Total of 14,000 pancreas worldwide
•
Current annual average around 1000
David Ting, MS IV
Gillian Lieberman, MD
7
Surgical Transplant Options
•
Simultaneous Pancreas Kidney (SPK)
•
Sequential Pancreas after Kidney (PAK)
•
Living Donor Kidney Transplant Alone
(LDKTA) + PAK
•
Pancreas Transplantation Alone (PTA)
David Ting, MS IV
Gillian Lieberman, MD
8
Transplant procedure:
Exocrine Drainage Methods
•
Cutaneous
graft duodenostomy
–
Metabolic acidosis (loss of bicarbonate)
•
Open duct free intraperitoneal
drainage
–
Severe peritonitis & amylase ascites
•
Polymer duct injection and occlusion
–
Severe pancreatitis
•
Enterovesical
drainage
–
Chronic cystitis, reflux pancreatitis, recurrent UTI,
metabolic acidosis, urethritis
•
Enteric drainage: Side-to-side
duodenoenterostomy currently preferred
David Ting, MS IV
Gillian Lieberman, MD
9
Side-to-side Duodenoenterostomy
Donor Duodenal Stump
Donor Kidney
Recipient jejunum
or ileum
Enteric anastomosis
Donor Pancreas
http://www.clevelandclinic.org/urology/news/misc/images/vol8jx.jpg
David Ting, MS IV
Gillian Lieberman, MD
10
Vascular Anastamoses
•
Arterial anastamosis: RLQ using donor splenic
artery and SMA to recipient common iliac via Y-
graft
•
Venous anastamosis
–
Portal:
•
Donor portal vein to recipient superior mesenteric vein
•
Physiologic, but technically very challenging
–
Systemic:
•
Donor portal vein to recipient common iliac vein
•
Technically less challenging
•
Possible complications: Hyperinsulinemia
resulting in
dyslipidemia, accelerated atherosclerosis, and insulin resistance
–
Retrospective study indicating graft survival higher in
portal (79%) vs
systemic (65%) anastomosis
Philosophe
B et al. Annals of Surgery
(2001), Vol. 234 (5), 689-696
David Ting, MS IV
Gillian Lieberman, MD
11
Vascular Anatomy
Splenic artery
Portal
vein
Splenic
vein
SMV
SMA
IPDA
Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
12
Causes for Graft Loss
•
Technical Failure: 9%
–
Vascular thrombosis (Most common complication)
–
Anastomotic
leak
–
Infection
–
Pancreatitis
–
Bleeding
•
Allograft Rejection: 3-16% at 1 yr
David Ting, MS IV
Gillian Lieberman, MD
13
HOW CAN WE IDENTIFY
THESE PROBLEMS?
RADIOLOGYRADIOLOGY
David Ting, MS IV
Gillian Lieberman, MD
14
Imaging technique:
Ultrasound
•
Advantages
–
Very good at assessing vasculature using spectral
and color flow doppler
–
No radiation
–
Can identify peri-pancreatic fluid collections
•
Limitations
–
Pancreas does not have discrete capsule resulting
in difficulty visualizing pancreas among bowel
loops
–
Etiology for fluid collections cannot be
delineated
David Ting, MS IV
Gillian Lieberman, MD
15
Arterial FlowVenous Flow
Patent Pancreatic Transplant Vessels
by Color Flow Doppler
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
16
Patent Pancreatic Transplant Vessels
by Spectral and Color Flow Doppler
Good Arterial and Venous Wave Pattern
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
17
US Vascular Evaluation #1
Proximal vessel
entering pancreas
Lack of vascular flow in
pancreas by color doppler
Diagnosis: Arterial Thrombosis
Resulted in allograft pancreatectomy
Patient with lower abdominal pain and rising glucose levels
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
18
US Vascular Evaluation #2
Patient with rising glucose levels
Hypoechoic region = fluid
Heterogenic
echoic region in
pancreatic head
Pancreatic Duct
Hyperechoic
region in
pancreatic tail
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
19
US Vascular Evaluation #2
Spectral flow analysis showed decreased arterial flow to pancreatic head
Diagnosis: Pancreatic Head Thrombosis
Resulted in pancreatic head resection
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
20
Imaging Technique: CT
•
Advantages
–
Effective enteric anastomotic
leak detection via oral contrast
extravasation
–
Detection and evaluation of fluid collections
•
Hematoma, ascites, pseudocysts, abscess, or urinoma
–
Evaluate complications of pancreatitis
•
Abscess, pseudocyst, adjacent tissue involvement
–
Vascular compromise evaluation can be done with contrast
–
CT guided drainage of pseudocysts, abscess, fluid
•
Disadvantages
–
Severe renal failure precludes IV contrast
–
Often difficult to differentiate fluid collections and changes
of pancreas morphology
–
Largest radiation dose
David Ting, MS IV
Gillian Lieberman, MD
21
Where is that pancreas?
Kidney
Transplant Pancreas
Transplant
Sutures
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
22
Common Findings Post-Transplant
Low attenuation
pancreatic transplant
dDx: 1) Pancreatitis
2) Vascular Occlusion
3) Rejection
Peri-pancreatic fluid
dDx: 1) Edema
2) Hematoma
3) Ascites
4) Pseudocyst
5) Abscess
6) Urinoma
Dx: Pancreatic Rejection with
surrounding edema from
inflammation
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
23
Abdominal Distension and ? Bowel Obstruction
Multiple Large Loculated
Hypodense Regions with
HU of Fluid
dDx: 1) Pseudocyst
2) Lymphocele
3) Seroma
4) Abscess
Dx: Pseudocyst
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
24
Fever and Abdominal Pain
Fluid collection
with air
Stranding and fluid indicating
inflammatory changes
dDx:
1) Abscess
2) Pseudocyst
3) Cyst
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
25
What can we do?
Drain the fluid with CT guidance!!
Pigtail Catheter Fluid was purulent
Dx: Abscess
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
26
Demonstration of Pancreas
Hypoperfusion
on Arterial Phase of CT
Non-enhanced
pancreas transplant
Contrast enhanced
kidney transplant
Contrast in external
and internal iliac
arteries
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
27
Imaging technique: MRI
•
Advantages
–
Excellent visualization of soft tissue structures
–
Effective alternative when difficult visualization by US or CT
–
Contrast enhanced MRA and MRI useful in assessment of
vasculature
•
Useful in pts who had a poor US study and cannot have CT IV contrast
(renal compromise)
•
Study by Boeve
WJ et al. indicates efficacy of modality when
compared to intra-arterial digital subtraction angiography
–
No radiation
•
Disadvantages
–
Still undefined role in pancreatic transplant evaluation
–
Takes more time to image
–
Some patients are contraindicated for imaging
David Ting, MS IV
Gillian Lieberman, MD
28
Persistent Abdominal Pain and Inconclusive CT study
Cecum
1) Thick Walls
2) Hypointense periphery
Suggestive of pneumatosis
NOT ALL POST-
SURGICAL
COMPLICATIONS
INVOLVE THE
PANCREAS
Images Courtesy of Dr. Tkacz and Dr. Kruskal
VIBE Sequence
David Ting, MS IV
Gillian Lieberman, MD
29
Persistent Abdominal Pain and Inconclusive CT study
Lack of
Contrast =
Portal vein
thrombus
Liver
Aorta
Spleen
Stomach
Dx: Ascending Pyelophlebitis with Portal Vein Thrombosis
IVC
Images Courtesy of Dr. Tkacz and Dr. Kruskal
VIBE scan –
Delayed post-gadolinium
David Ting, MS IV
Gillian Lieberman, MD
30
Diagnosis of Rejection
•
Histopathologic
by CT-guided or US-guided biopsy
•
Chemical markers
–
SKP -
↑
serum Cre
(Kidney function serves as proxy)
–
PTA vesical
drainage -
↓
urinary amylase
–
PTA enteric drainage -
? ↑
blood glucose levels
–
↑
serum amylase/lipase non-specific
•
Imaging???
–
US: Resistive Index not proven to be effective
–
CT: No role
–
MRI: Dynamic contrast enhanced MRI: Krebs TL et al.
David Ting, MS IV
Gillian Lieberman, MD
31
Percutaneous Biopsy
•
Can be done with CT or US guidance
•
Must consult and plan with transplant team
•
20g biopsy gun at more than one site
–
Possible differences in histology
–
Usually sample mid and proximal pancreas
•
Post-biopsy complication of mild to
moderate pancreatitis common
David Ting, MS IV
Gillian Lieberman, MD
32
CT-guided Biopsy
Biopsy
Needle
Kidney
Transplant
Pancreas
Transplant
Images Courtesy of Dr. Tkacz and Dr. Kruskal
David Ting, MS IV
Gillian Lieberman, MD
33
Comparison of Gadolinium-enhanced GRE MR
Krebs et al, Radiology
(1999), Vol. 210(2), 437-442.
Arrowheads: Kidneys Arrows: Pancreas Curved Arrows: Duodenal Stump
Viable Pancreas Rejected Pancreas
David Ting, MS IV
Gillian Lieberman, MD
34
Dynamic Contrast-enhanced MRI
Evaluation of Acute Rejection
•
Mean percentage of parenchymal
enhancement (MPPE) determined at 1
minute post-gadolinium load
•
MPPE corresponded to histopathologic
analysis
•
Demonstrates decreased MPPE with
rejection compared to viable transplant
Krebs et al, Radiology
(1999), Vol. 210(2), 437-442.
David Ting, MS IV
Gillian Lieberman, MD
35
Summary
•
Immediate Perioperative Evaluation of Symptomatic
Patient
–
US: Confirm vascular competency (r/o
thrombus)
–
CT:
•
Complications of severe pancreatitis
•
Anastomotic
leak
•
Fluid collections
–
MR: Evaluate inconclusive US and/or CT study
•
Rejection Evaluation
–
CT or US guided biopsy
–
? Utility of MR
David Ting, MS IV
Gillian Lieberman, MD
36
References
1.
Bernardino M, Fernandez M, Neylan
J et al. “Pancreas Transplants: CT guided biopsy”, Radiology
(1990), Vol. 177, pp. 709-711.
2.
Boeve
WJ, Kok
T, Tegzess
AM, et al. “Comparison of Contrast Enhance MR-angiography-MRI
and Digital Subtraction Angiography in the Evaluation of Pancreas and/or Kidney
Transplantation Patients: Initial Experience”, Magnetic Resonance Imaging (2001), Vol. 19, pp.
595-607.
3.
Eubank WB, Schmiedl
UP, Levy AE, and Marsh CL. “Venous Thrombosis and Occlusion After
Pancreas Transplantation: Evaluation with Breath-Hold Gadolinium-Enhanced Three-Dimensional MR
Imaging”, AJR (2000), Vol. 175, pp.381-385.
4.
Humar
A, Kandaswamy
R, Granger D et al. “Decreased Surgical Risks of Pancreas Transplantation in the
Modern Era”, Annals of Surgery (2000), Vol. 231 (2), pp. 269-275.
5.
Krebs TL, Daly B, Wong-You-Cheong JJ, et al. “Acute Pancreatic Transplant Rejection: Evaluation
with Dynamic Contrast-enhanced MR Imaging Compared with Histopathologic
Analysis”,
Radiology (1999), Vol. 210 (2), pp. 437-442.
6.
Sutherland DER, Gruessner
RWG, Dunn DL, et al. “Lessons Learned From More Than 1,000
Pancreas Transplants at a Single Institution”, Annals of Surgery (2001), Vol. 233(4), pp. 463-
501.
7.
Patel BK, Garvin PJ, Aridge
DL, et al. “Fluid Collections developing after pancreatic
transplantation: radiologic evaluation and intervention”, Radiology (1991), Vol. 181
(1), pp. 215-220.
8.
Philosophe
B, Farney
AC, Schweitzer EJ, et al. “Superiority of Portal Venous Drainage Over
Systemic Venous Drainage in Pancreas Transplantation”, Annals of Surgery (2001), Vol
234
(5), pp. 689-696.
9.
Pozniak
MA, Propeck
PA, Kelcz
F, and H Sollinger. “Imaging of Pancreas Transplants”, Rad
Clinics NA (1995), Vol. 33 (3), pp. 581-594.
10.
Robertson RP. “Pancreas and Islet Transplantation in Diabetes Mellitus”, (2003)
www.uptodate.com
11.
Robertson RP. “Patient Selection for and Immunologic Issues Relating to Kidney-Pancreas
Transplantation in Diabetes Mellitus”, (2003), www.uptodate.com
12.
Thoeni
RF and F Blankenberg. “Pancreatic Imaging: Computed Tomography and Magnetic Resonance
Imaging”, Rad Clinics NA (1993), Vol. 31 (5), pp. 1085-1112.
13.
http://www.clevelandclinic.org/urology/news/misc/images/vol8jx.jpg
David Ting, MS IV
Gillian Lieberman, MD
37
Acknowledgements
•
Jonathan Kruskal, MD, PhD
•
Jaroszlaw
Tkacz, MD
•
Larry Barbaras
our Webmaster
•
Gillian Lieberman, MD
•
Pamela Lepkowski
Radiographic Perioperative Evaluation of Pancreatic Transplant
Patient Presentation
Treatment Options
Selection Criteria at BIDMC
BIDMC Contraindications
How common is this procedure?
Surgical Transplant Options
Transplant procedure: �Exocrine Drainage Methods
Side-to-side Duodenoenterostomy
Vascular Anastamoses
Vascular Anatomy
Causes for Graft Loss
HOW CAN WE IDENTIFY �THESE PROBLEMS?
Imaging technique:�Ultrasound
Patent Pancreatic Transplant Vessels by Color Flow Doppler
Patent Pancreatic Transplant Vessels �by Spectral and Color Flow Doppler
US Vascular Evaluation #1
US Vascular Evaluation #2
US Vascular Evaluation #2
Imaging Technique: CT
Where is that pancreas?
Common Findings Post-Transplant
Slide Number 23
Fever and Abdominal Pain
What can we do?
Demonstration of Pancreas �Hypoperfusion on Arterial Phase of CT
Imaging technique: MRI
Persistent Abdominal Pain and Inconclusive CT study
Persistent Abdominal Pain and Inconclusive CT study
Diagnosis of Rejection
Percutaneous Biopsy
CT-guided Biopsy
Comparison of Gadolinium-enhanced GRE MR
Dynamic Contrast-enhanced MRI Evaluation of Acute Rejection
Summary
References
Acknowledgements