Pancreas-kidney transplantation: what every radiologist should know

Pancreas transplantation is a well-established treatment for patients with complicated diabetes mellitus and advanced renal failure. The most common procedure is simultaneous pancreas-kidney transplantation, in which the pancreas graft is positioned in the right pelvic region and the kidney graft is positioned in the left iliac fossa. Various imaging methods are used for the post-transplantation evaluation of the graft parenchyma and vascular anatomy, as well as for the identification of possible complications. As the number of cases increases, it is fundamental that radiologists understand the surgical procedure and the postoperative anatomy, as well as to recognize the possible postoperative complications and their imaging aspects, with the aim of providing the best guidance in the postoperative management of transplant recipients.

Keywords:
Pancreas transplantation; Kidney transplantation; Organ transplantation; Diabetes mellitus; Postoperative complications

Authorship

Alexandre Makoto Minoda Correspondence: Dr. Alexandre Makoto Minoda. Rua das Pernambucanas, 315, Graças. Recife, PE, Brazil, 52011-010. Email: alexandreminoda@hotmail.com.

Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brasil.Instituto de Medicina Integral Professor Fernando Figueira (IMIP)BrasilRecife, PE, BrasilInstituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brasil.

http://orcid.org/0000-0002-9813-3076

Fernando dos Santos Ferreira

Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.Universidade Federal de Pernambuco (UFPE)BrazilRecife, PE, BrazilUniversidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

http://orcid.org/0000-0001-7037-4700

Karllos Diego Ribeiro Santos

http://orcid.org/0000-0002-3226-8832

Cristiano de Souza Leão

http://orcid.org/0000-0003-2989-117X

Eduardo Just da Costa e Silva

Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.Universidade Federal de Pernambuco (UFPE)BrazilRecife, PE, BrazilUniversidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

http://orcid.org/0000-0002-0596-5827

Andréa Farias de Melo-Leite

Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.Universidade Federal de Pernambuco (UFPE)BrazilRecife, PE, BrazilUniversidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

http://orcid.org/0000-0003-0044-7278

Correspondence: Dr. Alexandre Makoto Minoda. Rua das Pernambucanas, 315, Graças. Recife, PE, Brazil, 52011-010. Email: alexandreminoda@hotmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.Universidade Federal de Pernambuco (UFPE)BrazilRecife, PE, BrazilUniversidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

Figures

Figures (13)

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Figure 1
A: Schematic drawing (anterior view) showing the acquisition of a pancreatic graft (PG), removed together with its vascular support and one duodenal segment (DS) from the donor. For the purposes of transplantation, the donor gastroduodenal artery (dGDA), donor splenic artery (dSA), donor superior mesenteric artery (dSMA), donor superior mesenteric vein (dSMV) donor inferior mesenteric vein (dIMV), and donor splenic vein (dSV) must be connected and sectioned, as must the proximal segment of the portal vein. B: Photograph showing acquisition of the pancreatic duodenal block, the pancreatic allograft (black dotted line) being removed from the donor together with the duodenal segment (white dotted line), prior to excision of the spleen (asterisk). CA, celiac artery.

Thumbnail

Figure 2
A: Schematic drawing showing a posterior view of the pancreatic graft (PG) and the duodenal segment (DS) of the donor, with an emphasis on the vascular anastomoses. End-to-end anastomosis between the donor external iliac artery (dEIA) and the donor superior mesenteric artery (dSMA) and between the donor internal iliac artery (dIIA) and the donor splenic artery (dSA) is performed, forming a Y graft. The donor common iliac artery (dCIA) serves as the common arterial channel of the pancreatic graft. The veins are resected together with a short segment of the portal vein (dPV), which is commonly used for venous anastomosis in the recipient. B: Pancreatic duodenal block with pancreatic graft (black arrow) and one duodenal segment (arrowhead) after anastomosis of the arterial Y graft, formed by the common iliac artery (white arrow), external iliac artery (white asterisk) and internal iliac artery (black asterisk) of the donor.

Thumbnail

Figure 3
Schematic drawing showing vascular anastomoses after revascularization of the pancreatic graft (PG) in the recipient. End-to-side anastomosis is performed to join the arterial Y graft, via the donor common iliac artery (dCIA) to the recipient common iliac artery (rCIA) or the recipient external iliac artery (rEIA). End-to-side anastomosis is also used to connect the donor portal vein (dPV) to the right common iliac vein of the recipient (rCIV). IVC, inferior vena cava; dSMA, superior mesenteric artery; dIIA, internal iliac artery; dSA, splenic artery.

Thumbnail

Figure 4
A: Schematic drawing illustrating the intraoperative appearance of the pancreatic graft (PG) positioned in the pelvis via side-to-side duodenojejunal anastomosis (arrows) linking the donor duodenal segment (DS) to the jejunum of the recipient. The donor duodenum is closed at both ends using sutures or staples (arrowheads). The native pancreas of the recipient remains in the upper abdomen. B: Intraoperative aspect of SPKT with enteric drainage of exocrine pancreatic secretions, by anastomosis between the donor duodenal stump (black asterisk) and the small intestine of the recipient (white asterisk), approximately 25 cm from the ileocecal valve. dIMV, inferior mesenteric vein; dSMV, superior mesenteric vein.

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Figure 5
Coronal reconstruction of contrast-enhanced CT, showing normal parenchymal enhancement of the body and tail of the pancreatic graft (white arrow) in the right iliac fossa. A nondilated segment of the pancreatic duct is displayed (arrowhead). Note the renal graft with normal parenchymal enhancement (black arrow) in the left iliac fossa.

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Figure 6
Maximum intensity projection image in the arterial phase of contrast-enhanced CT (coronal reconstruction), showing a patent Y graft (white arrow) anastomosed to the right external iliac artery. Note the anastomosis of the Y graft to the branches of the splenic artery (white arrowhead) and superior mesenteric artery (black arrowhead), with narrowing of the lumen of the superior mesenteric artery.

Thumbnail

Figure 7
Sagittal reconstruction of a contrast-enhanced CT scan of a pancreatic graft with enteric drainage in the right iliac fossa (white arrow), showing the surgical staples (arrowheads) along the duodenal stump (black arrow), which is partially distended and may simulate a fluid collection. Surgical staples facilitate this differentiation, as well as helping locate the pancreatic graft.

Thumbnail

Figure 8
Contrast-enhanced axial CT scan, in the portal phase, of a patient in the postoperative period after simultaneous transplantation of a pancreas (white arrowhead) and a kidney (black arrowhead), presenting a small amount of peripancreatic fluid (arrow), in addition to adjacent lymph nodes (asterisks), usually without clinical significance, which may occasionally mimic some abnormality.

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Figure 9
A: Unenhanced abdominal CT scan in patient who underwent SPKT, showing a linear image of a spontaneously hyperattenuating mass (arrow) suggestive of thrombosis. In addition, the pancreatic graft is heterogeneous, with hypoattenuating areas (ellipse). B: Contrast-enhanced abdominal CT scan, in the venous phase, of the same patient, showing arterial opacification (black arrow) and the absence of venous opacification (white arrow), confirming the venous thrombosis seen in the previous phases.

Thumbnail

Figure 10
A: Cross-sectional image obtained by ultrasound in power Doppler mode, showing abrupt interruption of flow in the distal segment of the superior mesenteric artery (arrow) of the pancreatic graft, with adjacent collateral circulation (arrowhead), a finding consistent with arterial thrombosis. B: Correlation with contrast-enhanced CT in the same patient, with maximum intensity projection in the arterial phase, identifying the same abrupt interruption and a filling defect in the distal segment of the superior mesenteric artery of the pancreatic graft (arrow), confirming the arterial thrombosis suggested by the ultrasound finding.

Thumbnail

Figure 11
A: Unenhanced axial CT scan of the abdomen, showing fluid collections (arrowheads) adjacent to the pancreatic graft (ellipse). Note also the minimal amount of liquid adjacent to the renal graft on the left (black arrow). B: Fluid collection (white arrow) in the right iliac fossa of patient who underwent SPKT with percutaneous drainage (black arrow) seen on an axial CT scan of the abdomen with oral contrast.

Thumbnail

Figure 12
Axial CT with oral contrast of a patient in the early postoperative period of SPKT, with dehiscence of the anastomosis between the duodenal stump of the donor and the small intestine of the recipient, showing a fluid collection with gaseous foci adjacent to the topography anastomosis (arrow).

Thumbnail

Figure 13
Contrast-enhanced axial CT of the abdomen, in the arterial phase, showing, at the level of the renal graft, a solid, slightly heterogeneous mass that is hypodense in relation to the renal parenchyma (asterisk), which was indicative of lymphoproliferative disease, after transplantation.

Figure 1 A: Schematic drawing (anterior view) showing the acquisition of a pancreatic graft (PG), removed together with its vascular support and one duodenal segment (DS) from the donor. For the purposes of transplantation, the donor gastroduodenal artery (dGDA), donor splenic artery (dSA), donor superior mesenteric artery (dSMA), donor superior mesenteric vein (dSMV) donor inferior mesenteric vein (dIMV), and donor splenic vein (dSV) must be connected and sectioned, as must the proximal segment of the portal vein. B: Photograph showing acquisition of the pancreatic duodenal block, the pancreatic allograft (black dotted line) being removed from the donor together with the duodenal segment (white dotted line), prior to excision of the spleen (asterisk). CA, celiac artery.

Figure 2 A: Schematic drawing showing a posterior view of the pancreatic graft (PG) and the duodenal segment (DS) of the donor, with an emphasis on the vascular anastomoses. End-to-end anastomosis between the donor external iliac artery (dEIA) and the donor superior mesenteric artery (dSMA) and between the donor internal iliac artery (dIIA) and the donor splenic artery (dSA) is performed, forming a Y graft. The donor common iliac artery (dCIA) serves as the common arterial channel of the pancreatic graft. The veins are resected together with a short segment of the portal vein (dPV), which is commonly used for venous anastomosis in the recipient. B: Pancreatic duodenal block with pancreatic graft (black arrow) and one duodenal segment (arrowhead) after anastomosis of the arterial Y graft, formed by the common iliac artery (white arrow), external iliac artery (white asterisk) and internal iliac artery (black asterisk) of the donor.

Figure 3 Schematic drawing showing vascular anastomoses after revascularization of the pancreatic graft (PG) in the recipient. End-to-side anastomosis is performed to join the arterial Y graft, via the donor common iliac artery (dCIA) to the recipient common iliac artery (rCIA) or the recipient external iliac artery (rEIA). End-to-side anastomosis is also used to connect the donor portal vein (dPV) to the right common iliac vein of the recipient (rCIV). IVC, inferior vena cava; dSMA, superior mesenteric artery; dIIA, internal iliac artery; dSA, splenic artery.

Figure 4 A: Schematic drawing illustrating the intraoperative appearance of the pancreatic graft (PG) positioned in the pelvis via side-to-side duodenojejunal anastomosis (arrows) linking the donor duodenal segment (DS) to the jejunum of the recipient. The donor duodenum is closed at both ends using sutures or staples (arrowheads). The native pancreas of the recipient remains in the upper abdomen. B: Intraoperative aspect of SPKT with enteric drainage of exocrine pancreatic secretions, by anastomosis between the donor duodenal stump (black asterisk) and the small intestine of the recipient (white asterisk), approximately 25 cm from the ileocecal valve. dIMV, inferior mesenteric vein; dSMV, superior mesenteric vein.

Figure 5 Coronal reconstruction of contrast-enhanced CT, showing normal parenchymal enhancement of the body and tail of the pancreatic graft (white arrow) in the right iliac fossa. A nondilated segment of the pancreatic duct is displayed (arrowhead). Note the renal graft with normal parenchymal enhancement (black arrow) in the left iliac fossa.

Figure 6 Maximum intensity projection image in the arterial phase of contrast-enhanced CT (coronal reconstruction), showing a patent Y graft (white arrow) anastomosed to the right external iliac artery. Note the anastomosis of the Y graft to the branches of the splenic artery (white arrowhead) and superior mesenteric artery (black arrowhead), with narrowing of the lumen of the superior mesenteric artery.

Figure 7 Sagittal reconstruction of a contrast-enhanced CT scan of a pancreatic graft with enteric drainage in the right iliac fossa (white arrow), showing the surgical staples (arrowheads) along the duodenal stump (black arrow), which is partially distended and may simulate a fluid collection. Surgical staples facilitate this differentiation, as well as helping locate the pancreatic graft.

Figure 8 Contrast-enhanced axial CT scan, in the portal phase, of a patient in the postoperative period after simultaneous transplantation of a pancreas (white arrowhead) and a kidney (black arrowhead), presenting a small amount of peripancreatic fluid (arrow), in addition to adjacent lymph nodes (asterisks), usually without clinical significance, which may occasionally mimic some abnormality.

Figure 9 A: Unenhanced abdominal CT scan in patient who underwent SPKT, showing a linear image of a spontaneously hyperattenuating mass (arrow) suggestive of thrombosis. In addition, the pancreatic graft is heterogeneous, with hypoattenuating areas (ellipse). B: Contrast-enhanced abdominal CT scan, in the venous phase, of the same patient, showing arterial opacification (black arrow) and the absence of venous opacification (white arrow), confirming the venous thrombosis seen in the previous phases.

Figure 10 A: Cross-sectional image obtained by ultrasound in power Doppler mode, showing abrupt interruption of flow in the distal segment of the superior mesenteric artery (arrow) of the pancreatic graft, with adjacent collateral circulation (arrowhead), a finding consistent with arterial thrombosis. B: Correlation with contrast-enhanced CT in the same patient, with maximum intensity projection in the arterial phase, identifying the same abrupt interruption and a filling defect in the distal segment of the superior mesenteric artery of the pancreatic graft (arrow), confirming the arterial thrombosis suggested by the ultrasound finding.

Figure 11 A: Unenhanced axial CT scan of the abdomen, showing fluid collections (arrowheads) adjacent to the pancreatic graft (ellipse). Note also the minimal amount of liquid adjacent to the renal graft on the left (black arrow). B: Fluid collection (white arrow) in the right iliac fossa of patient who underwent SPKT with percutaneous drainage (black arrow) seen on an axial CT scan of the abdomen with oral contrast.

Figure 12 Axial CT with oral contrast of a patient in the early postoperative period of SPKT, with dehiscence of the anastomosis between the duodenal stump of the donor and the small intestine of the recipient, showing a fluid collection with gaseous foci adjacent to the topography anastomosis (arrow).

Figure 13 Contrast-enhanced axial CT of the abdomen, in the arterial phase, showing, at the level of the renal graft, a solid, slightly heterogeneous mass that is hypodense in relation to the renal parenchyma (asterisk), which was indicative of lymphoproliferative disease, after transplantation.

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E-mail: radiologiabrasileira@cbr.org.br

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Pancreas-kidney transplantation: what every radiologist should know

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[1] Correspondence: Dr. Alexandre Makoto Minoda. Rua das Pernambucanas, 315, Graças. Recife, PE, Brazil, 52011-010. Email: alexandreminoda@hotmail.com.