胰腺移植术前影像学评估

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