This document outlines pancreatic transplant procedures, including indications, contraindications, techniques, and complications. The main points are: - Pancreatic transplant is typically performed for patients with type 1 diabetes to restore glycemic control. The standard technique is a simultaneous pancreas-kidney transplant. - Indications include end-stage kidney disease from diabetes and failure of insulin therapy. Contraindications include advanced heart or lung disease and active infections. - The donor pancreas is procured and revascularized using a Y-graft anastomosed to the recipient iliac vessels. Ultrasound is the primary imaging method for monitoring the transplant. - Complications include rejection, pancreatitis

1. By Nagawa Roy MDU

2. Objectives
 To outline indications and contraindications for
pancreatic transplant.
 To outline considerations for recipient assessment.
 To describe the surgical technique for pancreatic
transplant.
 To outline the imaging modalities for assessment of a
transplanted pancreas.
 To outline the ultrasound scan protocol for a
transplanted pancreas
 To outline the normal sonographic features of a
transplanted pancreas.
 To describe complications of pancreatic transplant.

3. Indications for pancreas transplant
 Any condition that results in end-stage renal disease (defined:
GFR<15 (stage V CKD); GFR<20 for DDRT (stage IV CKD);
Recipients with living donors may have GFR 20-30 (stage IV
CKD)) including, but not limited to:
 Treatment of patients with diabetes mellitus (typically type 1
diabetes mellitus), acting to restore glycaemic control and
reduce the impact of diabetes-related complications.
 Even though PT is not a lifesaving operation, it is performed due
to the significant increase to patient quality of life, through
halting of the progress of diabetic complications, cessation of
daily insulin injections, and overall improved life expectancy.

4. Indications for pancreatic transplant
 End-stage kidney disease
 Currently on dialysis
 Received a prior kidney transplant because of complications
related to type 1 diabetes
 Hypoglycemia unawareness
 Severe metabolic complications
 Persistent failure of insulin therapy

5. Contraindications for pancreatic transplant
 Advanced cardiopulmonary disease
 Active malignancy with the exception of skin cancer
 Severe local or systemic infection
 Severe neurologic deficits
 Active substance addiction/abuse

6. Absolute contraindications for children
include, but may not be limited to:
 HIV infection with viral load present
 Chronic active infection with Hepatitis B
 Severe multi-organ failure that precludes a combined
transplant with a kidney

7. Relative contraindications for adults and children
include, but may not be limited to:
 Advanced cardiopulmonary disease
 Multiple urinary tract reconstructions
 Lack of social support
 Age greater than 75 years
 Severe malnutrition/cachexia
 Evidence of significant non-adherence
 Cardiopulmonary disease
 BMI 40 - 45 (See Obesity protocol for details)
 Age less than 2 years or weight less than 10 kg

8. Risk factors
 Hepatitis
 Small size
 Complex genitourinary anomalies
 Neurogenic bladder
 Ileal loop
 Multi-visceral transplant
 Peripheral vascular disease
 HIV – (adult only under strict protocol)
 BMI greater than 35

9. Recipient assessment
 Can safely undergo a major surgical procedure
 Has no medical, psychosocial or other risk factors that
cannot be safely corrected before transplantation .
 Has a likely chance of benefiting from renal and/or
pancreas transplantation over the long-term .
 Will be able to obtain and is likely to be compliant
with taking post-transplant immunosuppression and
concomitant medications; and retuning for clinic visits

10. Other considerations
 Age: There is no upper or lower age limit as long as the
candidate has a good chance to withstand a major
surgical procedure, is able to tolerate post-transplant
immunosuppression and has a life expectancy of
greater than three years.
 Cancer: As immunosuppression therapy may favor the
growth of cancer, there should be a wait time of two
years between the last evidence of some types of
cancer. The wait time may vary with different tumors
or histology. In some situations, patients can be
evaluated and listed as inactive for transplant, prior to

11. Other considerations
 Obesity: Transplant candidates should have a body
mass index (BMI) less than 40 before transplantation.
Consideration is given to body habitus. Transplant
evaluation can be completed on a candidate with a
BMI greater than 40.
 Cardiovascular disease (CV): Renal disease is a risk
factor for CV disease. Cardiac evaluation is critical in
this population. Transplant candidacy will be based on
cardiac risk stratification. Individuals deemed high-
risk will be denied candidacy. Annual cardiac testing
will be required of most patients.

12. Pre-evaluation tests.
 Magnetic resonance imaging (MRI) of abdomen/pelvis
OR
 Computed tomography (CT) scan of abdomen/pelvis
 Dobutamine stress echocardiogram (DSE)
 Ultrasound of abdomen/pelvis
 Electrocardiogram/chest X-ray
 Colonoscopy
 Mammogram or Pap smear for women
 Other testing and blood work

13. Pancreatic transplant technique
 Simultaneous Pancreas and
Kidney (SPK),Pancreas After
Kidney (PAK),Pancreas Transplant Alone (PTA),
Pancreatic Islet Transplantation.
 The SPK transplantation accounts approximately for
80% of all PTs, offering better long-term patient
survival than kidney transplant alone.
 The PTA transplantation is offered for

14. Pancreatic Islet
Transplantation
 Pancreatic islet transplantation can also be used in
diabetes mellitus (DM) patients with preserved renal
function. Whilst it is a less invasive and risky
procedure, it comes with lower rates of long term
insulin independence therefore is only performed in
very select patients.

15. Donor Retrieval Procedure
 Full exposure of the abdomen is obtained via
laparotomy, with the bowel mobilised to gain full
access to the retroperitoneal space, before the
donor is heparinised, the distal abdominal aorta tied,
and the organs perfused with cold perfusion solution.
 The pancreas is removed with
the spleen and duodenum attached. The harvested
pancreas will eventually end up with three arterial
stumps (the SMA off the aorta, the splenic artery off
the celiac trunk, and the gastroduodenal artery off the
common hepatic artery) and one venous stump (the

16. Recipient Procedures
 The gastroduodenal artery is tied and the donor’s
common iliac artery Y graft is used to connect the
pancreas graft arteries into one arterial stump.
The native recipient pancreas is not removed.
 A recipient midline laparotomy is performed. The graft
is usually placed in the pelvis (similar to a kidney
transplant), with the graft arterial Y graft implanted on
the right common iliac artery and the pancreatic
venous stump draining into the recipient IVC. If a
SPK is performed, the kidney graft will then get
implanted on the recipient left iliac vessels.

17. SPK transplant technique
Pancreas is typically placed in right
lower intraperitoneal cavity or pelvis,
and kidney is placed on left during
simultaneous pancreas-kidney
transplantation. Common iliac
artery portion of Y-graft (red
arrowhead) is anastomosed to
recipient's common iliac artery or
external iliac artery. Donor superior
mesenteric vein (black arrowhead) is
anastomosed to distal inferior vena
cava in systemic drainage (curved
arrow, donor duodenum; black star,
pancreas; red star, kidney; arrows,
renal vessels).

18. PTA transplant technique
A. With systemic venous revasculization (arrow, anastomosis of graft
superior mesenteric vein [SMV] to inferior vena cava [IVC]; arrowhead,
anastomosis of donor Y-graft to common or external iliac artery). B. With
portal venous revascularization (arrow, anastomosis of graft SMV to major
branch of recipient SMV). Both procedures are performed with enteric
exocrine drainage (curved arrow, donor duodenum; black star, pancreas)

19. Pancreatic transplant Y-graft
Diagram of Y-graft used for
arterial anastomosis between
pancreatic vessels and the
recipient's CIA (CIA: Common
iliac artery, IIA: Internal iliac
artery, EIA: External iliac
artery, SMA: Superior
mesenteric artery, SA: Splenic
artery)

20. Pancreatic transplant Y-graft
Diagram shows anastomoses
for pancreatic transplant
(CIA: Common iliac artery,
CIV: Common iliac vein, PV:
Portal vein, SMV: Superior
mesenteric vein, SV: Splenic
vein, SA: Splenic artery, SMA:
Superior mesenteric artery)

21. Arterial venous and exocrine anastomoses
 Arterial supply: The donor superior mesenteric artery
(SMA) and splenic arteries are anastomosed to the
donor external and internal iliac arteries, using the
donor common iliac artery as the inflow (Y graft). The
donor common iliac artery component is often
anastomosed to the recipient common or external iliac
artery .
 Venous drainage: This may be via the systemic venous
or portal venous circulations. In the former, an
anastomosis is formed between donor portal vein,
which receives the donor superior mesenteric (SMV)

22. Imaging modalities
 Ultrasound is the preferred initial imaging modality to
evaluate the transplanted pancreas; gray-scale assesses
the parenchyma and fluid collections, while Doppler
interrogation assesses vascular flow and viability.
 Ultrasound guided biopsy is useful to guide
percutaneous interventions for the transplanted
pancreas.
 Contrast enhanced ultrasound scan to evaluate
perfusion.

23. Evaluation of a transplanted pancreas

24. Evaluation of a transplanted pancreas

25. Normal sonographic features of a
transplanted pancreas
 Initially, use a 4–6 MHz curvilinear probe to gain a
wider field of view and detect any deep collections.
Later, a high-frequency probe (9 MHz) may help as the
graft is often superficial and can resemble bowel or fat.
 Moderate distension of the urinary bladder can
displace and prevent bowel loops from obscuring the
intraperitoneal transplant; this is particularly an issue
if the graft is anastomosed to the CIA/IVC.
 Unlike kidney transplants that are positioned in the

26. Normal sonographic features of a
transplanted pancreas.
 Although the lack of an organ capsule generally results
in an ill-defined appearance, the pancreatic transplant
can be identified by its relatively cylindrical shape and
its normally homogeneous echotexture that lies
immediately anterior to the transplanted splenic vein.
 Compared to the surrounding mesenteric fat, the
pancreatic transplant is hypoechoic .
 The pancreatic transplant can be differentiated from
the adjacent fluid-filled bowel due to its lack of

27. Normal sonographic features of a
transplanted pancreas.
 If the pancreatic transplant is not apparent upon
initial gray-scale evaluation, it can usually be found by
applying color Doppler analysis and scanning the
length of the patient's iliac vessels.
 After the anastomosed vessels are identified, they
should be interrogated with spectral Doppler to
evaluate the velocities and waveforms .
 The arterial velocities can be quite variable, but
should be normalized to the ipsilateral iliac artery by

28. Normal transplanted pancreas
(a) Gray-scale ultrasound image shows a homogeneous right lower
quadrant pancreas allograft (arrows) that appears hypoechoic to adjacent
intra-abdominal fat. (b) Power Doppler image confirms the presence of
blood flow within the allograft, including within the Y-graft.

29. Normal transplanted kidney
Iliac vessels as landmarks.
The pancreatic transplant
was difficult to find at gray-
scale US. Transverse color
and spectral Doppler US
were used to scan along the
iliac artery (arrow) and vein
(arrowhead) which allowed
identification of the
transplant (P)

30. Normal arterial anastomosis
Normal arterial
anastomosis. Transverse
color and spectral
Doppler US show a
normal-appearing arterial
anastomosis and
waveform located just
medial to the pancreatic
transplant (P)

31. Normal intrapancreatic arterial flow
Normal intrapancreatic
arterial flow. Transverse
spectral US illustrates a
normal arterial
waveform within the
body of the pancreatic
transplant. Note the
brisk systolic upstroke
and the continuous
diastolic flow.

32. Complications of pancreatic transplant

33. Diagnostic approach of enlarged allograft with
altered echogenicity.

34. Allograft rejection
 Immune system-mediated rejection is a common
cause of pancreas allograft failure that may be
hyperacute, acute, or chronic.
 The rate of acute rejection is approximately 15 %, while
the rate of chronic rejection in allografts surviving
greater than 6 months is approximately 25 %.
 Imaging generally plays a limited role in the appraisal
pancreas allograft rejection due to a general lack of

35. Acute rejection
 There is little role for spectral Doppler in the
evaluation of pancreas allograft acute rejection. In a
study by Wong et al. a spectral Doppler resistive index
greater than 0.7 had sensitivity for acute rejection of
only 20 %. Nelson et al.
 compared the results of 40 transplant pancreas
biopsies with baseline resistive index measurements
and identified no statistically difference in mean
resistive index for individuals with no, mild, or
moderate rejection. In fact, neither the absolute
resistive index value nor any relative increase in

36. Acute rejection
Acute rejection.
Transverse gray-
scale US shows
an enlarged,
edematous
pancreas
(arrowheads)
due to an episode
of acute rejection

37. Chronic rejection
A 54-year-old man worsening hyperglycemia due to transplant pancreas
chronic rejection. (a) Gray-scale ultrasound image shows a shrunken,
heterogeneous pancreas allograft (arrows) in the right lower quadrant. (b)
Spectral Doppler waveforms acquired within the allograft demonstrate an
abnormally elevated resistive index. Chronic rejection was confirmed at biopsy

38. Allograft pancreatitis
 Severe pancreatitis affects only approximately 10% of
pancreatic transplants and can be confirmed by
elevation of the serum amylase level.
 In mild pancreatitis, the US findings are often normal.
With more severe disease, the pancreatic transplant
becomes heterogeneous and more hypoechoic due to
parenchymal edema.
 As edema and inflammation progress, the transplant
can develop a more globular appearance with

39. Pancreatitis
 On US, the hallmark of necrosis is lack of arterial and
venous flow within segments of the parenchyma or
throughout the entire gland
 On CT or MRI, there is regional or diffuse lack of
parenchymal enhancement. Regions of necrosis may
liquefy and lead to intraparenchymal fluid collections.
 Additionally, necrosis may be complicated by
superinfection with development of intraparenchymal
gas which manifests as echogenic foci with associated

40. Allograft pancreatitis
Transverse gray-scale US
shows an enlarged,
edematous pancreatic
transplant (P) and
adjacent fluid due to
pancreatitis. Note that
the pancreatic transplant
is slightly hypoechoic
compared to adjacent
fluid filled bowel (B)

41. Vascular thrombosis
 The most feared complication is complete vascular
thrombosis since it can quickly lead to infarction of
the allograft.
 Complete arterial thrombosis is shown as absence of
arterial Doppler signal within the graft despite
parameter optimization .
 The parenchyma becomes heterogeneous at gray scale
US, CT, or MRI; angiographic images can reveal the
site of vascular occlusion within the donor artery.
 Venous thrombosis is more common than arterial
thrombosis and can result in enlargement of the

42. Venous thrombosis
 Gray-scale US findings include increased
hypoechogenicity or heterogeneity of the pancreatic
parenchyma and perigraft fluid; occasionally,
echogenic clot can be identified within the splenic
vein.
 Spectral Doppler findings include the absence of a
venous waveform and reversal of diastolic flow on the
arterial waveform.
 In rare cases, extrinsic compression or kinking of the

43. Transplant thrombosis and infarction.
Transverse US image using color Doppler shows complete lack
of flow within the enlarged pancreatic transplant (P) (B)
Surgical specimen following pancreatectomy revealed infarction

44. Venous thrombosis
Spectral US of the pancreatic transplant reveals reversal of diastolic
flow (arrowheads) in an intrapancreatic artery. No venous waveforms
could be identified throughout the transplant

45. Pseudoaneurysms
 Result from damage to the arterial wall.
 While most pseudoaneurysms occur at, or near, the
arterial anastomosis, they can occur elsewhere
secondary to biopsy sites, pancreatitis, and infections.
 At gray-scale US, they appear as anechoic, round, or
ovoid structures of variable size.
 Color Doppler reveals internal flow with a typical
swirling or “yin-yang” appearance. When the neck of

46. Arteriovenous fistula
 Result from previous biopsy or during surgery.
 There are generally no gray-scale imaging findings
 Color Doppler can show a focus of color aliasing at the
abnormal connection between an artery and the
adjacent vein; the associated waveform is notable for a
high-velocity, low-resistance pattern with increased
diastolic flow in the artery and pulsatile flow in the
draining vein .

47. Arteriovenous fistula
. Transverse US using
color Doppler revealed
focal, turbulent flow
within pancreatic
transplant. Spectral
Doppler analysis showed
a low-resistance arterial
waveform with increased
diastolic flow due to a
small arteriovenous fisula
at a site of prior biopsy

48. Venous stenosis
Transverse spectral
US reveals an
approximately four
fold velocity
gradient between
the venous
anastomosis and the
adjacent iliac vein
due to venous
stenosis

49. Postoperative fluid collections
 Most common complication affecting pancreatic
transplants.
 Clinically significant fluid collections can be
identified by US, CT, or MRI. The development
of intra-abdominal fluid collections can be
variable, occurring anywhere from the immediate to
late postoperative periods.
 The presence of postoperative fluid collections may

50. Abscesses
 Can occur within any portion of the surgical field due
to contamination during surgery or can be associated
with anastomotic dehiscence and leakage of enteric
contents.
 Compared to most other types of fluid collections,
abscesses are generally more complex: They typically
contain internal debris, have thicker, more irregular
walls, and are associated with adjacent inflammation
or infiltration of the surrounding tissue planes .

51. Pseudocysts
 Majority of the pseudocysts are not infected.
 They appear as well-circumscribed collections with
relatively thin walls, anechoic and show strong
through transmission, but occasionally, a small
amount of layering debris can be observed as internal
low-level echoes.
 CT or MRI can show a mild degree of adjacent
inflammation. Pseudocysts are associated with prior
bouts of allograft pancreatitis and may form within the

52. Seroma
Transverse gray-scale
US shows an anechoic
fluid collection
(arrowheads) partially
surrounding the
pancreatic transplant
(P). Aspiration was
consistent with
seroma

53. Bowel-related complications
 Although most cases of allograft dysfunction are
readily assessed by US, bowel complications are better
evaluated by CT.
 As with any bowel surgery, there are risks of
anastomotic leak and obstruction.
 Anastomotic leak is relatively easy to diagnose when
ingested oral contrast extravasates from the
anastomotic site into the peritoneum .

54. Duodenal cuff leak
Duodenal cuff leak.
Axial CT
demonstrates
extravasation of
ingested oral
contrast material
(arrow) due to a leak
in the duodenal cuff
(P: Pancreatic
transplant, Bl:
Bladder, K: Kidney
transplant)

55. References
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173
685/ Imaging in whole organ pancreatic transplants
and a multimodality review of its complications Maira
Hameed et al.
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247
503/ Imaging in pancreatic transplants Matthew T
Heller and Puneet Bhargava1
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909861/ Imaging Spectrum
after Pancreas Transplantation with Enteric DrainageJian-
Ling Chen et al.

56. ADVANCEMENTS IN
ULTRASOUND IMAGING

57. AI & advanced pattern recognition
algorithms
 Automation of time-consuming tasks, quantification
and picking out the ideal image slice from a 3-D
dataset, visual mapping and annotation of screened
anatomy, voice-recognition for hands-free operation
are all being performed through artificial intelligence
(AI).
 E.g. Latest version of the Konica Minolta Sonimage
HS1 uses AI-voice recognition for hands-free
operation. Mindray Resona 7 also enhances clinical
research capabilities with its revolutionary V Flow for
vascular hemodynamic evaluation and intelligent

58. AI acquired image

59. Advantages of AI in ultrasound imaging
 To enhance the quality of ultrasonographic images, to
provide various forms of diagnostic support (e.g.,
automated characterization of findings on
ultrasonographic images; extraction of quantitative or
predictive information from ultrasonographic images,
which is difficult for a human examiner to do based on
visual observations; and automated detection or
segmentation of various structures on
ultrasonographic images).
 To improve workflow efficiency.

60. 3D/4D Ultrasound
 3D / 4D Ultrasound is more popular in Maternity or
Obstetric scanning mainly due to excitement from
parents-to-be to see their baby. The slower frame rates
and higher price of 3-D ultrasound machine and
probes may have limited its wider adoption in other
areas, but 3-D imaging is very useful when used by
specialists for procedural planning or guidance.
 This is because 3D imaging can provide more
identifiable anatomical images for clinicians to more
accurately plan their intervention or surgery. E.g.
ultrasound technology is used to help guide catheter

62. Work-flow automation
 Workflow improvements in current generation
ultrasound machines include, automation/semi-
automation of measurement, auto-image
optimization, reducing repetitive user tasks, support
functions like Scan Assistant, Scan Coach etc. – aimed
at faster processing time and Improving efficiency and
productivity as well as enabling lesser acquainted
physicians to do the scans, rather than Radiologists.
 E.g. GE Versana Premier is designed with medical
practitioners in mind. So that clinicians other than
Radiologists can also confidently diagnose without any

63. Hand-held Ultrasound
 The objective of Point-of-care ultrasounds is quick use
by physicians at the patient bed-side.
Examples :
 Vscan Extend handheld, pocket-sized ultrasound, GE
Healthcare, SonoSite iViz, Philips Lumify portable
Ultrasound system are some of the latest point-of-care
ultrasound systems in the market.
 As more and more image manipulation is getting
automated or AI enabled, there is less use for plathora

64. PHILIPS-Lumify

65. V-scan GE

66. M-scan uganda

67. Application of hand held ultrasound
machines
 They are widely used in Emergency, Anesthesia,
Critical Care, and Vascular departments.
 Home based care
 Medical outreaches
 Pocus

68. Contrast-Enhanced Ultrasound (CEUS)
 The recent decade has witnessed the great improvement of (CEUS) and its extensive use in clinical
practice, which is undoubtedly the major breakthrough in the field of diagnostic ultrasound in recent
years.
 The concept of CEUS can be looked back to 60s in the last century, whereas only in 2000s CEUS
regained increasing attention in both clinical practice and basic research. The current popularization
of CEUS is largely due to the emergence of low acoustic power contrast-specific imaging mode and
microbubble-based contrast agent filled with inert gas.
 After administration of ultrasound contrast agent intravenously, the low acoustic power contrast-
specific imaging mode facilitates visualization of the nonlinear signals from the microbubbles in the
circulation and suppresses the linear signals from the surrounding tissues, which leads to an
improved signal-to-noise ratio and facilitates depiction of macro- and microcirculation of the region
of interest (ROI) noninvasively.
 The low acoustic power also limits the damage to the microbubbles under acoustic push; thus, more
microbubbles will remain in the circulation and a long time CEUS depiction is available

69. Examples of ultrasound contrast agents (brand
names) available commercially
 Definity (Lantheus Medical Imaging)
 Optison (GE Healthcare)
 Sonazoid (GE Healthcare)
 SonoVue/Lumason (Bracco)

70. Applications of CEUS
 Better visualisation of organs and blood vessels within
the abdomen and pelvis. This exam may evaluate the
liver, spleen, kidneys, pancreas, bowel, and/or bladder.
 Characterisation of masses for example in the
liver,kidneys,spleen.
 Assessing vascularity of organs and masses.

71. Transverse dual
image with
simultaneous
display of B-mode
image (left) and
contrast image
(right) of a
hepatoblastoma
(arrow) in a 13-
month-old girl.

72. SHEAR WAVE ELASTOGRAPHY
 The concept is similar to strain elastography, but instead of
using transducer pressure to compare a shift in an
ultrasound A-line (thereby measuring changes in strain), a
higher intensity pulse is transmitted to produce shear
waves, which extend laterally from the insonated
structure. The shear waves may then be tracked with low
intensity pulses to find the shear velocity and this velocity
is related to Young's modulus.
 Types
 point shear wave elastography (pSWE)
 2D-shear wave elastography (2D-SWE)

73. Applications
 Applications of shear wave elastography are currently being
developed for:
 breast ultrasound
 liver ultrasound
 detection of small lesions
 evaluation of diffuse liver disease
 prostate ultrasound
 thyroid nodule ultrasound
 musculoskeletal ultrasound
 There may also be some applications in echocardiography.

74. Fibroscan vs shear wave elastography.
 FibroScan® is a non-invasive device that assesses the ‘hardness’
(or stiffness) of the liver via the technique of transient
elastography. Liver hardness is evaluated by measuring the
velocity of a vibration wave (also called a ‘shear wave’) generated
on the skin. Shear wave velocity is determined by measuring the
time the vibration wave takes to travel to a particular depth
inside the liver.
 A graphical representation of this is provided on the screen
Because fibrous tissue is harder than normal liver, the degree of
hepatic fibrosis can be inferred from the liver hardness .
 This can be used to estimate the degree of stiffnes ,monitor
diseaseprogress and guide prognosis and further treatment.

75. Fibroscan

76. Shear wave elastography