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I
II
III
Ultrasound of
Abdominal Transplantation
Paul S. Sidhu, B.Sc., M.B.B.S.,
M.R.C.P., F.R.C.R., D.T.M.&H.
Consultant Radiologist
Department of Radiology
Kings College Hospital
Denmark Hill
London, UK
Grant M. Baxter, M.B.Ch.B., F.R.C.R.
Department of Radiology
Western Infirmary NHS Trust
Dumbarton Road
Glasgow, UK
With contributions by
Syed Babar
Richard C. Beese
Matthew Bowles
Richard Edwards
David Hamilton
Bryon C. Jaques
Rahul M. Jindal
Ajai Khanna
Heather Maxwell
Jon G. Moss
Suzanne Norris
N.H. Patel
Mohamed Rela
R. Stuart C. Rodger
Suzanne M. Ryan
Ashley Shaw
Z. Song
Jonathan Tibballs
257 Illustrations
Thieme
Stuttgart · New York
IV
Library of Congress Cataloging-in-Publication Data
is available from the publisher.
Sponsored by
All clinical images acquired with
The Acuson Sequoia
®
Ultrasound Platform
Any reference to or mention of manufacturers or
specific brand names should not be interpreted as an
endorsement or advertisement for any company or
product.
Some of the product names, patents, and registered
designs referred to in this book are in fact registered
trademarks or proprietary names even though specific
reference to this fact is not always made in the text.
Therefore, the appearance of a name without designa-
tion as proprietary is not to be construed as a represen-
tation by the publisher that it is in the public domain.
This book, including all parts thereof, is legally pro-
tected by copyright. Any use, exploitation, or com-
mercialization outside the narrow limits set by copy-
right legislation, without the publisher’s consent, is
illegal and liable to prosecution. This applies in partic-
ular to photostat reproduction, copying, mimeograph-
ing or duplication of any kind, translating, preparation
of microfilms, and electronic data processing and
storage.
© 2002 Georg Thieme Verlag, Rüdigerstraße 14,
D-70469 Stuttgart, Germany
Thieme New York, 333 Seventh Avenue, New York,
NY 10001, USA
Cover drawing by Martina Berge, Erbach
Typesetting by primustype R. Hurler GmbH,
D-73274 Notzingen, Typeset on Textline
Printed in Germany by Staudigl, Donauwörth
ISBN 3-13-131081-2 (GTV)
ISBN 1-58890-101-7 (TNY) 12345
Important Note: Medicine is an ever-changing science
undergoing continual development. Research and
clinical experience are continually expanding our
knowledge, in particular our knowledge of proper
treatment and drug therapy. Insofar as this book men-
tions any dosage or application, readers may rest as-
sured that the authors, editors, and publishers have
made every effort to ensure that such references are in
accordance with the state of knowledge at the time
of production of the book.
Nevertheless, this does not involve, imply, or express
any guarantee or responsibility on the part of the pub-
lishers in respect of any dosage instructions and forms
of application stated in the book. Every user is re-
quested to examine carefully the manufacturers’ leaf-
lets accompanying each drug and to check, if necessary
in consultation with a physician or specialist, whether
the dosage schedules mentioned therein or the con-
traindications stated by the manufacturers differ from
the statements made in the present book. Such exami-
nation is particularly important with drugs that are
either rarely used or have b een newly released on the
market. Every dosage schedule or every form of appli-
cation used is entirely at the user’s own risk and re-
sponsibility. The authors and publishers request every
user to report to the publishers any discrepancies or
inaccuracies noticed.
V
Preface
Over the last two decades, renal and liver transplanta-
tion have become an almost routine aspect of medi-
cine, allowing the replacement of an organ to be part of
the treatment option for a number of previously fatal
diseases. This has come about through advances in im-
munosuppressive therapy, better surgical techniques,
improved medical and nursing care, and technical ad-
vances associated with anesthetic equipment. In this
overall scene of advancement, imaging has allowed
assessment of disease processes that were but a fig-
ment of the imagination 20 years ago. However, it has
not been due (as perceived mainly by nonradiologists)
to advances in CT and MRI. Rather, ultrasound has le d
the way, particularly color Doppler ultrasound. Ultra-
sound, especially in the postoperative period, allows
complications to be detected early, often at the bed-
side, directing further imaging or altering medical
management. Ultrasound is nearly always the prelimi-
nary investigation prior to radiological intervention
and is often used to direct the interventional pro-
cedure itself, bypassing the need for CT and MRI.
To this effect, we have compiled a textbook that
specifically deals with the role of ultrasound in imag-
ing of abdominal transplantation. We have include d
chapters on intervention in liver and renal transplanta-
tion, as an ultrasound examination invariably leads
directly to intervention, often by the same radiologist.
It is important that the radiologist has an overview of
transplantation and works as a “team member” with
physicians, surgeons, and nursing staff. To this end, we
have included an overview of the medical work-up to
transplantation, medical diseases that result in the
need for transplantation, and the surgical technique it-
self. An understanding of the surgical technique is of
paramount importance to a successful ultrasound ex-
amination. We have also included chapters on pan-
creatic and small bowel transplantation, currently in
its infancy but likely to become more important in the
future.
Our aim was to produce a textbook with high-quality
images that allows the practicing radiologist, sonog-
rapher, or physician insight into techniques of trans-
plant ultrasound and that gives, as well, an overview of
medical and surgical management of transplantation.
Paul S. Sidhu and Grant M. Baxter
VI
Acknowledgments
To publish a book requires a lot of effort, enthusiasm,
and dedication across many fronts. Our thanks go to
the many unnamed heroes involved in the successful
completion of our project, i.e. in illustrating, typeset-
ting, designing, and printing this book. Although we
cannot thank them all individually in print, we do wish
to thank them collectively for their cooperation and
tireless effort.
In addition, the editors are aware of the time and effort
invested by each of the contributors and would like to
thank them for this. We apologize for pushing (en-
couraging) them on occasion but we are proud to say
that this is the only book we have worked upon that
has truly run to schedule.
Finally we would like to acknowledge the support of our
families during this project and the work and guidance
of our secretaries, Mrs. R. McQueen and Mrs. P. Warren,
who essentially manage our working lives as efficiently
as we will let them, take the strain of many of the or-
ganizational aspects of our job, and still manage to
smile. Last but not least, we would like to thank our
wives, Nuala and Monica, together with our children
(Matthew,Joshua, Jamie, Francesca, and Gianluca), all of
whom have been reluctantly understanding!
VII
Contributors
Syed Babar, D.M.R.D., F.R.C.R.
Specialist Radiology Registrar
Department of Radiology
Royal Free Hospital
London, United Kingdom
Richard C. Beese, B.Sc., M.B.B.S., M.R.C.P., F.R.C.R.
Consultant Radiologist
Department of Radiology
Kings College Hospital
Denmark Hill
London, United Kingdom
Matthew Bowles, M.S., F.R.C.S. (Gen)
Consultant Transplant Surgeon
Institute of Liver Studies
Kings College Hospital
Denmark Hill
London, United Kingdom
Richard Edwards, M.R.C.P., F.R.C.R.
Consultant Interventional Radiologist
Gartnavel General Hospital
Glasgow, United Kingdom
David Hamilton, Ph.D., F.R.C.S.
Consultant Surgeon
Transplant Unit
Western Infirmary
Glasgow, United Kingdom
Bryon C. Jaques, F.R.C.S., Ph.D.
Consultant Transplant and Hepatobiliary Surgeon
Freeman Hospital
Newcastle upon Tyne, United Kingdom
Rahul M. Jindal, M.D., F.R.C.S., M.Sc.
Director of Transplantation
Department of Surgery
University of Glasgow
Glasgow, United Kingdom
Ajai Khanna, M.D., Ph.D., F.R.C.S. (Eng. & Glasg.)
Director Pediatric Abdominal Transplantation
and Transplantation Research
Department of Surgery
University of California San Diego
and Childrens Hospital and Health Center of San Diego
San Diego, California, USA
Heather Maxwell, M.D.
Consultant Paediatric Nephrologist
Renal Day Unit
Royal Hospital for Sick Children
Yorkhill NHS Trust
Yorkhill
Glasgow, United Kingdom
Jon G. Moss, F.R.C.S., F.R.C.R.
Consultant Interventional Radiologist
Gartnavel General Hospital
Glasgow, United Kingdom
Suzanne Norris, M.R.C.P.I., Ph.D.
Consultant Hepatologist
Institute of Liver Studies
Kings College Hospital
Denmark Hill
London, United Kingdom
N.H. Patel, M.D.
Associate Professor of Radiology
Department of Radiology
Indiana University
Indianapolis, Indiana, USA
Mohamed Rela, M.S., F.R.C.S.
Consultant Transplant Surgeon
Institute of Liver Studies
Kings College Hospital
Denmark Hill
London, United Kingdom
R. Stuart C. Rodger, M.B.Ch.B., F.R.C.P.
Consultant Physician/Honorary Clinical
Senior Lecturer
Renal Unit
Western Infirmary
Glasgow, United Kingdom
Suzanne M. Ryan,
M.B.B.Ch.B.A.O., M.R.C.P.I., F.R.C.R.
Specialist Radiology Registrar
Department of Radiology
Kings College Hospital
Denmark Hill
London, United Kingdom
VIII
Ashley Shaw, M.B.Ch.B., M.R.C.P.
Specialist Radiology Registrar
Department of Radiology
Kings College Hospital
Denmark Hill, London
United Kingdom
Z. Song, M.D.
Research Assistant
Department of Surgery
University of Glasgow
Glasgow, United Kingdom
Jonathan Tibballs, M.R.C.P., F.R.C.R., F.R.A.N.Z.C.R.
Consultant Radiologist
Department of Radiology
Royal Free Hospital
London, United Kingdom
Contributors
IX
Contents
Section 1: Introduction
Historical Introduction:
The Impact of Imaging on Organ
Transplantation .............................. 1
D. Hamilton
Ancient Times ................................ 1
Skin Grafting: Flaps and Other Methods ........ 1
The Middle Ages .............................. 1
Plastic Surgery Revives ........................ 2
Vascular Surgery .............................. 2
The Hesitant 1920s and 1930s ................. 2
Sense Returns ................................. 3
Organ Assessment and Imaging Commence ..... 3
Understanding the Rejection Mechanism ....... 4
Experimental Kidney Transplants .............. 4
Boston and Paris .............................. 4
Back to the Laboratory ........................ 5
The Twins .................................... 5
Radiation and Immunosuppression ............. 6
Chemical Immunosuppression ................. 6
Dialysis Back-Up .............................. 7
Tissue Typing ................................. 7
The Heart Transplants and After ............... 7
The 1970s .................................... 8
Cyclosporine .................................. 9
The 1990s .................................... 10
Organ Supply ................................. 11
Xenografting .................................. 11
References .................................... 12
Section 2: Renal Transplantation
Chronic Renal Failure and Pretransplantation
Assessment .................................. 13
R.S.C. Rodger and G.M. Baxter
Presentation and Investigation of Renal Failure . 13
Treatment of Chronic Renal Failure ............. 18
Assessment for Renal Replacement Therapy .... 18
Assessment for Cadaveric Renal Transplantation . 19
Assessment for Live Donor Transplantation ..... 20
Assessment of the Live Kidney Donor .......... 20
References .................................... 22
Renal Transplant Surgery ..................... 23
B.C. Jaques
Introduction .................................. 23
Donor Kidney ................................. 23
Transplant Procedure .......................... 23
Postoperative Considerations .................. 26
References .................................... 26
Ultrasound Imaging in Renal
Transplantation .............................. 27
G.M. Baxter
Indications and Contraindications .............. 27
Donor Supply ................................. 27
Histocompatibility Testing ..................... 27
Preoperative Management ..................... 28
Surgery ....................................... 28
Immunosuppression .......................... 28
Imaging the Transplant Kidney ................. 28
Early Complications ........................... 31
Late Complications ............................ 36
Long-Term Complications ..................... 40
Summary ..................................... 41
References .................................... 41
Pediatric Renal Transplantation .............. 43
H. Maxwell
Etiology of Chronic Renal Failure ............... 43
Management of Chronic Renal Failure .......... 43
References .................................... 52
Interventional Radiology and the Transplant
Kidney ....................................... 55
J.G. Moss and R. Edwards
Patient Preparation ............................ 55
Biopsy ........................................ 55
Calculus Disease .............................. 56
Fluid Collections and Abscesses ................ 56
Renal Obstruction ............................. 57
Nephrostomy ................................. 57
Ureteric Balloon Dilatation and Stenting ........ 58
Renal Artery Stenosis .......................... 58
Renal Artery Angioplasty ...................... 60
References .................................... 60