Diagnostic ultrasound ( PDFDrive )

672 PART II Abdominal and Pelvic Sonography
A
B
U
C
FIG. 18.57 Urinoma Secondary to High-Grade Ureterovesical
Junction Obstruction. (A) Sagittal sonogram shows dilation
of upper-pole calyx (arrow). (B) Dilation eventually ruptures through
the adjacent cortex (arrow). (C) Obstruction forms a cortical defect
(arrow) and subsequently a perinephric urinoma (U).
recurrent urinary tract infections and hematuria. In male patients
there is a higher risk of urethral infections and balanitis, which
in turn may lead to urethral strictures.
hese complication risks have resulted in a move toward the
intestinal or enteric-based drainage procedure whereby a
duodenojejunostomy is created for exocrine drainage of pancreatic
secretions. his is performed as either a side-to-side anastomosis
or a Roux-en-Y anastomosis.
he endocrine drainage is either systemic (anastomosis of
donor portal vein to right common iliac vein or distal IVC) or
portal venous (anastomosis of donor portal vein to SMV) (Fig.
18.61). his type of surgery provides a more physiologic transplant
than the more traditional techniques and is not associated with
dehydration or metabolic acidosis. In addition, it provides more
appropriate glycemic control, with lower fasting insulin levels,
and may be associated with a lower incidence of transplant
rejection than the more traditional systemic venous-bladder
drainage allograts. 3,78 Table 18.1 shows the major diferences
between two types of pancreatic transplants (exocrine bladder
drainage and exocrine enteric drainage).
Venous Drainage
he two methods for venous drainage can be categorized as
systemic, wherein the transplanted portal vein is anastomosed
to an iliac vein or vena cava, or alternately as using the portal
technique, whereby it drains into the SMV of the recipient. he
latter technique has over time been shown to confer no additional
advantage in terms of outcome compared with the systemic
technique.
Arterial Supply
In both techniques (systemic and portal venous drainage) the
arterial blood supply to the grat is via the donor common iliac
artery being attached to the common or external iliac artery of
the recipient. Most commonly at our institution, an arterial Y
grat of the donor common iliac artery and external and internal
iliac artery is anastomosed end to end with two separate anastomoses
to the donor superior mesenteric and splenic arteries.
here are some alternate methods, however, which include
forming a single donor iliac arterial conduit (comprising either
the common iliac and either the external or internal iliac artery),