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Objectives: The purposes of this study were to develop a protocol for evaluating pancreas allografts, to describe a method for successfully studying pancreatic transplants, and to determine whether the resistive index (RI) of the splenic artery is a useful differentiator between complications., Methods: We retrospectively analyzed clinical, surgical, procedural, and radiologic reports in 51 consecutive patients undergoing 182 sonographic examinations during a 4.5-year period. Complications included splenic vein thrombosis, rejection, and pancreatitis. We obtained RIs in normal and complication groups and performed mixed model regression methods and receiver operating characteristic analysis., Results: The mean RI ± SD for normal transplants was 0.65 ± 0.09; for splenic vein thrombosis, 0.76 ± 0.09; after resolution of splenic vein thrombosis, 0.73 ± 0.09; during rejection, 0.94 ± 0.09; after successful treatment of rejection, 0.74 ± 0.09; for pancreatitis, 0.83 ± 0.09; and for fluid collections, 0.66 ± 0.09. There was a statistically significant difference (P < .05) between normal transplants and splenic vein thrombosis (P = .0003), rejection (P < .0001), and pancreatitis (P = .04). A significant difference was also seen between rejection and successful treatment thereof (P < .0001)., Conclusions: We developed a protocol that allowed us to successfully evaluate 96% of the pancreatic allografts studied. Furthermore, our data show that the RI can be used as a therapeutic guide. When the RI is less than 0.65, the risk of vascular abnormalities is very low; however, fluid collections may be present. When greater than 0.75, splenic vein thrombosis, pancreatitis, or rejection should be suspected. When greater than 0.9, rejection must be seriously considered.

In this article's coverage of miscellaneous pancreatic topics, a brief review of pancreatic trauma; pancreatic transplantation; rare infections, such as tuberculosis; deposition disorders, including fatty replacement and hemochromatosis; cystic fibrosis; and others are discussed with pertinent case examples., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Pancreatic surgery, until the Whipple era in the early 1900s, was once regarded as calamitous by most surgeons. With advances in surgical techniques, operative mortality has been greatly reduced, although morbidity remains a significant problem. Knowledge of the surgical options for treatment of pancreatic neoplastic and inflammatory disease is important for the practicing radiologist, to anticipate and identify complications commonly sought and well depicted with imaging., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Simultaneous pancreatic-kidney transplantation is the definitive treatment for patients with type 1 diabetes mellitus and renal failure. Pancreatic graft failure is an important postoperative complication and most commonly occurs as a result of pancreatitis, graft thrombosis or rejection. Distinguishing between these causes is necessary to determine timely, appropriate management and thereby potentially minimising graft loss. Multi-detector CT imaging may be used to identify the cause of pancreatic graft dysfunction when renal function is not markedly impaired., (© 2011 The Authors. Journal of Medical Imaging and Radiation Oncology © 2011 The Royal Australian and New Zealand College of Radiologists.)

Cadaveric, whole pancreas transplantation has proved an effective therapy in the treatment of long-standing type 1 diabetes mellitus and is capable of achieving an insulin-independent eugyclaemic state. As a result, this procedure is being increasingly performed. However, the surgical procedure is complex and unfamiliar to many radiologists. Imaging with computed tomography (CT) and magnetic resonance imaging (MRI) gives excellent results and can be used confidently to diagnose vascular, enteric, and immune-mediated complications. We present a review of the normal post-transplantation appearance and the features of early and late complications.

Pancreas transplantation has become more commonplace over the past several decades. Consequently, the radiological evaluation of patients with such transplants has also become more common. Radiologists must therefore be familiar with the normal imaging appearances of pancreas transplant grafts as well as a wide variety of transplant-related complications. In this article, we review the cross-sectional imaging appearances of normal pancreas transplant grafts as well as present representative examples of complications associated with the procedure.

Enteric drainage is currently the preferred method of pancreatic transplantation. This technique results in long-term good control of diabetes. In this report we discuss the postoperative radiologic anatomy and complications.

Feasibility of secretin-augmented magnetic resonance (MR) pancreatography and dynamic contrast material-enhanced MR measurements for evaluation of functional status of pancreatic allografts was determined by quantifying the excretion and perfusion of the grafts. Ten patients were included prospectively before pancreatic transplantation. Dynamic T2-weighted sequences after secretin stimulation and dynamic contrast-enhanced T1-weighted gradient-echo sequences were performed. Area under the curve and maximum signal intensity-to-time ratio were determined in selected regions of interest. Biochemical parameters, Doppler ultrasonography, and/or surgery were standards for final diagnosis. Patients with normal outcome (n = 7) produced 236 mL +/- 104 (standard deviation) of pancreatic juice, and patients with dysfunctional grafts (n = 3) produced 42 mL +/- 25. Area under the curve and maximum signal intensity-to-time ratio provided thresholds of 0.5 and 0.3, respectively, for distinction between functional and dysfunctional grafts. Secretin-augmented MR pancreatography combined with MR perfusion measurements may aid in differentiation between patients with and those without graft dysfunction., (Copyright RSNA, 2004)

Purpose: Solitary pancreas or combined kidney-pancreas transplantation is currently the only therapeutic procedure for complete resolution of diabetes mellitus type I. The aim of the present study is to investigate the role of multislice computed tomography (MSCT) in the follow-up of patients subjected to solitary pancreas or combined kidney-pancreas transplantation., Materials and Methods: Sixteen patients who had undergone solitary pancreas (n=8) or combined kidney-pancreas (n=8) transplantation, with systemic-bladder (n=6) or portal-enteric (n=10) pancreatic drainage were evaluated with MSCT (Light Speed Plus, GE Medical System). In solitary pancreas follow-up the MSCT study included arterial and portal phases; in combined kidney-pancreas transplanted patients the urographic phase was included. The acquisition was performed with 1.25 mm collimation, 0.6 mm reconstruction interval and a pitch of 6. An MSCT scan of the thorax was included in patients suspected of having lung complications., Results: In all cases MSCT allowed identification of the surgical technique performed, evaluation of the transplanted pancreas, and assessment of complications, if present. The following major complications were identified: thrombosis or stenosis of the arterial graft, pancreatic infarction, ectasia of the common iliac artery and arterial graft, dehiscence of the duodenocystostomy, infected abdominal collections, pulmonary infections., Conclusions: MSCT is able to detect complications arising in the transplanted organs and those related to immunosuppressive therapy, and confirms its usefulness in the follow-up of solitary pancreas or combined kidney-pancreas transplanted patients.

Pancreatic abnormalities usually are detected on US when it is used for screening patients with abdominal pain and for assessment of the gallbladder and bile ducts. Pancreatic visualization is limited by bowel gas, but with experienced sonographers and newer techniques, including harmonic imaging and oral contrast US, diagnosis of pancreatic abnormalities has significantly improved compared with earlier reports. Appropriate initial diagnosis by US can tailor further investigation, and US-guided biopsy may establish definitive diagnosis.

Purpose: To review the normal radiologic appearance of pancreatic transplants that use portal venous and enteric drainage, and to review the appearance of a variety of postoperative complications., Method: We retrospectively reviewed the computed tomographic (CT) scans, magnetic resonance (MR) images, and ultrasounds of patients who had undergone pancreatic transplantation using portal venous and enteric drainage., Results: At CT, the normal pancreatic transplant appears as a heterogeneous mass composed of pancreatic parenchyma, vessels, and omental wrap. On MR imaging, a normal transplant demonstrates intermediate signal intensity on T1- and T2-weighted sequences. Sonographic evaluation of a normal transplant reveals a hypoechoic gland that contains readily detectable low-resistance arterial and venous Doppler waveforms. Acute postoperative complications include acute rejection, which has a nonspecific radiologic appearance, and transplant pancreatitis, which is often manifested on CT by stranding of the peritransplant fat. Chronic postoperative complications include small bowel obstructions, graft pancreatitis secondary to obstruction of the Roux loop, and chronic rejection., Conclusion: Knowledge of the radiologic appearance of the normal pancreatic transplant is required before transplant-related complications can be detected.

Objective: We describe the normal radiologic appearance of pancreatic allografts transplanted using portal venous drainage with enteric drainage of exocrine secretions. We also describe the radiologic appearance of postsurgical complications., Materials and Methods: Of 56 patients who received pancreatic transplants using the portal-enteric technique, 24 patients subsequently required radiologic examination for suspected complications involving the pancreatic allograft. Twenty-three patients underwent CT scanning; a total of 58 CT scans were obtained. Nine abdominal sonograms were obtained in five patients, and one patient underwent angiography. The radiologic appearance of each transplant and the complications were analyzed retrospectively and correlated with the clinical course., Results: The most common indications for CT scanning were fever, elevated levels of serum amylase, and evaluation or follow-up of fluid collections. CT showed the normal and abnormal anatomy of the allograft. Abnormal findings seen in the 58 CT scans included fat stranding (30 scans), ascites (21 scans), peripancreatic fluid or pseudocyst (13 scans), and heterogeneity of the allograft (five scans). One patient had pancreatic infarction with pneumatosis and pneumoperitoneum. The allograft was obscured by bowel gas on three sonograms. Four sonograms showed no abnormalities (one Doppler sonogram showed the arterial supply and venous drainage), and one sonogram showed a pseudocyst. In the one patient who underwent angiography, imaging showed no arterial blood flow to the transplant., Conclusion: Pancreatic transplantation with portal venous drainage and enteric drainage of exocrine secretions and the complications of such transplantation were revealed with CT, sonography, and angiography. Knowledge of normal anatomic configuration will allow proper interpretation of normal and abnormal findings.

Objective: Our objective was to determine whether elevated pancreatic transplant arterial resistive index (RI) and absence of venous flow correlate with pancreatic transplant venous thrombosis., Materials and Methods: Thirteen episodes of surgically documented pancreatic venous thrombosis occurred in 175 pancreases that had been transplanted over a 3-year period. Duplex sonography was performed before surgical exploration in 11 cases. We retrospectively reviewed these 11 sonograms to determine whether blood was flowing in the veins and arteries of the graft. The RI was calculated from all pancreatic artery waveforms. We compared these arterial RIs and the presence or absence of venous flow with those of pancreatic grafts without venous thrombosis to determine sensitivity and specificity., Results: In the venous thrombosis group, thrombosis occurred within 12 days of transplantation (mean, 3.5 days) in all 11 cases. Six cases of thrombosis (55%) occurred within 1 day. Arterial flow was detected within the graft in nine cases (82%) and in the stump of the donor artery between the graft and the recipient iliac artery in the two remaining cases. Antegrade diastolic flow was absent in all arterial tracings. Diastolic flow reversal was present in seven (78%) of nine grafts with detectable intrapancreatic arterial flow. Arterial RIs ranged from 1.00 to 2.00 (mean +/- SD, 1.27 +/- 0.29). Intrapancreatic venous flow was absent in all 11 cases. In the control group (43 examinations in 34 patients) RIs ranged from 0.46 to 1.29 (mean +/- SD, 0.72 +/- 0.18). Two of 43 arterial tracings had diastolic flow reversal (RI > 1.0). Venous flow was present in all examinations in the control group. A statistically significant difference existed between the RIs in the thrombosis group and the RIs in the control group (p = .0001)., Conclusion: Reversal of diastolic flow in pancreatic transplant arteries is highly specific for detection of graft venous thrombosis during the first 12 days after transplantation. Our findings suggest that an RI greater than or equal to 1.00 and absence of venous flow, in combination, are highly sensitive and specific for the diagnosis of pancreatic graft venous thrombosis.

We report a successful en bloc pancreas and kidney transplantation on a type I diabetic patient with advanced peripheral arterial calcific disease, who had frequent life-threatening episodes of hypoglycemia. The en bloc double organ, created by joining the graft renal artery to the arterial Y graft of the pancreas, was implanted to the proximal left common iliac artery, which was the only site available for an arterial anastomosis. Under appropriate circumstances, this procedure would be an option for potential combined pancreas-kidney transplant recipients with severe calcific arterial disease.

Objective: This study was undertaken to determine whether arterial resistive indexes (RIs) in pancreas transplants correlate with biopsy-proven transplant rejection., Materials and Methods: We retrospectively reviewed arterial RIs in pancreas transplants for all patients who underwent Doppler sonography within 1 week before transcystoscopic or percutaneous biopsy of pancreas transplants. RIs were correlated with type and degree of rejection in the 20 transplants for which biopsies provided sufficient tissue for diagnosis. Three patients were subsequently eliminated from the study because of significant intervening therapy between sonography and biopsy., Results: The nine transplants with no evidence of rejection had a mean arterial RI of 0.64 (range, 0.49-0.80). The six transplants with acute mild or moderate rejection had a mean RI of 0.67 (range, 0.56-0.73). The two transplants with acute severe rejection had a mean RI of 0.85 (range, 0.80-0.90). We found no statistically significant difference between arterial RIs in pancreas transplants of patients with acute mild or acute moderate rejection and those with no evidence of rejection., Conclusion: Arterial RIs of pancreas transplants do not differentiate between acute mild or acute moderate rejection and absence of rejection. The higher mean value of arterial RIs in pancreas transplants with acute severe rejection suggests that elevated arterial RIs are sensitive, but not specific, for revealing acute severe rejection of pancreas transplants. However, our study data are limited, and a larger sample size is necessary to draw statistically significant conclusions.

Purpose: In order to evaluate the prognostic significance of chest film findings in connection with cytomegalovirus (CMV) and/or pneumocystis carinii infection (PC), a retrospective review was made of the pulmonary charts of 274 recipients of kidney and/or pancreatic grafts transplanted between April 1987 and December 1990., Material, Methods and Results: Positive laboratory findings for CMV and/or PC were seen in 92 patients. In 77 patients only CMV was found, 13 patients had both CMV and PC, and 2 patients had only PC. In 57 patients a chest examination was performed. The films were reviewed by 2 radiologists independently. In 32 patients normal chest film findings were seen, while 25 patients demonstrated pathological changes. Of the patients with pathological changes 3 had only pleuritis while the remaining 22 demonstrated parenchymal infiltrations. No deaths occurred among patients infected with CMV and/or PC, when the chest film findings were normal or pleuritis only was seen, but there were 9 deaths in the group of patients with parenchymal infiltrations. Of the patients who died, 2 had only CMV, 5 had both CMV and PC, and 2 had only PC. The overall mortality, regardless of radiological findings, did not exceed 3% in patients with CMV only, but increased to 38% in patients with both CMV and PC. In patients with parenchymal infiltrations the corresponding mortality figures were increased to 18% and 56%, respectively., Conclusion: We conclude that a radiologically verified pneumonia related to the infectious agent influences the prognosis, and that CMV pneumonia has a better prognosis than PC pneumonia.

We describe the radiographic imaging modalities that were used in the first twelve consecutive patients who have undergone simultaneous pancreas and kidney transplantation (SPK) at our institution. The total number of examinations undertaken in this study included ultrasound (n = 22), radionucleide scanning (n = 19), cystography (n = 14), computed tomography (n = 2) and magnetic resonance imaging (n = 1). Eighteen percent (5/22) ultrasound examinations were abnormal (perirenal collection [n = 4], peri-pancreatic collection [n = 1]. Two collections required aspiration and were confirmed as lymphocoeles. Cystography showed ureteric reflux in two patients and radionucleide DTPA scanning revealed a delay in the excretory phase in 20% of patients. CT was used in two patients with SPK and demonstrated large peri-pancreatic collections. No episodes of rejection or late graft pancreatitis were noted in this series. We discuss the role of radiographic imaging in detecting early graft failure and also in defining the surgical complications that may arise following transplantation. We also outline the merits and disadvantages of each imaging modality. We conclude that the most useful initial imaging techniques in the evaluation of patients following SPK are ultrasound including Doppler and nuclear medicine.

Absolute quantification of pancreatic perfusion in man has been extremely difficult to date. This paper describes a relatively simple application of dynamic computed tomography to provide perfusion imaging of the human pancreas. Values for perfusion in eight normal pancreases ranged between 1.25 and 1.66 ml min-1 ml-1 (mean: 1.52 ml min-1 ml-1). Increased perfusion values were present in a patient with an islet cell tumour (overall perfusion 2.11 ml min-1 ml-1) and a patient with Wilson's disease (3.43 ml min-1 ml-1). Pancreatic perfusion was reduced in a patient with diabetes (0.60 ml min-1 ml-1) and in a failing pancreatic transplant (0.97 ml min-1 ml-1). The combination of functional information and good spatial detail afforded by computed tomography (CT) perfusion imaging means the technique is well suited for the evaluation of the human pancreas. It is currently the only technique which allows non-invasive absolute quantification of pancreatic perfusion.

Impairment of glomerular filtration rate (GFR) after simultaneous pancreas and kidney (SPK) transplantation is an important marker of chronic renal rejection and recurrence of diabetic glomerulopathy. The use of unmodified serum creatinine to estimate GFR, however, is limited by variations in muscle mass. In this study, predictive factors for long-term GFR were evaluated in consecutive SPK recipients (n = 33) using a Tc99m DTPA GFR reference method between 90 days and 6 years after transplantation (n = 136 measurements). Substantial variability between serum creatinine and isotopic GFR after SPK (R2 = 0.30) high-lighted the inaccuracy of an unmodified serum creatinine in the evaluation of GFR. Factors which predicted GFR apart from serum creatinine included age, sex, height and body weight. A detailed formula was derived for accurate estimation of GFR (ml/min) = [71.4 (male) or 50.4 (female)] + 5520/creatinine (mumol/l) + 0.27 x body weight (kg) - 0.50 x age (yr) - 0.29 x height (cm). This formula was more accurate in estimation of GFR in SPK recipients than six published predictive methods which were derived from chronic renal failure patients using creatinine clearance. All of these methods overestimated GFR at lower levels of renal function. Most correlated poorly with Tc99m DTPA GFR and contained a generalized systematic overestimation of GFR which ranged from 4.7 to 8.4 ml/min (p < 0.05). A simplified version for rapid calculation was also derived as GFR (ml/min) = [25 (male) or 5 (female)] + 5000/creatinine (mumol/l).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of allograft biopsies to guide treatment after solid organ transplantation is a valuable tool in the detection and treatment of rejection. Prior development and use of the cystoscopically guided pancreatic allograft biopsy have allowed for more accurate and timely diagnosis of pancreatic allograft dysfunction, possibly contributing to our 1-year pancreas graft, renal allograft and patient survival rates of 87.1%, 88.5% and 96.8%, respectively. We reviewed our experience, examining efficacy and complication rates of pancreas and kidney biopsies in 31 cadaveric pancreas or combined kidney and pancreas transplants performed between June 1990 and February 1992 with at least 1 year of followup. There were 94 pancreas, 54 kidney and 53 duodenal mucosal biopsies in 29 evaluable patients. This biopsy technique uses a 24.5F side-viewing nephroscope to view the cystoduodenostomy, with the duodenum acting as a portal for biopsy needles into the pancreas. Pancreatic tissue is obtained with either an 18 gauge, 500 mm. Menghini aspiration/core needle or an 18 gauge, 500 mm. Roth core needle. Percutaneous renal allograft biopsies are performed independently or simultaneously with the pancreas biopsies using a 16 gauge spring loaded needle. Pancreas biopsies were prompted by clinical indications of rejection (decreased urinary amylase, increased serum amylase or increased serum creatinine) or by protocol (10, 21 and 40 days postoperatively). Among the biopsies 30% were required by protocol, of which 10 (36%) revealed abnormal pathological findings and 5 (18%) showed evidence of occult cellular rejection. Renal biopsies demonstrated rejection in 69% of the cases. Of simultaneous pancreas/kidney biopsies 33% revealed concomitant rejection. A total of 88 Menghini needles with 170 passes was used in 73 biopsy attempts, yielding 126 tissue cores with a 16% complication rate. A total of 41 Roth needles was used with 73 passes in 34 biopsy attempts, yielding 55 tissue cores with a complication rate of 21%. Complications included self-limited bleeding from the biopsy site in 13% of the cases, bleeding requiring clot evacuation and fulguration in 1% and asymptomatic hyperamylasemia in 12%. Renal biopsy complications included 1 arteriovenous fistula (2%). We conclude that ultrasound and cystoscopically guided pancreatic allograft biopsy and percutaneous renal allograft biopsies are safe and essential methods of obtaining tissue for histological diagnosis without serious sequelae. The Menghini and Roth needles in cystoscopically guided pancreatic allograft biopsy have similar yield and complication rates in obtaining pancreatic tissue, although they require different performance techniques. In some cases both needles are necessary and are complementary in obtaining adequate tissue.(ABSTRACT TRUNCATED AT 400 WORDS)

We present two cases of compromised pancreatic graft perfusion on a routine 99mTc-HMPAO-scan. The radiopharmaceutical, hexamethylpropyleneamine oxime (HMPAO), labeled with 99mTc-provided high-quality scintigraphic images of transplanted pancreatic grafts. Findings were compared with subsequently performed x-ray digital subtraction angiographs. Pathological examination of both resected grafts revealed venous thrombosis in one case and graft pancreatitis in the other case of disturbed graft perfusion on a 99mTc-HMPAO-scan. While 99mTc-HMPAO scans of pancreatic grafts are not specific for early thrombosis, they seem to be a helpful tool in diagnosing pancreatic dysfunction in general, necessitating further diagnostic steps to elucidate the specific cause.

Combined pancreatic-renal transplants promise the restoration of physiologic control of serum glucose and normal renal function. As pancreatic transplantation becomes more common, there is an increased need for rapid, noninvasive evaluation of vascular graft patency and function. Pancreatic transplants share the renal transplant's complications of ischemia at harvest but are at greater risk. Tc-99m HMPAO is a lipophilic complex that clears rapidly from the blood after intravenous injection, and tissue accumulation is proportional to regional perfusion. Using Tc-99m HMPAO to monitor the vascular competency has the advantage of a high count rate during dynamic scintigrams but, in contrast to Tc-99m DTPA, has excellent delayed static images. Four patients who received combined cadaveric pancreatic-renal transplants and had a total of eight Tc-99m HMPAO scintigraphic examinations were reviewed.

Imaging of the renal, hepatic, and pancreas allograft is essential for evaluation of postoperative complications. Surgical complications after organ transplantation can generally be specifically diagnosed. These complications include obstruction, leakage, peritransplant fluid collections, and vascular problems such as vascular stenosis or thrombosis, arteriovenous fistula, and pseudoaneurysm. Using computed tomography (CT) or ultrasound guidance, interventional procedures can often be performed to treat various surgical complications. On the other hand, medical causes of allograft transplant dysfunction such as rejection, acute tubular necrosis, drug toxicity, ischemia, infection, inflammation, or the development of recurrent disease are frequently associated with nonspecific imaging findings. Allograft biopsy is still usually necessary for definitive diagnosis in these cases. In this article, we will briefly outline the spectrum of abnormalities that can be seen in the allograft recipient and show some examples of these complications.

In a prospective study, 17 early baseline computed tomography (CT) scans were obtained 2 or 3 days after simultaneous kidney-pancreas transplantation. Morphological changes and their relevance to the early detection of graft rejection and complications were evaluated. The pancreatic grafts were enlarged and showed signs of mild pancreatitis. Serial scans obtained during the first renal graft rejection episode were compared with the baseline CT scans (n = 7). They showed a significant increase in pancreatic graft size in the case of biopsy-proven severe renal graft rejection (P = 0.008). Normally functioning pancreatic allografts showed a 15%-40% decrease in size 1-6 months after transplantation. We conclude that the morphological changes observed early after transplantation are compatible with mild pancreatitis, which may contribute to the development of pancreatic graft thrombosis. There is an increase in the number of morphological changes during severe rejection, yet enlarged pancreatic grafts appear to recover from transplantation-related damage and regain their normal size without signs of atrophy.

Two cases of scintigraphically detected asymptomatic graft anastomotic pseudoaneurysms are reported. Both patients previously underwent simultaneous renal and pancreatic transplantation. The role of imaging in the diagnosis of this relatively rare, but potentially lethal, vascular complication of pancreatic transplantation is discussed. This is the first report of anastomotic pseudoaneurysms in pancreatic transplants being diagnosed by scintigraphy.

A preliminary investigation of the role of ultrasound, including color and duplex Doppler, was performed in recipients of cadaveric pancreatico-duodenal transplants. Twenty such examinations were done on three patients. Three different complications were noted: rejection, pancreatitis, and peripancreatic abscess. The mean normal resistive index (RI) was 0.71 +/- 0.12. The normal allograft anteroposterior (AP) dimension ranged from 1.5 to 2.0 cm. Intraparenchymal and main feeding vessels were demonstrated easily. RI calculations alone were not helpful in diagnosing graft rejection. However, this diagnosis can be made using a new biochemical marker, serum anodal trypsinogen. We conclude that when used in conjunction with a reliable biochemical marker for rejection (serum anodal trypsinogen), ultrasound, including color and duplex Doppler, provides an important adjunct for the rapid, inexpensive, and complete evaluation of patients with pancreatico-duodenal transplants.