Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions.

PURPOSE: To determine the usefulness of magnetic resonance (MR) cholangiography in defining the extent of biliary ductal involvement in patients with malignant hilar and perihilar biliary obstruction and to evaluate whether findings at MR cholangiography alone are sufficient to plan percutaneous interventions in these patients. MATERIALS AND METHODS: Twenty-nine patients with malignant hilar and perihilar biliary obstruction were examined with MR cholangiography. Two radiologists evaluated MR images and determined the extent of biliary ductal involvement. A hypothetical plan for biliary drainage was established prior to any intervention. All patients underwent percutaneous cholangiography, and 27 of 29 patients also underwent biliary drainage and/or stent placement within 7 days after MR cholangiography. By using direct cholangiography as the standard of reference, the usefulness of MR cholangiography in defining the extent of biliary ductal involvement was determined. The type of drainage performed was compared with the type that had been anticipated at MR cholangiography. RESULTS: MR cholangiography was adequate in helping predict the extent of biliary ductal involvement in 28 (96%) of 29 patients and led to underestimation of the extent of the disease in one patient. The therapeutic plan anticipated with MR cholangiography matched the one actually used in 24 (83%) of 29 patients. CONCLUSION: The high accuracy of MR cholangiography for defining extent of ductal involvement in patients with malignant hilar and perihilar obstruction allows adequate planning of percutaneous interventions in a majority of patients.     

Complementary role of helical CT cholangiography to MR cholangiography in the evaluation of biliary function and kinetics

To explore the potential role of computed tomographic cholangiography (CTC) in relation to magnetic resonance cholangiography (MRC) in cases in which knowledge of biliary kinetics and functional information are important for therapeutic decisions, 31 patients (14 men and 17 women) underwent MRC followed by CTC. We examined nine post-cholecystectomy cases with right upper quadrant abdominal pain, six cases with a previous biliary-enteric anastomosis and clinical evidence of cholangitis, eight biliary strictures with pain or symptoms of cholangitis, four cases with strong clinical evidence of sclerosing cholangitis, three cases with suspected post-laparoscopic cholecystectomy bile leakage, and one case with chronic pancreatitis and a common bile duct stent associated with cholangitis. In relation to MRC, CTC provided additional biliary functional information as follows: abnormal biliary drainage through the ampulla in 7/9 cholecystectomy cases, impaired drainage in 3/6 biliary-enteric anastomoses, and complete obstruction in 2/8 biliary strictures. CTC diagnosed early sclerosing cholangitis in 4/4 cases and confirmed suspected bile leakage in 1/3 post-laparoscopic cholecystectomy patients, and the patency of the biliary stent in the patient with chronic pancreatitis. Thus, CTC provides clinically important information about the function and kinetics of bile and complements findings obtained by MRC.     

经皮肝穿刺胆道支架植入后再狭窄分析及介入治疗

目的探讨恶性胆道梗阻性黄疸经皮肝穿刺胆道支架置放术后支架再狭窄原因及介入治疗。方法20例胆道支架再狭窄患者,根据术后引流量及黄疸消退情况,于2周,1个月,2个月,3个月复查肝功、血、尿、粪及B超、CT、经引流管胆道造影,确认支架再狭窄性质、部位后,利用外置引流管途径行介入再通治疗。支架均为国产普通镍钛合金胆道支架,直径10mm,长度40~80mm。结果20例支架再狭窄中,9例为肿瘤浸润压迫所致,3例为支架上端成角致阻塞,4例为胆泥及食物残渣或陈旧性凝血块阻塞支架,2例为胆管炎性狭窄,2例为肉芽组织增生引起阻塞。全部再狭窄病例经引流管抽吸、药物灌注、冲洗、导管导丝疏通、球囊扩张、支架再植入予以复通,生存期超过6个月。结论经皮肝穿刺胆道支架植入术治疗恶性胆道梗阻,术后支架再狭窄率仍较高,应引起重视。     

Intrabiliary MR imaging: assessment of biliary obstruction with use of an intraluminal MR receiver coil

PURPOSE: The primary aim of this study was to determine whether intrabiliary magnetic resonance (MR) imaging is feasible in a clinical setting and to optimize MR imaging parameters for the technique. In addition, it was attempted to determine the accuracy of intrabiliary MR imaging in the setting of biliary obstruction of unknown cause. MATERIALS AND METHODS: Intrabiliary MR was performed prospectively in 15 patients with biliary obstruction of unknown cause. A 0.030-inch MR intravascular receiver coil was placed in an existing biliary tube. Intrabiliary MR was performed on a 1.5-T system. T1-weighted, T2-weighted, and single-shot fast spin-echo images were acquired. T1-weighted images were also acquired after the administration of a gadolinium contrast agent. Signal intensity analysis was conducted in the region of the common bile duct. Accuracy of intrabiliary MR, computed tomography (CT), MR, and cholangiography were determined by correlation with surgical pathologic findings. RESULTS: Intrabiliary MR was successfully performed in 14 of 15 patients. MR examinations were performed in less than 1 hour. The signal-to-noise ratio in the region of the common bile duct with the intrabiliary MR technique was increased by a factor of 9 compared with standard surface-coil MR imaging (P < .00001). The mean n-plane resolution achieved was 740 +/- 20 microm x 1,150 +/- 20 microm obtained with use of a field of view of 18 cm x 18 cm (range, 15-24 cm) and a matrix of 256 x 160. Of the pulse sequences tested, the gadolinium-enhanced T1-weighted image was the best for identifying tumor and delineating tumor margins. Intrabiliary MR had a higher sensitivity than CT (100% vs 50%), a higher specificity than cholangiography (80% vs 20%), and a better correlation (P = .015) with surgical pathologic findings than CT, MR imaging, or cholangiography. CONCLUSIONS: Intrabiliary MR was well tolerated in a clinical setting and provided high spatial resolution and excellent contrast between the biliary lumen and adjacent structures. Intrabiliary MR demonstrated an advantage in detecting the presence or absence of biliary malignancies compared with currently available standard imaging techniques. The technique may be useful to evaluate biliary obstruction of unknown cause.     

Ampullary carcinoma: Demonstration by current MR techniques

The objective of this study was to demonstrate the appearance of ampullary carcinoma using current MR techniques, including fat suppression, gadolinium enhancement, and MR cholangiography. Nine patients with ampullary carcinoma were examined by MRI at 1.5 T. MR examinations included T1-weighted spoiled gradient echo, T1-weighted fat-suppressed, and immediate postgadolinium spoiled gradient echo images for all patients and MR cholangiography for three patients. The imaging features of ampullary carcinomas, including tumor size and morphology, signal intensity, and enhancement characteristics, were determined. Ampullary carcinomas shown on MR images ranged in size from 1.5 to 5.5 cm. Tumors were low in signal intensity on precontrast T1-weighted spoiled gradient echo and T1-weighted fat-suppressed images relative to normal pancreatic tissue and enhanced less than normal pancreas on immediate postgadolinium spoiled gradient echo images. Tumor conspicuity was greatest on immediate postgadolinium spoiled gradient echo images. MR cholangiography demonstrated high grade obstruction of the common bile duct and mild dilatation of the pancreatic duct at the level of the ampulla with abrupt termination of the ducts in two untreated patients and moderate dilatation of the common bile duct in one patient who had a biliary stent. Ampullary carcinomas can be demonstrated on MR images as small masses arising at the ampulla. Tumors are well defined on immediate postgadolinium spoiled gradient echo images.     

MR cholangiography of late biliary complications after liver transplantation.

OBJECTIVE: The aim of our study was to assess the role of MR cholangiography in the diagnosis of late biliary complications after liver transplantation. SUBJECTS AND METHODS: Twenty-three liver transplantation patients (18 men and five women; mean age, 46 years) underwent MR cholangiography using a nonbreath-hold, fat-suppressed three-dimensional turbo spin-echo sequence (TR/TE, 3000/700; echo train length, 128) optimized on a 0.5-T magnet. Inclusion criteria were liver function tests with abnormal results and hyperbilirubinemia with a clinical pattern not specific for biliary obstruction. All patients were referred by clinicians for contrast-enhanced cholangiography. Diagnostic confirmation was obtained with percutaneous transhepatic cholangiography (n = 4), endoscopic retrograde cholangiography (n = 8), T-tube cholangiography (n = 1), or clinical follow-up (n = 10). RESULTS: In 11 patients, no abnormalities of the biliary tract were revealed by MR cholangiography. In 11 patients, twelve strictures were diagnosed (nine anastomotic, two nonanastomotic-intrahepatic, and one nonanastomotic-extrahepatic, with association between anastomotic and nonanastomotic strictures in two cases). In one other patient, kinking of the common bile duct at the level of the anastomosis was observed. In all cases, MR cholangiography correctly showed the site of the stricture and the dilatation of bile ducts above, with excellent correlation with contrast-enhanced cholangiographic findings. Strictures were correctly graded in eight of 10 patients and were overestimated in two. Other findings included a 1-cm stone detected proximal to the obstructed common bile duct in one patient and multiple intrahepatic stones in another patient. CONCLUSION: MR cholangiography can show biliary obstruction and provide important information for planning therapeutic procedures.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Treatment of Malignant Bile Duct Obstruction: What the Interventional Radiologist Needs to Know

Management of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.     

MR cholangiography with manganese dipyridoxyl diphosphate in the evaluation of biliary-enteric anastomoses: preliminary experience

OBJECTIVE: The purpose of our study was to assess the usefulness of manganese dipyridoxyl diphosphate (Mn-DPDP)-enhanced T1-weighted MR cholangiography for evaluating patients with biliary-enteric anastomoses. CONCLUSION: Mn-DPDP-enhanced T1-weighted MR cholangiography may provide useful functional information and may aid in the assessment of the patency of biliary-enteric anastomoses.     

Biliary obstruction: evaluation with three-dimensional MR cholangiography.

Three-dimensional (3D) magnetic resonance (MR) projection imaging was evaluated as a noninvasive alternative to direct cholangiography in 12 patients with malignancy-related obstructive jaundice. The 3D images of the bile ducts were formed by subjecting consecutive coronal MR images obtained with a fast imaging method to a maximum-intensity projection algorithm. Dilatation and obstruction of the biliary system were well documented in all cases, and good correlation between findings at 3D MR cholangiography and percutaneous transhepatic biliary drainage performed 0-21 days later was observed.     

Retrograde or antegrade double-pigtail stent placement for malignant ureteric obstruction?

AIM: To determine the optimum approach for double-pigtail stent placement in malignant ureteric obstruction. PATIENTS AND METHODS: Retrograde stent placement was attempted in a consecutive series of patients presenting with malignant ureteric obstruction. If retrograde stent placement was unsuccessful, percutaneous nephrostomy was performed immediately followed by elective antegrade stent placement. Identical digital C-arm fluoroscopy for image-guidance and conditions for anaesthesia and analgesia were employed for both retrograde and antegrade procedures. Identical 8 Fr (20-26 cm) double-pigtail hydrophilic coated stents were used for each approach. RESULTS: Retrograde placement was attempted in 50 ureters in 30 patients {19 male, 11 female, average age 61.4 yr (range 29-90 yr)} over a 24-month period. The success rate for retrograde ureteric stent placement was 50% (n = 25/50). Technical failures were due to failure to identify the ureteric orifice (n = 22), failure to cross the stricture (n = 1), failure to pass the stent (n = 1) and failure to pass a 4 Fr catheter (n = 1). Antegrade placement was attempted in 25 ureters with a success rate of 96% (n = 24/25). Failure in the one case was due to inability to cross an upper third stricture secondary to pyeloureteritis cystica. CONCLUSION: It is suggested that retrograde route should be the initial approach if imaging shows no involvement of ureteric orifice (UO), when nephrostomy is technically very difficult or in cases of solitary kidney. The antegrade route is preferred if imaging shows tumour occlusion of the UO or if there is a tight stricture very close to the uretero-vesical junction (UVJ) making purchase within the ureter difficult for crossing the stricture.     

Sonography accurately detects biliary obstruction in patients with surgically created biliary-enteric anastomosis

The use of sonography to determine the patency of surgically created biliary-enteric anastomoses has been questioned by authors who favor use of cholescintigraphy and percutaneous transhepatic cholangiography for this purpose. We retrospectively reviewed the sonographic findings in 35 patients with such anastomoses: 16 choledochojejunostomies, 11 choledochoduodenostomies, five intrahepatic cholangiojejunostomies, and three cholecystoenterostomies. The anastomosis was patent in 25 patients, completely obstructed in four, and partially obstructed in six. Five of the 25 patients with patent anastomoses had nonanastomotic complications with biliary stasis and cholangitis. In the 20 patients with patent anastomoses and no complication, sonography showed bile ducts ranging from 2 to 9 mm in diameter filled with bile (six), gas (two), or both (12). No patient with a normally functioning anastomosis had evidence of a dilated bile-filled duct in the upright position. In four patients with complete obstruction of the anastomosis, sonography showed dilated, bile-filled ducts ranging from 6 to 14 mm in diameter proximal to the anastomosis. Sonograms in all six patients with partial obstruction showed both gas and bile in dilated bile ducts with superficial gas-filled ducts and dependent bile-filled ducts creating gas/fluid interfaces, which were persistent in the upright position. The 15 patients with anastomotic obstruction or other complication had confirmatory percutaneous transhepatic cholangiography (nine patients), scintigraphy (five patients), CT (four patients), and surgery (eight patients). Our experience suggests that sonography can be used to accurately assess surgically created biliary-enteric anastomoses for both anastomotic patency and for other complications.     

Clinical impact of MR cholangiopancreatography in patients with biliary disease

PURPOSE: To evaluate the role of MR Cholangiopan-creatography (MRCP) as a first imaging modality in patients with suspected biliary tree pathology and indications to endoscopic retrograde cholangiopancreatography (ERCP). MATERIAL AND METHODS: Eighty-eight patients, with clinical signs of biliary tree pathology underwent MRCP, performed with a 1.5 T unit and a phased-array coil. Surgery, intraoperative cholangiography, percutaneous transhepatic cholangiography (PTC) or ERCP were regarded as the gold standard in patients with obstruction; the remaining patients underwent follow-up MRCP examinations at 6-9 months. The MR examination was performed with baseline T1w 2D FLASH and T2w TSE sequences, followed by the MRCP study (single-slab breath-hold RARE and multislice breath-hold HASTE sequences). The MR images were independently evaluated by two radiologists. RESULTS: MRCP showed normal findings in 20 patients; 68 patients had biliary duct dilatation. In 11 out of 68 patients MRCP did not identify any obstruction (9/11 were true negative cases). A diagnosis of benign obstruction was expressed in 36/59 patients (4 chronic pancreatitis, 29 choledocolithiasis, 4 inflammatory obstruction, 2 primary sclerosing cholangitis), with 1 false positive and 5 false negatives (sensitivity, specificity and diagnostic accuracy of 86%, 95% and 90%, respectively). MRCP identified 23 neoplastic stenoses (20/23 were true positives): the sensitivity, specificity and diagnostic accuracy values were 100%, 87% and 95%, respectively. MRCP correctly identified the level of obstruction in 100% of cases. CONCLUSIONS: MRCP may be considered as a first-step imaging method in patients with clinical signs of biliary disease. The workload of ERCP in the diagnostic stage could therefore be reduced and its use be reserved for therapeutic indications.     

Navigator-triggered isotropic three-dimensional magnetic resonance cholangiopancreatography in the diagnosis of malignant biliary obstructions: comparison with direct cholangiography

PURPOSE: To compare the diagnostic accuracy of navigator-triggered isotropic three-dimensional (3D) MR cholangiopancreatography (MRCP) using parallel imaging for malignant biliary obstruction with direct cholangiography. MATERIALS AND METHODS: A total of 23 patients with malignant biliary obstruction underwent MRCP and endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous transhepatic cholangiography (PTC). Two observers retrospectively evaluated 3D-MRCP and ERCP/PTC and recorded the level of obstruction and extent of tumor along with their confidence. The quality of images and morphologic appearance of stricture were also evaluated by two reviewers. The results of MRCP and ERCP/PTC were compared with surgical and histopathological data. RESULTS: 3D-MRCP was of diagnostic quality and free of artifacts in all patients, whereas ERCP/PTC examinations failed in three patients. For the evaluation of level of obstruction, there was no statistical significance between 3D-MRCP and ERCP/PTC. 3D-MRCP was superior to ERCP/PTC in the assessment of anatomical extent of hilar bile duct involvement, but did not show statistical significance. The accuracy of 3D-MRCP in determining tumoral extent of hilar cancer was higher than that of ERCP/PTC, but it was not statistically significant. The image quality of 3D-MRCP was superior to ERCP/PTC. There was good agreement between morphologic appearance at MRCP and those at ERCP/PTC. CONCLUSION: 3D-MRCP can accurately assess the level of obstruction and extent of tumor in patients with malignant biliary obstruction.     

T-configured dual stent placement in malignant biliary hilar duct obstructions with a newly designed stent

PURPOSE: To evaluate the technical success and clinical efficacy of T-configured dual stent placement in the management of malignant biliary hilar duct obstructions with a newly designed stent. MATERIALS AND METHODS: Between January 2001 and July 2002, 57 patients with malignant biliary hilar duct obstruction were treated with percutaneous transhepatic placement of two self-expandable metallic endoprostheses in a T configuration with use of a newly designed stent. The patients ranged in age from 46 to 85 years and included 37 men and 20 women. RESULTS: Stent placement with two endoprostheses was successful in all patients. The mean survival and stent patency times were 193.6 days (range, 7-442 days) and 170.3 days (range, 7-305 days), respectively. There were no statistical differences in age, sex, or Bismuth type. CONCLUSION: T-configured dual stent placement with a newly designed stent is simple, safe, and reliable in achieving bilateral internal bile drainage in patients with malignant biliary hilar obstructions.     

MR cholangiography and CT cholangiography of pediatric patients with choledochal cysts.

OBJECTIVE: We report our experience using MR cholangiography and CT cholangiography in pediatric patients with choledochal cysts. SUBJECTS AND METHODS: Fourteen patients (two boys, 12 girls; mean age, 7.8 years) with either a preoperative diagnosis of choledochal cyst or a surgical finding of choledochal cyst underwent non-breath-hold MR cholangiography using T2-weighted fat-suppressed fast spin-echo sequences with a 1.5-T magnet, and CT cholangiography with IV infusion of meglumine iodoxamic acid. Radiologic findings were correlated with findings from surgery, operative cholangiography, or percutaneous transhepatic cholangiography. RESULTS: The biliary tree was visualized in all 14 patients with MR cholangiography and in 13 patients (92.9%) with CT cholangiography. In the 11 preoperative cases of choledochal cyst, MR cholangiography correctly showed all cysts and CT cholangiography showed 10 cysts (90.9%). The quality of images on CT cholangiography and MR cholangiography was comparable. The sensitivity of CT cholangiography and MR cholangiography in revealing intrahepatic stones was 83.3% and 66.7%, respectively; the specificity for both techniques was 100%. The rate of detecting the pancreatic duct and the common channel by CT cholangiography and MR cholangiography was 63.6% and 45.5% respectively. After surgery, CT cholangiography was superior to MR cholangiography in revealing the location of biliary-enteric anastomosis and the extent of anastomotic narrowing. CONCLUSION: Because non-breath-hold MR cholangiography is not invasive and does not use ionizing radiation and potentially toxic contrast agents, it is recommended as the imaging technique of choice in children with choledochal cysts. CT cholangiography can be considered as an adjunct after surgery and in patients in whom MR cholangiography is unsatisfactory.     

Value of MR cholangiography in patients with iatrogenic bile duct injury after cholecystectomy

OBJECTIVE: Our aim was to determine the diagnostic role of MR cholangiography in the evaluation of iatrogenic bile duct injuries after cholecystectomy. SUBJECTS AND METHODS: Nineteen patients (14 women and five men; mean age, 47 years; age range, 24-75 years) with suspected bile duct injury as a result of laparoscopic cholecystectomy (17 patients) and open cholecystectomy (two patients) underwent MR cholangiography. MR images were evaluated for bile duct discontinuity, presence or absence of biliary dilation, stricture, excision injury, free fluid, and collections. Bile duct excision and stricture were classified according to the Bismuth classification. Final diagnosis was made on the basis of findings at surgery in 15 patients, on percutaneous transhepatic cholangiography (PTC) in one patient, and on endoscopic retrograde cholangiography (ERC) and at clinical follow-up until hospital discharge in the remaining three patients. RESULTS: In 16 patients, injury of the bile duct was observed. Two patients had Bismuth type I injury; one patient, type II injury; 11 patients, type III injury; and one patient each, type IV and V injuries. Three patients showed findings suggestive of leakage from the cystic duct remnant, which were confirmed on ERC. CONCLUSION: MR cholangiography is an accurate diagnostic technique in the identification of postoperative bile duct injuries. This technique allows exploration above and below the level of obstruction, a resource provided by neither ERC nor PTC, and allows the accurate classification of these injuries, which is essential for treatment planning.     

Malignant biliary hilar stenosis: MR cholangiography compared with direct cholangiography]

AIM: To assess the diagnostic value of three-dimensional (3D) magnetic resonance cholangiography (MRC) versus direct cholangiography such as endoscopic retrograde cholangiography (ERC) and percutaneous transhepatic cholangiography (PTC) in malignant biliary stenosis. MATERIAL AND METHODS: Twenty-nine patients (15 female and 14 male) (mean age 62 years) with malignant biliary strictures underwent MRC and ERC. Breath-hold 3D steady state free precession MR cholangiography was performed on a 1.5-T imager in the patients before ERC. In 25 patients findings at ERC/PTC were considered the standard of reference: 19 patients underwent ERC, 5 PCT and 1 both ERC and PTC due to unsuccessful papilla cannulation during the endoscopic examination. In the 4 remaining patients the surgical specimen was considered the standard of reference. In the 29 patients studied, histology performed during direct cholangiography and the examination of the surgical specimens demonstrated that the malignant hilar stenoses were caused by hilar cholangiocarcinoma (n=7), cholangiocarcinoma of the distal VBP (n=1), gallbladder cancers (n=6), endometrial metastasis (n=2), ovary metastasis (n=1), colon metastasis (n=1), breast metastasis (n=1). The correct identification of biliary stenosis and extension of the tumor (according to the Bismuth classification) by MR cholangiography and ERC were independently assessed by two readers blinded to each other's report. The results were compared. RESULTS: Identification of biliary stenosis and neoplastic extension were accurate in respectively 29/29 (100%) and 26/29 (89%) cases with MR cholangiography. The comparison of ERC/PTC and MRC images yielded the following results: Bismuth Type I (6 vs 6), Type II (5 vs 8), Type III (13 vs 10), Type IV (5 vs 5). Our results indicate that MR is less capable of identifying the extension of small lesions at the primary confluence of bile ducts than are ERC/PCT. DISCUSSION AND CONCLUSIONS: MR cholangiography is a non-invasive technique for biliary tract imaging. It does not require administration of contrast medium and allows complete visualisation of the biliary ducts. MR cholangiography allowed accurate diagnosis of malignant hilar stenosis providing equal information as direct cholangiography and may therefore obviate the need for ERC/PTC.     

Etiology of biliary stenosis at MR Cholangiography: correlation with pathology findings

OBJECTIVE: To evaluate the accuracy of MR cholangiography to differentiate between the benign and malignant etiology of biliary strictures, excluding bilioenteric anastomoses. MATERIALS AND METHODS: 49 patients (26 males, 23 females) with suspected biliary stricture underwent MR cholangiography at 1.5T (Siemens Symphony). RARE and HASTE sequences were acquired in the coronal, oblique and axial planes. MR cholangiography findings were reviewed by two independent radiologists and correlated with the final histological diagnosis. Sensitivity, specificity, and agreement were calculated with a 95% confidence interval. RESULTS: Benign stenosis was identified in 23 patients (47%) and malignant stenosis in 26 (53%). The sensitivity of MR cholangiography was 64% and the specificity was 96%. The agreement between results at MR cholangiography and histology was moderate. The inter-observer agreement for MR cholangiography was good with a Kappa value of 0.61. CONCLUSION: MR cholangiography has the potential to replace diagnostic cholangiography in patients with suspected biliary stricture. Direct cholangiography could be reserved for patients where a therapeutic procedure is anticipated.     

Percutaneous cystic duct stent placement for the treatment of acute cholecystitis resulting from common bile duct stent placement for malignant obstruction

Common bile duct (CBD) stent placement to relieve malignant biliary obstruction can occasionally cause cystic duct obstruction and acute cholecystitis. Cholecystostomy tube placement is often performed in patients with limited life expectancy but can have a significant impact on quality of life. To allow cholecystostomy tube removal, percutaneous metallic stent placement was performed across the cystic duct via the tube tract in such a patient. The procedure included traversal across the previously placed CBD stent. At 5-month follow-up, the patient remained symptom-free. In select patients who develop acute cholecystitis after CBD stent placement for malignant obstruction, percutaneous stent placement across the cystic duct may be considered a treatment option.     

Multiple biliary papillomatosis: comparison of MR cholangiography with endoscopic retrograde cholangiography

PURPOSE: The purpose of this work was to compare MR cholangiography with endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of multiple biliary papillomatosis (MBP). METHOD: Nine patients with pathologically proven MBP underwent MR cholangiography and ERCP. A comparison was made between ERCP, multislice HASTE, and single-shot RARE. Each biliary tract was divided into five sections for assessment; therefore, 45 biliary duct areas were used for lesion detection and determination of quality of depiction. RESULTS: Of the 35 segments detected by percutaneous transhepatic cholangioscopy, pathologic examinations were performed in 31 segments: papillary adenocarcinoma was proved in 28 and papillary adenoma in 3. The multislice HASTE sequence showed bile duct branches with biliary papillomatosis better than did ERCP (p = 0.0029) and single-shot RARE sequence (p = 0.0558). The multislice HASTE procedure had the highest number of lesions detected, followed by single-shot RARE and ERCP, but there was no significant difference between the imaging techniques. CONCLUSION: Our preliminary data suggest that MR cholangiography can replace ERCP for the detection of MBP.