Stratifying risk of biliary complications in adult living donor liver transplantation by magnetic resonance cholangiography

BACKGROUND: Accurate preoperative assessment of biliary anatomy in live donor hepatectomy may be helpful to assess the suitability of a graft and to stratify risk of biliary complications. METHODS: A retrospective review of existing data among donor and recipients of 36 living donor transplants was performed to assess role of preoperative magnetic resonance cholangiography (MRC) for defining biliary anatomy and to stratify risk of biliary complications. RESULTS: Thirty-six living liver donors underwent MRC, and subsequently right lobectomy. Intraoperative cholangiography and biliary exploration revealed that 24 donors (66.6%) had conventional and 12 (33.3%) had aberrant biliary anatomy. Intraoperative cholangiography demonstrated a strong correlation with MRC (P=0.001) and intraoperative findings (P=0.001). MRC had specificity and positive predictive value of 100%. The risk of developing biliary complication was 5.9 times higher if the biliary anatomy was of any type other than A (P=0.03, CI 1.06-32.9) after controlling for donor age, recipient age, and type of anastomosis. CONCLUSION: MRC reliably identified variant biliary anatomy. The preoperative MRC demonstrated congruence with the intraoperative cholangiogram and with the intraoperative findings. MRC is helpful in predicting risk of biliary complications in recipients, and identifies donors who would otherwise be excluded intraoperatively by cholangiography, thus limiting the risk of an unnecessary operation.     

Role of magnetic resonance cholangiography in assessing biliary anatomy in right lobe living donors

BACKGROUND: The value of magnetic resonance cholangiography (MRC) in assessing potential adult-to-adult living liver transplant (ALDLT) donors remains poorly defined. The purpose of this study is to determine the accuracy of MRC in assessing biliary anatomy with intraoperative confirmation. METHODS: A prospective cohort of 30 ALDLT donors who underwent right hepatectomy from October 2000 to July 2003 was evaluated. MRC was performed using a heavily T2 weighted radial slab technique. MRC was interpreted preoperatively by a radiologist and a surgeon and compared with the intraoperative biliary findings in all patients derived from cholangiography (IOC) and bile duct exploration. The sensitivity, specificity, and positive and negative predictive values of MRC for aberrant biliary anatomy were calculated. RESULTS: MRC suggested normal, aberrant, and indeterminate biliary anatomy in 16, 12, and 2 donors, respectively. IOC revealed normal and aberrant biliary anatomy in 17 and 13 patients, respectively. MRC demonstrated biliary anatomy accurately in 27 of 30 patients. The sensitivity, specificity, positive predictive, and negative predictive values of MRC in detecting aberrant biliary anatomy were 92%, 100%, 100%, and 94%, respectively. CONCLUSIONS: Preoperative MRC accurately depicts biliary anatomy in potential ALDLT donors and may guide the intraoperative management of the biliary tract.     

活体肝移植供者术前磁共振胰胆管成像检查中脂肪餐的应用

目的 评价脂肪餐后磁共振胰胆管成像(MRCP)在活体肝移植(LDLT)供者术前胆道系统评估中的应用价值.方法 具有术中胆道造影(IOC)资料的LDLT供者50例.术前供者脂肪餐(进食2个油煎鸡蛋)前后分别行MRCP,比较脂肪餐前后二级胆管的显示情况及直径差异;脂肪餐后MRCP显示胆道分型的结果与相应术中IOC结果相比较,计算脂肪餐后MRCP评估正常与变异胆管的准确度、敏感度、特异度、阳性预测值和阴性预测值.结果所有供者中,脂肪餐前MRCP显示的二级胆管82%能满足评估要求,脂肪餐后MRCP显示的二级胆管100%能满足评估要求,脂肪餐前后MRCP显示二级胆管的图像质量和直径的差异均有统计学意义(P＜0.05);以相应术中IOC为参考标准,脂肪餐后MRCP准确评估胆管解剖结构分型49例(98%),显示正常与变异解剖结构的敏感度、特异度、阳性预测值、阴性预测值分别为98%、94.7%、100%、100%、96.9%.结论 脂肪餐后MRCP对二级胆管结构显示明显改善,完全能够满足临床LDLT供者术前胆道系统评估的需要,可以作为常规MRCP的有益补充.

Abstract：

Objective To evaluate the applications of magnetic resonance cholangiopancreatography (MRCP) after fat meal in the preoperative evaluation of biliary anatomy of living liver donors.Methods Fifty cases of the preoperative donors for living liver transplantation were included and all had the corresponding intraoperative cholangiography (IOC) information. The MRCP of the donors for living liver transplantation was performed before and after fat meal (two fried eggs). The visualization and diameter of the secondary bile duct were analyzed before and after the fat meal. The results of the biliary branching pattern by MRCP after fat meal were compared with the corresponding IOC results. The accuracy, sensitivity,specificity, positive predictive value and negative predictive value of MRCP after the fat meal in distinguishing normal and any type of variant biliary anatomy were calculated. Results In all cases,82% of the 50 cases in MRCP before the fat meal could meet the diagnosis needs of the preoperative evaluation,and 100% of the 50 cases in MRCP after the fat meal could meet the diagnosis needs. There was significant difference in the demonstration quality and diameter of the secondary bile duct in MRCP before and after the fat meal (P＜0. 05). MRCP showed accurate anatomy of the biliary system, using IOC as the reference standard, in 49(98%) subjects. The sensitivity, specificity, positive predictive value and negative predictive value of MRC in distinguishing normal and any type of variant biliary anatomy were 98%,94. 7%, 100%, 10% and 96. 9%,respectively. Conclusion The MRCP after fat meal can clearly demonstrate the secondary bile duct and perfectly meet the needs of the preoperative evaluation of the living liver transplantation. The MRCP after fat meal and routine MRCP should be considered complementary to one another in order to avoid complications in living liver transplantation donors.     

磁共振胰胆管成像在成人活体右半供肝术前胆道评估中的应用

目的 探讨磁共振胰胆管成像( MRCP)在成人活体右半供肝术前胆道评估中的应用.方法 76例活体肝移植供者,均切取右半肝用于移植.脂肪餐后进行术前MRCP检查,比较MRCP胆管分型与术中胆道造影胆管分型的一致性;在MRCP图像上测量右后肝管汇入部距左右肝管汇合部的距离及相应右后肝管的直径,对相应胆管测量长度及直径与术中胆道重建方式进行二分类Logistic回归分析,并得出术中胆道是否成形的ROC曲线及其长度临界值.结果 MRCP胆管分型与术中胆道造影胆管分型的符合率为97.4％.MRCP所测右后肝管汇入部距左右肝管汇合部的距离和胆管分型是术中胆道重建方式的重要影响因素,而右后肝管直径对术中胆道重建方式的选择无影响.胆道解剖结构变异或Ⅰ型胆管(MRCP分型)中右肝管长度≤4.2mm时,95％的供肝胆道断端数多于1支,且95％行胆道成形术;Ⅲ、Ⅳ型胆管(MRCP分型)所测胆管长度为3.8mm,是选择胆道成形术的分界点.结论 MRCP胆管分型能准确反映胆道解剖结构,MRCP右后肝管汇入部距左右肝管汇合部距离测量值可以指导术中胆道重建方式的选择.     

Preoperative evaluation of biliary anatomy in adult live liver donors with volumetric mangafodipir trisodium enhanced magnetic resonance cholangiography.

Accurate preoperative depiction of biliary anatomy is not always adequately accomplished by imaging techniques in living donor liver transplantation (LDLT). We present the results of a prospective study designed to evaluate the ability of mangafodipir trisodium (Mn-DPDP)-enhanced magnetic resonance (MR) cholangiography (MRC) for this purpose in a series of 25 adult living liver donors (LLDs). We also analyze if a simple or a more complex surgical procedure can be preoperatively suggested for biliary reconstruction in the recipients. Findings on MRC were compared with operative cholangiography (OC). A conventional distribution with a right hepatic duct (RHD) longer than 1 cm anticipated a simple procedure (duct-to-duct anastomosis or hepaticojejunostomy [HJ]). A shorter RHD or any variant were predictors of a more complex surgery (bench ductoplasty or multiple anastomoses). Agreement between MRC and OC in assessing the biliary anatomy was measured using the kappa statistic, and differences between the kind of surgery predicted at MRC and the biliary anastomosis performed were evaluated with Fisher's exact test. Normal variants were present in 16 / 25 donors (64%). MRC was accurate in depicting the pattern of bile duct distribution observed at OC in 22 / 25 (88%) donors (kappa = .831), and correctly predicted the complexity of biliary anastomosis in the recipient in 22 / 25 (88%) donors. No significant differences were observed between complexity of biliary surgery proposed at MRC and the final surgery performed (P = .002). In conclusion, Mn-DPDP-enhanced MRC is highly accurate in depicting the biliary duct anatomy and can be used preoperatively for surgical planning in LDLT.     

The role of Intraoperative cholangiography (IOC) and methylene blue tests in reducing bile leakage after living donor hepatectomy

AimLiver transplantation remains the only curative treatment in end stage liver disease. Biliary complications remain the most common major morbidity causes in hepatic resection. We aimed to determine and eliminate the bile leakage in donor hepatectomy of LDLT.Material and methodsThis study was conducted retrospective and one center study. The study population included 110 consequential liver donors with major liver resection (more than three segments). The population was divided into three groups for data analyses. Primary study groups included 40 donors subjected to methylene blue test starting in April 2013 and 40 donors subjected to intraoperative cholangiography started in March 2014.ResultsA total of 110 liver donors (42.7% women) were included in the study. Postoperative biliary complications were less in methylene blue and intraoperative cholangiography (IOC) groups. Bile leakage was significantly higher in control group (23.3%) compared to methylene blue (5%) and IOC groups (2%) Average duration of hospital stay and duration of operation were significantly higher in control group compared to methylene blue and IOC groups.ConclusionIn our study we conducted to establish biliary leakage in living donor hepatectomy which intraoperative cholangiography test was used to determine. Many intraoperative methods have been introduced to prevent biliary leakage and development of complications. We have showed that IOC test used in the present study could be easily applied in both living liver donor hepatectomy and other major hepatectomy cases. IOC test reduced postoperative biliary leakage incidence and did not increase incidence of other complications.     

应用MRCP术前评估活体肝移植供者胆管系统

目的 评价应用MRCP术前评估活体肝移植供者胆管系统的临床意义.方法 60例活体肝移植供者(男50例,女10例,年龄19～60岁,平均32.3岁),于右半肝切取术前行MRCP检查,术中经胆囊管行胆道造影.回顾性分析这些活体肝移植供者术前MRCP和术中胆道造影结果,二者进行比较,对比术中胆道造影结果评价MRCP在活体肝移植供者胆管分型方面的准确性.结果 根据术前MRCP结果,所有60例活体肝移植供者均可以判断出肝内胆管分型情况,1型胆管40例,2型胆管12例,3型胆管5例,其他3例.术中胆道造影显示1型胆管39例,MRCP正确诊断38例,准确率为97.4%;术中胆道造影显示2型胆管12例,MRCP正确诊断出11例,准确率为91%;术中胆道造影显示其他胆管类型为9例,MRCP正确诊断出8例,准确率为89%;MPCP总体准确率为95%(57/60).结论 MRCP可以在术前较为准确地显示活体肝移植供者胆管分型,为临床制定手术方案提供依据.     

The efficiency of Gd‐EOB‐DTPA‐enhanced magnetic resonance cholangiography in living donor liver transplantation: a preliminary study

The aim of this study was to evaluate utility of gadoxetic acid disodium (Gd‐EOB‐DTPA)‐enhanced magnetic resonance cholangiography (MRC) for the detection of biliary complications after living donor liver transplantation (LDLT). A total of 18 patients with suspected biliary complications underwent MRC. T2‐weighted MRC and contrast‐enhanced MRC (CE‐MRC) were used to identify the biliary complications. MRC included routine breath‐hold T2‐weighted MRC using half‐Fourier acquisition single‐shot turbo spin‐echo (HASTE) sequences and Gd‐EOB‐DTPA‐enhanced MRC T1‐weighted volumetric interpolated breath‐hold examination (VIBE) sequences. Before confirming the biliary complications, one observer reviewed the MRC images and the CE‐MRC images separately. The verification procedures and MRC findings were compared, and the sensitivity, specificity, and accuracy of both techniques were calculated for the identification of biliary complications. The observer found six of seven biliary complications using CE‐MRC. The sensitivity was 85.7% and the accuracy was 94.4%. Using MRC alone, sensitivity was 57.1% and accuracy was 55.5%. The accuracy of Gd‐EOB‐DTPA‐enhanced MRC was superior to MRC in locating biliary leaks (p < 0.05). The usage of Gd‐EOB‐DTPA‐enhanced MRC yields information that complements the MRC findings that improve the identification of biliary complications. We recommend the use of MRC in addition to Gd‐EOB‐DTPA‐enhanced MRC to increase the preoperative accuracy when assessing the biliary complications after LDLT.     

Correlation between 3D-MRCP and intra-operative findings in right liver donors

A correct preoperative definition of the hepatic duct confluence anatomy of right liver living donors is a pivotal step in determining their candidacy for donation and planning the surgery. The purposes of this study are to evaluate the accuracy of three-dimensional Magnetic Resonance Cholangiography (3D MRCP) when compared with intraoperative cholangiography (IOC) in assessing biliary anatomy and to identify imaging characteristics that may help predict the yield of hepatic duct orifices in the right liver graft. Twenty consecutive right liver donors were imaged with 3D MRCP and IOC. The MRCP and IOC findings were compared, and the results confirmed against actual donor anatomy. Three-D MRCP accurately predicted the biliary anatomy in 18 of 20 cases. Specificity and positive predictive value of 3D MRCP in defining normal biliary anatomy was 100%. In 2 patients, 3D MRCP failed to indentify abnormal anatomy. The yield of more than one hepatic duct was associated with: (I) The presence of abnormal biliary anatomy, (II) The length of the main right hepatic duct, and (III) The presence of an acute angle at the confluence of right and left hepatic duct. In conclusion, 3D MRCP reliably represents normal biliary anatomy. The presence of anatomical variations decreases MRCP sensitivity and makes IOC or duct probing a necessary tool for accurately performing the transection of the right hepatic duct.Key Words: Cholangiogram, liver transplantation, live donors, preoperative evaluation, magnetic resonance cholangio-pancreaticogram (MRCP)     

Safety of donor right hepatectomy for adult-to-adult living donor liver transplantation

The purpose of this study was to ascertain the usefulness of preoperative evaluations of donors by computed tomography (CT) volumetry and CT cholangiography for prevention of unexpected liver failure and biliary complications after donor right hepatectomy for adult-to-adult living donor liver transplantation. Fifty-two donors who underwent right hepatectomy without the middle hepatic vein were enrolled in this study. The values of graft weight (GW) were significantly correlated with those of estimated graft volume (GV; P < 0.0001). GW was predicted by the following formula: GW = 155.25 + 0.658 x GV; r(2) = 0.489. CT cholangiography revealed anatomical variants of biliary structure in one-third of the donors and also clearly showed one or two small biliary branches from the caudate lobe to the right hepatic ducts or the confluence in 58% of the donors. Biliary leakage, which was treated by conservative therapy, occurred in only one donor (1.9%). No donors received homologous blood transfusion. Hyperbilirubinemia (serum total bilirubin >5 mg/dl) occurred in 5.8% of the donors during their early postoperative periods. Precise evaluations of liver remnant volume by CT volumetry and biliary variation by CT cholangiography are essential for performing safe donor hepatectomy, preventing hepatic insufficiency and minimizing the risk of biliary tract complications.     

Noninvasive preoperative evaluation of biliary anatomy in right-lobe living donors with mangafodipir trisodium-enhanced MR cholangiography

BACKGROUND: Accurate preoperative radiologic imaging is essential to assess the vascular and biliary anatomy of right-lobe living donors and to ensure their safety. Volumetric magnetic resonance cholangiography (MRCP) using Mangafodipir trisodium (Mn-DPDP) contrast has been recently proposed to evaluate the biliary anatomy of living donor candidates. METHODS: During their preoperative evaluation, 18 right-lobe (RL) living donors underwent 3D Mn-DPDP-enhanced MRCP in addition to the standard thin- and thick-slab MRCP imaging. Immediately prior to hepatectomy all 18 RL donors underwent intraoperative cholangiography (IOC) via the cystic duct. We compared the efficacy of these different radiologic techniques to actual intraoperative IOC findings. RESULTS: Sixty-eight intrahepatic bile ducts were identified on IOC, 67(98.5%) by Mn-DPDP-enhanced 3D MRCP, 41 (60%) by thick-slab SSFSE imaging, and 35 (51%) by thin-slice SSFSE imaging. Mn-DPDP-enhanced 3D MRCP detected 100% (n = 5) of the anomalous origins of the right bile duct, and thick-slab MRCP detected 20% (n = 1) and thin-slab MRCP detected 0%. Anterior and posterior right intrahepatic bile ducts were identified by MnDPDP-enhanced 3D MRCP 100% of the time, by thick-slab SSFSE imaging 35% of the time, and by thin-slice SSFSE imaging only 12% of the time. CONCLUSIONS: Mn-DPDP-enhanced 3D MRCP imaging was highly sensitive and specific in identifying variants of the intrahepatic bile ducts. This technique should be included in the standard protocol of preoperative radiologic evaluation of RL living donor candidates.     

Preoperative imaging evaluation of potential living liver donors: reasons for exclusion from donation in adult living donor liver transplantation

Accurate pretransplant evaluation of a potential donor in living donor liver transplantation (LDLT) is essential in preventing postoperative liver failure and optimizing safety. The aim of this study was to investigate the reasons for exclusion from donation of potential donors in adult LDLT. From September 2003 to June 2006, 266 potential donors were evaluated for 215 recipients: 220 potential donors for 176 adult recipients; 46 for 39 pediatric recipients. Imaging modalities including Doppler ultrasound, computerized tomography (CT), and magnetic resonance (MR) angiography provided vascular evaluation and MR cholangiopancreatography to evaluate biliary anatomy. Calculation of liver volume and assessment of steatosis were performed by enhanced and nonenhanced CT, respectively. In the adult group, only 83 (37.7%) potential donors were considered suitable for LDLT. Of the 137 unsuitable potential donors, 36 (26.2%) candidates were canceled because of recipient issues that included death of 15 recipients (10.9%), main portal vein thrombosis (8%), recipient condition beyond surgery (5%), and no indication for liver transplantation due to disease improvement (2%). The remaining 101 (73.8%) candidates who were excluded included steatosis (27.7%), an inadequate remnant volume (57.4%), small-for-size graft (8.9%), HLA-homozygous donor leading to one-way donor-recipient HLA match (3%), psychosocial problems (4%), as well as variations of hepatic artery (4%), portal vein (1%), and biliary system anatomy (5%). Anatomic considerations were not the main reason for exclusion of potential donors. An inadequate remnant liver volume (<30%) is the crucial point for the adult LDLT decision.     

活体肝移植供体手术及术后管理（附22例临床分析）

目的 探讨提高活体肝移植供体手术安全性和加强术后管理的措施。方法 回顾性分析北京大学人民医院2003年2月至2009年6月22例活体肝移植供体的临床资料,总结供体术前评估、手术技术、术后并发症及随访情况。结果 术前对供体进行三步法评估,术中采用超吸刀 （CUSA）进行肝脏实质分离,术后定期随访。供肝移植物包括肝左外叶2例、左半肝6例、扩大左半肝1例、右半肝5例和扩大右半肝8例。1例在术后早期出现腹腔内出血,1例合并胸水,1例枕后皮下血肿,其他供体未出现严重并发症,术后肝功能迅速恢复正常,随访至今无供体死亡。结论 活体肝移植供体手术复杂,严格术前评估,术中精细操作,术后加强随访是提高活体肝移植供体安全的重要保证。     

Biliary complications among live donors following live donor liver transplantation

Introduction

In live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse.

Analysis of caudate lobe biliary anatomy and its implications in living donor liver transplantation – a single centre prospective study

Biliary complications are a significant cause of morbidity after living donor liver transplant (LDLT). Bile leak may occur from bile duct (anastomotic site in recipient and repaired bile duct stump in donor), cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post‐operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. To minimize caudate duct bile leaks, it is important to understand the anatomy of hilum with attention to the caudate lobe biliary drainage. This single‐centre prospective study of 500 consecutive LDLTs between December 2011 and December 2016 aims to define the biliary anatomy of the caudate lobe in liver donors based on intraoperative cholangiograms (IOCs) with special attention to crossover caudate ducts and to study their implications in LDLT. Caudate ducts were identified in 468 of the 500 IOCs. Incidence of left‐to‐right crossover drainage was 61.37% and right to left was 21.45%. Incidence of bile leak in donors was 0.8% and in recipients was 2.2%. Proper intraoperative identification and closure of divided isolated caudate ducts can prevent bile leak in donors as well as recipients.     

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目的：分析10例活体肝移植术中的血管变异，总结其外科处理经验，进一步提高手术成功率，减少并发症。方法：2001年1月至12月，行活体肝移植10例，其中左半肝8例，左外叶1例，右半肝1例，供肝者均为其母，经术中B超及胆管造影以确定肝切线。供体单支肝动脉分支与受体肝动脉吻合，两支肝动脉分别与受体肝左、右动脉吻合。门静脉分支与受体门静脉主干吻合。供体肝静脉与受体下腔静脉行端侧吻合。胆管重建均采用肝管分支与受体胆总管端端吻合，置T管引流。结果：10例活体肝移植，1例因肝动脉血栓形成，术后5天需次肝移植；1例发生排斥；其余8例均康复出院，5例已上学。结论：活体肝移植术中血管重建技术是其重要环节，术前和术中了解供受体解剖变异并正确处理，可减少术后血管和胆道的并发症。     

Accuracy of magnetic resonance cholangiography in the evaluation of late biliary complications after orthotopic liver transplantation

INTRODUCTION: The aim of our study was to evaluate the role of magnetic resonance cholangiography (MRC) in the diagnosis of late biliary complications after orthotopic liver transplantation (OLT) and to assess the diagnostic accuracy of this imaging technique. MATERIALS AND METHODS: Seventy-one MRC were performed in 46 OLT patients with suspected biliary complication after T-tube removal. We used a fat-suppressed three-dimensional turbo spin-echo sequence (TR/TE 1800/700, ETL 100) with a 1.5-T magnet. The images and maximum intensity projections were evaluated by two radiologists. Diagnostic confirmation was obtained with percutaneous transhepatic cholangiography (PTC) (n = 10), endoscopic retrograde cholangiography (ERC) (n = 24), surgery (n = 5), and clinical and ultrasound follow-up (n = 30). RESULTS: The MRC studies were considered diagnostic by the two radiologists in 69 cases (97.2%). MRC had a sensitivity of 93%, a specificity of 97.6%, a positive predictive value of 96.3%, a negative predictive value of 95.2%, and a global diagnostic accuracy of 95.6% to detect late biliary complications in OLT patients. The interobserver agreement was excellent (kappa = .92). CONCLUSION: MRC is a reliable technique to detect and exclude late biliary complications after OLT.     

多层螺旋CT在活体肝移植供体术前评估中应用现状

影像学评估是活体肝移植供体术前综合评估的核心步骤.多层螺旋CT功能强大,基本可满足活体肝移植供体术前的"一站式"影像学检查.本文参考国内外文献,从外科医师的角度,综述多层螺旋CT在活体肝移植供体术前评估中的应用现状,为活体肝移植供体术前影像学检查方法的选择提供指导.     

多层螺旋CT在活体肝移植供体术前评估中应用现状

影像学评估是活体肝移植供体术前综合评估的核心步骤.多层螺旋CT功能强大,基本可满足活体肝移植供体术前的"一站式"影像学检查.本文参考国内外文献,从外科医师的角度,综述多层螺旋CT在活体肝移植供体术前评估中的应用现状,为活体肝移植供体术前影像学检查方法的选择提供指导.     

多层螺旋CT在活体肝移植供体术前评估中应用现状

影像学评估是活体肝移植供体术前综合评估的核心步骤.多层螺旋CT功能强大,基本可满足活体肝移植供体术前的"一站式"影像学检查.本文参考国内外文献,从外科医师的角度,综述多层螺旋CT在活体肝移植供体术前评估中的应用现状,为活体肝移植供体术前影像学检查方法的选择提供指导.