Value of MR cholangiography in the evaluation of postoperative biliary complications following orthotopic liver transplantation

The aim of this study was to describe the spectrum of abnormal biliary findings as seen with magnetic resonance cholangiography (MRC) in symptomatic patients after orthotopic liver transplantation (OLT). In our study we included 12 consecutive patients post-OLT who presented with clinical and/or biochemical suspicion of biliary complications. In all patients MRC was performed on a 1.0-T whole-body magnet and breathhold half-Fourier acquired single-shot turbo spin echo and rapid acquisition with relaxation enhancement sequences were used. Diagnostic confirmation was obtained with percutaneous transhepatic cholangiography (PTC; n = 3 patients), endoscopic retrograde cholangiography (ERC; n = 3 patients), or clinical follow-up. A vast array of biliary abnormalities were detected in 11 of 12 patients: high-grade, obstructive, anastomotic stricture was the most common unique abnormality. Findings consistent with bile duct necrosis, the second most common abnormality, were accompanied by arterial abnormalities in 2 of 5 patients on subsequent MR- and digital subtraction angiography. Compared with the findings obtained with direct cholangiography (n = 5 patients), MRC was highly accurate for the detection and characterization of postoperative biliary complications. Compared with the final diagnosis, which was based on PTC-ERC findings and/or all available clinical data, MRC imaging alone was able to provide a specific diagnosis in 9 of 12 patients. Magnetic resonance cholangiography is an accurate, time-saving, and non-invasive imaging modality in the evaluation of post-OLT patients in whom suspicion of biliary complications exists. Although the precise value of MRA in this patient group requires larger dedicated studies, single session “all-in-one” MR evaluation of both biliary and arterial system in our series proved to be a substantial benefit in obtaining an accurate and complete diagnosis. Received: 2 December 1999; Revised: 24 February 2000; Accepted: 24 February 2000     

Diagnosing biliary complications of orthotopic liver transplantation with mangafodipir trisodium-enhanced MR cholangiography: comparison with conventional MR cholangiography

OBJECTIVE: This study was designed to determine whether the addition of mangafodipir trisodium-enhanced MRI could improve the image quality, visualization of ductal structures, and diagnostic confidence provided by conventional T2-based MR cholangiography (MRC) in patients with suspected biliary complications after orthotopic liver transplantation. SUBJECTS AND METHODS. Our study group consisted of 25 consecutive patients who were referred for MR evaluation of clinically suspected biliary complications after orthotopic liver transplantation. Conventional MRC in the axial and coronal planes was performed in each patient, followed by fat-suppressed volumetric gradient-echo imaging in the same planes both before and after the IV administration of mangafodipir trisodium. Imaging was performed in all patients until the contrast agent was seen in the bowel. Images were then graded for quality, visualization of bile ducts and anastomoses, presence of significant stricture or leak, and level of diagnostic confidence. RESULTS: Mangafodipir trisodium-enhanced MRC tended to outperform conventional MRC in overall image quality and extrahepatic duct visualization; it was also more effective in delineating biliary anastomoses, and the difference was statistically significant (p < 0.001). All 25 enhanced examinations were considered diagnostic. Diagnostic confidence was scored as poor or lacking in 14 of the conventional MRC examinations for biliary stenosis and in 12 examinations for biliary leak. CONCLUSION: Enhancement with mangafodipir trisodium improves the performance of MRC for the detection and exclusion of biliary abnormalities after orthotopic liver transplantation. Future investigations should compare the performance of mangafodipir trisodium-enhanced MRC with the performance of more invasive techniques.     

MR cholangiography in biliary complications after liver transplantation in children

PURPOSE: To evaluate the role of MR Cholangiography in a pediatric population with biliary complications after liver transplantation and particularly with anastomotic stenosis. PATIENTS AND METHODS: Ten MR cholangiography studies were performed in 10 children with liver transplant who were suspected of having biliary complications between December 1996 and April 1998. The findings on MR were correlated with the results from liver biopsy, liver ultrasound, liver function tests and with clinical information when available. RESULTS: MR cholangiography identified 9 children with biliary tree dilatation, 4 with anastomotic stenosis, 5 with multiple bile ducts stenosis, 2 with stones in the intra-hepatic biliary tree and 2 with abnormalities suspicious for acute cholangitis. Three of 4 anastomotic stenoses were confirmed and treated by percutaneous cholangiography. There was no correlation between the different exams in 6 children but MR cholangiography confirmed the final diagnosis. CONCLUSION: In children with liver transplantation, MR cholangiography may be useful to evaluate and to confirm a diagnosis of bile duct complications and it is helpful in the absence of correlation between liver biopsy, ultrasound and liver function test.     

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.     

经皮肝穿胆道引流术治疗肝移植术后胆道并发症

目的 评价介入方法治疗肝移植术后胆管并发症的价值.方法 回顾性分析1999年10月-2005年10月肝移植术后发生的6例胆道并发症的相关资料,其中胆总管狭窄2例、胆总管狭窄并胆瘘1例、胆瘘1例、胆汁瘤2例.结果 术后出现胆道并发症患者,经皮肝穿胆道引流治疗5例,放置胆道支架1例.手术均取得成功,患者的临床症状有所好转.结论 介入方法治疗肝移植术后胆管并发症可减少再手术创伤,提高生存率与生存质量,具有良好的近期效果.     

Biliary complications following orthotopic liver transplantation

The gall-bladder conduit anastomosis (choledocho-cholecysto-choledochostomy) has been the most frequently used technique for the biliary tract anastomosis in the Cambridge/King's College Hospital joint liver transplantation programme since 1976. Cholangiograms and interventional biliary procedures performed over a 3 year period were reviewed retrospectively. Seventy-six of 148 patients managed post-operatively at King's College Hospital were studied (79 transplants). Cholangiograms were abnormal in 63 (80%) transplants with biliary strictures; inspissated bile formation, bile leak and T-tube malposition occurring in 50, 23, 14 and three transplants respectively. Anastomotic strictures occurred most frequently, predominantly at the proximal anastomosis, and the presence of inspissated bile and the T-tube in relation to these contributed towards subsequent biliary obstruction. Non-anastomotic strictures in the donor biliary tract were associated with a high position of the T-tube tip at or above the liver hilum. Saline irrigation of the bile ducts for inspissated bile or its removal via the endoscope were effective measures in the management of biliary obstruction but percutaneous balloon dilatation and endoscopic stent insertion for biliary strictures were found to have a limited role.     

Biliary complications after orthotopic liver transplantation

Liver transplantation has made many advances since its inception in the early 1970s. Despite volumes of basic science and clinical research related to liver transplantation, biliary complications continue to present the interventional radiologist with challenging cases in all transplant centers. Biliary complications can range from minor complications such as contained bile leaks to severe complications such as biliary necrosis resulting from hepatic artery thrombosis. Minor complications may require minimal or no intervention, whereas the more severe complications can require urgent surgery. To treat biliary complications such as anastomotic strictures, nonanastomotic strictures, biliary leaks, sludge or biliary necrosis, an accurate diagnosis must first be obtained. One must also be aware of how these complications can impair both allograft and transplant patient survival. With this information one can then plan a treatment knowing the potential success rates of specific treatments. Using proper technique with this information at hand can greatly increase the success rate in treating the spectrum of biliary complications. Interventional radiology serves a critical role in diagnosis and treatment of these liver transplant biliary complications and is important to the success of all transplant programs.     

Magnetic resonance cholangiography of biliary strictures after liver transplantation: a prospective double-blind study

PURPOSE: To compare magnetic resonance cholangiography (MRC) with endoscopic retrograde cholangiography (ERC) in quantitatively evaluating biliary strictures in liver transplant recipients. MATERIALS AND METHODS: Eight liver transplant recipients with suspected biliary complications were referred for ERC and also underwent MRC within 24 hours using a combination of single-shot rapid acquisition with relaxation enhancement (SS-RARE) and three-dimensional (3D)-RARE sequences. The studies were independently interpreted by two blinded radiologists and a single blinded endoscopist who recorded the presence of a stricture and/or upstream dilatation, the ratio of recipient-to-donor duct diameters at the anastomosis, as well as the proximal duct diameter, length, and percent stenosis of any stricture detected. RESULTS: Using ERC as the standard of reference, MRC had a sensitivity and negative predictive value of 100%, mean specificity of 83.3%, and mean positive predictive value of 92.9% in the detection of six strictures. Compared with ERC, MRC obtained accurate measurements of recipient-to-donor duct diameter ratios (r, 0.91; P < 0.01), proximal duct diameters (r, 0.83, P < 0.05), stricture lengths (r, 0.58; P = 0.06), and percent stenosis (r, 0.78; P = 0.06). CONCLUSION: MRC can provide equivalent imaging to ERC and can reliably identify and quantitatively evaluate biliary strictures in post-orthotopic liver transplantation (OLT) patients.     

Functional magnetic resonance cholangiography (fMRC) of the gallbladder and biliary tree with contrast-enhanced magnetic resonance cholangiography

PURPOSE: To determine the diagnostic performance of functional magnetic resonance cholangiography (fMRC) for the evaluation of anatomic and functional biliary disorders. MATERIALS AND METHODS: At 1.5 T, 39 MR examinations with conventional MRC and mangafodipir trisodium-enhanced fMRC were retrospectively reviewed by three observers who recorded anatomic (duct dilation, stricture, filling defects) and functional (cholecystitis, obstruction) abnormalities in three modes: MRC alone, fMRC alone, and MRC and fMRC images together (combined-MRC). Performance was determined by comparing findings with each mode to findings of invasive cholangiography (IC) and surgery. RESULTS: Among 75 biliary segments (correlated with IC), the sensitivity/specificity for diagnosing dilation (N = 41) with MRC was 95%/97%; with fMRC, 90%/100%; with combined-MRC, 100%/97%. For stricture (N = 7), the sensitivity/specificity of MRC was 86%/98%; of fMRC, 43%/100%; of combined-MRC, 86%/100%. For filling defects (N = 9), the sensitivity/specificity of MRC was 91%/98%; of fMRC, 82%/100%; of combined-MRC, 91%/100%. For diagnosing obstruction (N = 9), the sensitivity/specificity of MRC, fMRC, and combined-MRC were 89%/100%, 100%/100%, and 100%/100%, respectively. For surgically proven cholecystitis (N = 13), positive predictive values for diagnosing acute/chronic cholecystitis for MRC were 33%/40%; for fMRC, 100%/50%; for combined-MRC, 100%/50%. CONCLUSION: Although single-shot fast spin echo (SSFSE)-MRC is valuable, the addition of fMRC increased diagnostic performance for functional biliary disorders.     

The role of sonography and transhepatic cholangiography in the diagnosis of biliary complications after liver transplantation

We retrospectively reviewed the results of real-time sonography in 41 patients in whom biliary complications after liver transplantation were documented by percutaneous transhepatic cholangiography. Abnormalities included bile duct stricture (26 cases), occluded internal biliary stent (six cases), common duct redundancy with resultant functional biliary obstruction (three cases), bile leak (three cases), choledocholithiasis (two cases), and an abscess in a cystic duct remnant (one case). Sonography was abnormal in 22 of the 41 cases (sensitivity, 54%). Bile duct dilatation was the positive sonographic finding in 19 (86%) of the 22 abnormal examinations. In the remaining 19 patients, sonography was normal. Sonography is not a reliable test for the early detection of biliary abnormalities after liver transplantation. Percutaneous transhepatic cholangiography should be performed in patients with suspected biliary complications after liver transplantation.     

Minimizing the postoperative biliary complications in living donor liver transplantation,by utility of preoperative non-enhanced magnetic resonance cholangiopancreatography

Aim of the work

The aim of this study was to assess the utility of non-enhanced MRCP in reduction of biliary complications in LDLT donors and compare the results with IOC.

The role of interventional radiology in biliary complications after orthotopic liver transplantation: a single-center experience

This study evaluated interventional radiological experience in the management of biliary complications of OLT at the National Cancer Institute of Milan. Seventeen patients who had undergone orthotopic liver transplantation in various hospital were referred to our unit with biliary complications. Group I consisted of 8 patients with anastomotic biliary fistula who came to our attention a short time after transplantation. Group II consisted of 9 patients with anastomotic strictures who came to our attention in a longer period. Two different interventional radiological approaches were used: (a) percutaneous transhepatic biliary drainage (PTBD) in the presence of fistulas in patients of group I; and (b) percutaneous transhepatic biliary drainage combined with dilatation of the strictures with a balloon catheter in patients of group II. On the whole resolution of the biliary complications was achieved in 13 of the 17 cases treated (76.5%), 5 of 8 in group I and 8 of 9 in group II. No secondary stenosis after PTBD were observed in group I, whereas two patients of group II needed a second dilatation. Percutaneous biliary drainage is indicated as a valid treatment in the management of biliary complications, either to allow closure of the fistula either to perform balloon dilatation of stenosis.     

Diagnosis of biliary stone disease: T1-weighted magnetic resonance cholangiography with Gd-EOB-DTPA versus T2-weighted magnetic resonance cholangiography

ObjectiveWe aimed to compare diagnostic performance of gadoxetic-acid-enhanced-T1-weighted-MR cholangiography (MRC) with that of conventional T2-weighted-MRC in diagnosing biliary stone disease.Materials and MethodsNinety patients who underwent MRC for evaluation of biliary disease were included. Presence of stones in extrahepatic duct, gallbladder and intrahepatic duct, and presence of acute cholecystitis were evaluated. Sensitivity, specificity, and accuracy of biliary stone disease diagnosis in each biliary duct location according to each image sets were measured.ResultsThere was no significant difference in diagnostic performance between two sets of MRC in diagnosing biliary stone disease.ConclusionsDiagnostic performance of T1-MRC with gadoxetic-acid in diagnosing biliary stone disease is comparable to that of T2-MRC.     

Magnetic resonance cholangiography in the assessment and management of biliary complications after OLT

Despite advances in patient and graft management, biliary complications (BC) still represent a challenge both in the early and delayed period after orthotopic liver transplantation (OLT). Because of unspecific clinical presentation, imaging is often mandatory in order to diagnose BC. Among imaging modalities, magnetic resonance cholangiography (MRC) has gained widespread acceptance as a tool to represent the reconstructed biliary tree noninvasively, using both the conventional technique (based on heavily T2-weighted sequences) and contrast-enhanced MRC (based on the acquisition of T1-weighted sequences after the administration of hepatobiliary contrast agents). On this basis, MRC is generally indicated to: (1) avoid unnecessary procedures of direct cholangiography in patients with a negative examination and/or identify alternative complications; and (2) provide a road map for interventional procedures or surgery. As illustrated in the review, MRC is accurate in the diagnosis of different types of biliary complications, including anastomotic strictures, non-anastomotic strictures, leakage and stones.     

Contrast-enhanced magnetic resonance cholangiography versus heavily T2-weighted magnetic resonance cholangiography

RATIONALE AND OBJECTIVES: To investigate the feasibility of contrast-enhanced magnetic resonance cholangiography (CE-MRC) and compare it with single-shot turbo spin-echo magnetic resonance cholangiography (SSTSE-MRC). METHODS: Fifteen patients with suspected metastatic liver disease (n = 10) or biliary tree abnormalities (n = 5) underwent a magnetic resonance imaging (1.5-T system) examination before and after mangafodipir administration. Contrast-enhanced MRC with a three-dimensional fast low-angle shot sequence after mangafodipir trisodium administration was compared with SSTSE-MRC. Four anatomic segments were evaluated: the intrapancreatic and extrapancreatic common bile duct segments, the cystic duct, and the area of hepatic bifurcation. Contrast-enhanced MRC and SSTSE-MRC were separately analyzed on a 5-point grading scale in terms of ductal segment visualization and lumen narrowing or dilatation. RESULTS: There was no difference (P = 0.375) in segment visualization between CE-MRC and SSTSE-MRC; 56 of the 60 segments were visualized by both techniques. In the evaluation of ductal narrowing or dilatation, nonsignificant differences (P = 0.500) were observed. Contrast-enhanced MRC was not influenced by fluid superimposition and provided additional information from background tissues. CONCLUSIONS: Contract-enhanced MRC is a feasible technique showing anatomic correlation with SSTSE-MRC, and it can in addition provide functional information. Contrast-enhanced MRC may be used in selected patients when traditional SSTSE-MRC is inconclusive.     

Value of magnetic resonance cholangiography in benign and malignant biliary stenosis: comparative study with direct cholangiography

PURPOSE: Magnetic resonance cholangiography (MRC) is currently under investigation for imaging of biliary stenosis. The purpose of this study was to evaluate the diagnostic value of MRC compared with direct cholangiography in biliary duct diseases, with the exception of biliary-enteric anastomosis. METHOD: Forty-nine patients (26 men, 23 women; median age 60 years) with clinically suspected bile duct stenosis were prospectively included. Magnetic resonance cholangiography was performed within 7 days before direct cholangiography, considered to be the gold standard. Stenosis location, extension, and type according to Bismuth classification as well as diagnostic presumed causes were determined by 2 radiologists and 1 endoscopist. RESULTS: Magnetic resonance cholangiography correctly identified the level of biliary ductal obstruction compared with direct cholangiography findings in 96% patients. Excellent agreement between MRC and direct cholangiography was found for the stenosis location (kappa value, 0.89). Sensitivity and specificity of MRC to detect common bile duct stenosis were 88% and 100%, respectively. Sensitivity and specificity of MRC to detect biliary confluence stenosis were 96% and 93%, respectively. Precise location of the lesion according to Bismuth classification was correctly evaluated on MRC in 74% of patients (kappa value, 0.64). The overall interobserver concordance between radiologists for the level of stenosis was good (kappa value, 0.625). In 35 patients with intrahepatic bile ducts dilation identified on direct cholangiography, 97% of patients were identified on MRC. Moderate concordance between MRC and direct cholangiography was confirmed in the evaluation of the surgical management (kappa value, 0.55). CONCLUSION: Magnetic resonance cholangiography is able to replace diagnostic direct cholangiography to restrict the use of invasive procedures to cases in which therapeutic procedures are anticipated or MRC findings are equivocal, especially in biliary tract diseases.     

肝移植术后并发症与介入治疗六、胆道并发症的介入治疗

肝移植(LT)已成为终末期肝脏疾病和部分肝脏恶性肿瘤的有效疗法.胆道并发症(BC)是LT后常见的并发症及死亡原因.采用引流、球囊扩张、支架植入等多种介入手段,处理BC已经获得广泛认同,但是引起LT后BC发生的因素很多,了解BC的发病机制、病理、分类和诊断有助于合理制订治疗策略,提高LT并发症的处理水平和临床成功率.     

Hilar biliary strictures after liver transplantation: cholangiography and percutaneous treatment

Nonanastomotic hilar bile duct strictures developed in 16 of 152 patients who underwent liver transplantation. The type of pretransplantation liver disease did not significantly affect the likelihood of hilar stricture formation. Possible causes of hilar biliary strictures include hepatic artery occlusion, ductopenic arteriopathic rejection, and cytomegalovirus infection; however, five of the 16 patients had hilar strictures without these complications. Hilar strictures developed within 3 months after transplantation in 11 of the 16 patients. Strictures began as a slight common hepatic duct irregularity and progressed to mucosal cast formation and later to firm strictures. Fifteen of the 16 patients underwent percutaneous stricture dilation. Of 12 patients who no longer have stents, four have had no stricture recurrence for 12-30 months. Eight patients have had to undergo retransplantation or have died. Percutaneous dilations were most likely to result in patient bile ducts if strictures developed within 3 months after transplantation and in the absence of pretransplantation primary sclerosing cholangitis, ductopenic arteriopathic rejection, cytomegalovirus infection, or hepatic artery thrombosis.