Biliary anatomy in potential right hepatic lobe living donor liver transplantation (LDLT): the utility of CT cholangiography in the setting of inconclusive MRCP

Objective

To determine the utility of CT cholangiography (CT-Ch) in preoperative evaluation of the biliary anatomy of living-donor liver transplantation (LDLT) donors when magnetic resonance cholangiopancreatography (MRCP) is inconclusive.

Materials and methods

Over a 2-year period, 22 potential living liver donors underwent contrast-enhanced CT-Ch for preoperative evaluating biliary anatomy due to inconclusive results on MRCP and subsequently donated their right hepatic lobe. Nineteen of them underwent intraoperative cholangiography and were included in this study. Two radiologists retrospectively reviewed both MRCP and CT-Ch with 1-month interval and documented the types of bile duct branching patterns and visualization score of intrahepatic bile ducts (4-point scale).

Results

There were no complications associated with CT-Ch examinations. CT-Ch was concordant with the reference standard in 18/19 (95%) including 7/8 typical branching type and 11/11 anomalous branching types. MRCP was concordant with the reference standard in 14/19 (74%) including 4/8 typical branching types and 10/11 anomalous branching types. The discordant case by CT-Ch was the identification of a tiny accessory right intrahepatic duct joining the common bile duct which was not visualized on intraoperative cholangiography. CT-Ch showed higher visualization score (mean, 3.9) than MRCP (mean, 2.6) (P < .001).

Conclusion

CT-Ch can be effectively used for the depiction of the branching pattern of the bile duct at the hepatic hilum when MRCP is inconclusive.     

Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation

Backgrounds and aims

Accurate assessment of graft bile duct is important to plan surgical procedure. Magnetic resonance cholangiopancreatography (MRCP) has become an important diagnostic procedure in evaluation of pancreaticobiliary ductal abnormalities and has been reported as highly accurate. We aim to estimate the efficacy of preoperative MRCP on depicting biliary anatomy in living donor liver transplantation (LDLT), and to determine whether inaccurate preoperative imaging assessment would increase the biliary complications after LDLT.

Methods

The data of 118 cases LDLT were recorded. Information from preoperative MRCP was assessed using intraoperative cholangiography (IOC) as the gold standard. The possible risk factors of recipient biliary complications were analyzed.

Results

Of 118 donors, 84 had normal anatomy (type A) and 34 had anatomic variants (19 cases of type B, 9 cases of type C, 1 case of type E, 2 cases of type F and 3 cases of type I) confirmed by IOC. MRCP correctly predicted all 84 normal cases and 17 of 34 variant cases, and showed an accuracy of 85.6% (101/118). The incidence of biliary complications was comparable between cases with accurate and inaccurate classification of biliary tree from MRCP, and between cases with normal and variant anatomy of bile duct. While cases with graft duct opening ≤5 mm showed a significant higher incidence of total biliary complications (21.1% vs. 6.6%, P = 0.028) and biliary stricture (10.5% vs. 1.6%, P = 0.041) compared with cases with large duct opening >5 mm.

Conclusion

MRCP could correctly predict normal but not variant biliary anatomy. Inaccurate assessment of biliary anatomy from MRCP not increases the rate of biliary complications, while small-sized graft duct may cause an increase in biliary complications particularly biliary stricture after LDLT.     

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

Purpose

To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation.

Materials and methods

Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures.

Results

By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p = 0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p < 0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p = 0.01); however, using both techniques, sensitivity increased to 95%.

Conclusions

MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.     

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.

Paediatric MRCP: 10 year experience with 195 patients

Purpose

Magnetic resonance cholangiopancreatography (MRCP) has now largely substituted endoscopic retrograde cholangiopancreatography (ERCP) in evaluating the biliary tree in adults giving its high sensitivity and specificity. Whilst smaller series published to date suggests this may be extrapolated to the paediatric population, its routine use in children is still debatable. The aim of our study is therefore to review the utility of MRCP in a large series of paediatric patients.

Methods and materials

All MRCPs performed in our institution were examined for diagnostic quality, spectrum of diagnoses and correlation with direct cholangiography (DC) were available. Correlation with histopathology results and final clinical diagnosis was made in the subset of patients in whom a MRCP had been performed to evaluate the presence of primary sclerosing cholangitis (PSC).

Results

There were 245 MRCP examinations performed on 195 patients and 219 were diagnostic. There was 100% MRCP and DC concordance in the 16 cases where both had been performed. MRCP yielded a sensitivity of 89% in the subset of patients with PSC.

Conclusion

MRCP was a valuable diagnostic tool in our paediatric population. Image quality is sufficiently diagnostic and shows good correlation with clinical diagnosis in conditions encountered in our population, including primary sclerosing cholangitis, post liver transplant biliary strictures, post surgical complications, dilated common bile ducts, choledochal cysts, cholelithiasis and choledocholithaisis.     

Primary biliary cirrhosis: evaluation with T2-weighted MR imaging and MR cholangiopancreatography

Purpose

The aim of this retrospective study is to evaluate the role of T2-weighted MR imaging (MRI) and MR cholangiopancreatography (MRCP) findings in the diagnosis of primary biliary cirrhosis (PBC).

Materials and methods

The following T2-weighted MRI and MRCP findings: segmental hepatic atrophy/hypertrophy, irregular liver surface, parenchymal lace-like fibrosis, rounded low signal intensity lesions centering portal vein branches (periportal halo sign), periportal hyperintensity (cuffing), splenomegaly, ascites, lymphadenopathy, venous collaterals, and the configuration of intrahepatic biliary ducts were reviewed for their diagnostic significance by two observers in 13 female patients (mean age: 49 years) with PBC. Discordant readings of the observers were resolved at consensus.

Results

When parenchymal lace-like fibrosis and periportal halo sign were seen together the sensitivity of T2-weighted MR images was 69%. In six cases periportal hyperintensity (cuffing) and periportal halo sign were seen together. Segmental hypertrophy was present in nine patients and hepatic surface irregularity due to regenerative nodules were present in 10 patients. Lymphadenopathy was seen in 10, splenomegaly was seen in 5, collateral vascular structures were seen in 2 and minimal perihepatic free fluid was seen in 2 patients. MRCP images revealed various mild irregularity in the intrahepatic bile ducts in 8 patients and focal narrowing at the common bile duct level in 1 patient.

Conclusion

MRI and MRCP may support the clinical and laboratory findings of PBC even in the early stages of the disease. MRI can also be a choice of method for the recommended prolonged follow up.     

Diagnostic value of magnetic resonance cholangiopancreatography in cholestatic jaundice

The aim of the study

To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography in patients with cholestatic jaundice.

Patients and methods

Clinical, laboratory and investigational data were evaluated from 50 patients with cholestastic jaundice. MRCP findings were compared with ERCP or operative findings and appropriate clinical endpoints.

Results

The ERCP or operative findings and appropriate clinical endpoints revealed 23 patients with intra or extra hepatic biliary dilatation and 27 patients without intra or extra hepatic biliary dilatation. As regards the 23 patients with biliary dilatation, biliary dilatation was evident in 19 patients by U/S versus 23 patients by MRCP. ERCP was successful in 20 patients (87%) and was not done in three patients (13%). In cases of obstructive jaundice the sensitivity of MRCP was 100% versus 86% in choledocholithiasis and malignant detection, respectively p value <0.05.

Conclusion

MRCP is highly sensitive and specific for biliary dilatation and avoids the need for invasive imaging in most patients with cholestasis. MRCP permits reservation of ERCP to patients with a high probability of therapeutic intervention.     

Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience

PURPOSEBiliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment.METHODSA total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed.RESULTSA total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient.CONCLUSIONGenerally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.

Liver transplantation is a life-saving treatment method for end-stage liver disease and hepatocellular carcinoma (1–3). As cadaveric liver transplantation is limited, especially in Asian countries, or in situations where there is no time to wait for a suitable liver from a cadaver, living donor liver transplantation (LDLT) is an appropriate alternative method (4, 5). The first successful LDLT was performed by Strong et al. (6) in 1989, using segments 2–3 of left lobe in a child with biliary atresia. In 1993, Ichida et al. (7) performed adult-to-adult transplantation using the left lobe in a female with primary biliary cirrhosis. The firstright lobe LDLT was performed by Tanaka et al. (8) in 1994.Initially, because of the risks to the donor, left lobe transplantation was considered to be the only option in adult LDLT. However, as the left lobe grafts are thought to meet only 30%–50% of the metabolic needs of adult recipients, potentially leading to small-for-size syndrome, left lobe donation was limited (9). Although the current use of right lobe LDLT has resolved the problem of graft size in the recipient, it has caused an increase in the risks for donors. Recent studies have shown that left lobe LDLT have shifted the donor risks to the recipients (10).In previous studies, biliary complications in the recipient patient group have ranged as 10%–15% in cadaveric liver transplantation and 9%–37% in LDLT. Of the biliary complications that develop after LDLT, bile leakage constitutes 5%–19% and biliary stricture 4%–37% (11–14).The management of biliary complications includes endoscopic, radiological and surgical procedures. Endoscopic methods are generally the first step in treatment, and success rates after LDLT have been reported as 60%–75% in anastomotic strictures and 25%–33% in non-anastomotic strictures. Percutaneous radiological methods are the second step in treatment, with a reported success rate of 50%–75% (15).Almost all studies on biliary complications biliary complications following LDLT have been made with right lobe. The aim of the current study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and percutaneous radiological treatment.     

Postoperative imaging of living donor liver transplantation complications

Background

There is no doubt that the role of Different diagnostic imaging is well established in the evaluation of patients who are being evaluated for potential liver transplantation but it plays a huge role in the success of transplanted liver operations. Technical advances in imaging equipment and techniques allow more accurate assessment of postoperative living donor transplantation complications.

Multi-slice computed tomography imaging of the post transplant complications in the recipients after living donor liver transplantation

Aim

To evaluate the clinical utility of MSCT in the detection and proper management of the different post-transplant complications in the recipients after LDLT.

Patients and methods

33 patients (28 males & 5 females) who underwent LDLT were referred to the Radiology department (CT unit) for evaluation of vascular, biliary, and parenchymal complications after LDLT using MSCT.

Results

Vascular complications were found in 16 cases (48.5%) [hepatic artery thrombosis (8 cases), hepatic artery stenosis (1 case), portal vein thrombosis (3 cases), portal vein stenosis (2 cases), hepatic veins stenosis (2 cases)]. Biliary complications were found in 9 cases (27.3%) [biloma (6 cases) 18.2%, biliary stricture (3 cases) 9.1%]. Hepatic abscess was found in 2 cases (6%), acute rejection was found in 2 cases (6%), recurrent HCC was found in 3 cases (9.1%). Neoplastic lympho-proliferative disorder was found in 1 case (3%).

Conclusion

MSCT is a non-invasive and accurate examination to detect complications after LDLT, it provides synchronous evaluation of the hepatic vasculature, biliary tract, liver parenchyma and the other abdominal organs in a single examination. MSCTA is the best option for confirming the US suspicion of vascular complications, with DSA reserved if therapeutic intervention is contemplated.     

Feasibility and Midterm Results of Endovascular Treatment of Hepatic Artery Occlusion within 24 Hours after Living-Donor Liver Transplantation

Purpose

To evaluate the feasibility and midterm results of endovascular treatment of hepatic artery occlusion within 24 hours after living-donor liver transplantation (LDLT).

Detection of biliary stenoses in patients after liver transplantation: Is there a different diagnostic accuracy of MRCP depending on the type of biliary anastomosis?

Purpose

Two different forms of biliary anastomosis can be created in patients undergoing liver transplantation: (a) bilio-digestive anastomoses or (b) choledocho-choledochostomy. Aim of this study was to assess the accuracy of MR cholangiopancreatography (MRCP) for the depiction of biliary stenoses in liver transplant patients depending on the type of biliary anastomosis.

Method and materials

24 liver transplant patients with clinical suspicion of biliary stenosis were studied (each 12 with bilio-digestive anastomosis/choledocho-choledochostomy). MRCP was performed on a 1.5T scanner (Magnetom Avanto, Siemens) including 2D single shot RARE, 2D T2w HASTE, TrueFISP and 3D high-resolution navigator corrected sequences. Presence of (a) anastomotic stenoses (AST) and (b) NAS (non-anastomotic strictures) were assessed. Percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP) were performed within 48 h after MRCP and served as the standard of reference.

Results

In patients with bilio-digestive anastomoses sensitivities of MRCP for the detection of AST and NAS amounted to 50% and 67%, respectively with specificity values of 83% and 50%. In patients with choledocho-chledochostomy sensitivities (AST: 100%, NAS: 100%) and specificities (AST: 100%, NAS: 88%) were significantly higher.

Conclusion

Biliary strictures after liver transplantation can be accurately detected by MRCP in patients after choledocho-chledochostomy. However, the diagnostic value of MRCP is lower if liver transplantation was performed in combination with a bilio-digestive anastomosis. This may be due to the less exact depiction of the anastomosis in the bowel wall. Thus, it is crucial to know the type of biliary anastomosis before choosing a diagnostic procedure.     

Alternative Techniques for Cannulation of Biliary Strictures Resistant to the 0.035" System Following Living Donor Liver Transplantation

Objective

To assess the clinical efficacy of alternative techniques for biliary stricture cannulation in patients undergoing living donor liver transplantation (LDLT), after cannulation failure with a conventional (0.035-inch guidewire) technique.

Subjects and Methods

Of 293 patients with biliary strictures after LDLT, 19 (6%) patients, 11 men and 8 women of mean age 48.5 years, had the failed cannulation of the stricture by conventional techniques. Recannulation was attempted by using two alternative methods, namely a micro-catheter set via percutaneous access and a snare (rendezvous) technique using percutaneous and endoscopic approaches.

Results

Strictures were successfully cannulated in 16 (84%) of the 19 patients. A microcatheter set was used in 12 and a snare technique in four patients. Stricture cannulation failed in the remaining three patients, who finally underwent surgical revision.

Conclusion

Most technical failures using a conventional technique for biliary stricture cannulation after LDLT can be overcome by using a microcatheter set or a snare (rendezvous) technique.     

The added value of diffusion-weighted MR imaging to MR cholangiopancreatography in differentiating malignant from benign extrahepatic biliary strictures

Purpose

To investigate the added value of diffusion-weighted imaging (DWI) to magnetic resonance cholangiopancreatography (MRCP) in differentiating benign from malignant extrahepatic biliary strictures.

Methods

Magnetic resonance examination including, T2-weighted imaging, MRCP and DWI using different b-values (0,500,800 s/mm²) were performed in 38 patients with suspicious extrahepatic biliary strictures. Apparent diffusion coefficient (ADC) value was calculated. The signal intensity of the lesions on DWI using b = 500 and 800 s/mm² was examined. Analysis of the DWI and MRCP images for the cause of the extrahepatic biliary stricutre was performed. Patients were further confirmed by histopathological diagnosis and follow up. Sensitivity, specificity, accuracy, positive predictive and negative predictive values were calculated for both the MRCP images and DWI.

Results

Of the 38 cases, 23 cases had malignant extrahepatic biliary strictures and 15 had benign strictures. DWI detected 21 out of the 23 malignant biliary strictures and 14 out of 15 benign biliary strictures. Malignant strictures more frequently appeared hyperintense than benign strictures on DWI using b-values of 500 and 800 s/mm². There was a significant difference in sensitivity (91.3% vs. 73%), specificity (93.3% vs. 64.7%), accuracy (92.1% vs. 73.6%), positive predictive value (95.4% vs. 81%), and negative predictive value (87.5% vs. 64.7%) between DWI and MRCP in differentiating biliary strictures.

Conclusion

Combined evaluation using DWI added to MRCP improves the differentiation of malignant from benign extrahepatic biliary strictures.     

Imaging features of portal biliopathy: frequency of involvement patterns with emphasis on MRCP

Purpose

To investigate the imaging features of portal biliopathy with emphasis on MR cholangiopancreatography (MRCP). The ancillary vascular findings of portal biliopathy were also evaluated by accompanying MR portography, dynamic contrast-enhanced (CE) CT, and dynamic CE MRI studies.

Materials and methods

Sixteen patients with portal cavernoma were included in the study. Patients had undergone MRCP (n = 16) studies accompanied by MR portography (n = 13), dynamic CE CT (n = 3) or dynamic CE MRI (n = 2) of the liver. Two patients had undergone both dynamic CE CT and dynamic CE MRI. Two radiologists evaluated all the examinations together, retrospectively. MRCP images were analyzed for the presence of biliary stenosis, upstream (prestenotic) dilatation, wavy appearance of the bile ducts, angulation of the common bile duct (CBD), and choledocholithiasis. MR portography, dynamic CE CT and dynamic CE MRI studies were evaluated for the existence of portal cavernomas, and the presence of gall bladder/choledochal varices.

Results

All patients had signs of portal biliopathy on MRCP. Frequencies of the biliary findings on MRCP were as follows: biliary stenosis, 93.7%; upstream dilatation, 68.7%; wavy appearance of the biliary tree, 87.5%; angulation of the CBD, 75%. None of the patients had choledocholithiasis. Frequencies of the ancillary vascular findings detected on CE studies were as follows: gall bladder varices, 100%, choledochal varices, 93.7%.

Conclusion

MRCP features of portal biliopathy in order to their frequencies were as follows: biliary stenosis, wavy appearance of the bile ducts, angulation of the CBD, and upstream dilatation of the bile ducts.     

Bile duct evaluation of potential living liver donors with Gd-EOB-DTPA enhanced MR cholangiography: Single-dose,double dose or half-dose contrast enhanced imaging

Introduction

Detailed knowledge of the biliary anatomy is essential to avoid complications in living donor liver transplantation. The aim of this study was to determine the optimal dosage of Gd-EOB-DTPA for contrast-enhanced magnetic resonance cholangiography (ce-MRC) with reference to contrast-enhanced CT cholangiography (ce-CTC).

Materials and methods

30 potential living liver donors (PLLD) underwent both ce-CTC and ce-MRC. Ten candidates each received single, double or half-dose Gd-EOB-DTPA. Ce-MRC images with and without inversion recovery pulses (T1w ± IR) were acquired 20–30 min after intravenous contrast injection. Image data was quantitatively and qualitatively reviewed by two radiologists based on a on a 5-point scale. Data sets were compared using a Mann–Whitney-U-test or Wilcoxon-rank-sum-test. Kappa values were also calculated.

Results

All image series provided sufficient diagnostic information both showing normal biliary anatomy and variant bile ducts. Ce-CTC showed statistically significant better results compared to all ce-MRC data sets. T1w MRC with single dose Gd-EOB-DTPA proved to be superior to half and double dose in subjective and objective evaluation without a statistically significant difference.

Conclusions

Ce-MRC is at any dosage inferior to ce-CTC. As far as preoperative planning of bile duct surgery is focused on the central biliary anatomy, ce-MRC can replace harmful ce-CTC strategies, anyway. Best results were seen with single dose GD-EOB-DTPA on T1w MRC+IR.     

Role of contrast-enhanced ultrasound in decision support for diagnosis and treatment of hepatic artery thrombosis after liver transplantation

Objective

To assess role of contrast-enhanced ultrasound (CEUS) in decision support for diagnosis and treatment of hepatic artery thrombosis (HAT) after liver transplantation.

Materials and methods

Between January 2005 and January 2011, 605 patients underwent liver transplantation in our medical center. All the liver transplant recipients received Doppler ultrasound scanning and CEUS examination was performed in 45 patients with suspected HAT on Doppler ultrasound. Sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were determined based on the results from angiography, surgery and clinical follow-up.

Results

Fourteen HATs, including one late HAT, were diagnosed by CEUS. Twelve HAT cases were confirmed by angiographic and/or surgical findings, while the late HAT and other 31 patients with negative CEUS finding were confirmed by the clinical follow-up. There was a false positive HAT diagnosed by CEUS in which angiography revealed a patent hepatic artery. The sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were 100%, 96.9%, 97.8%, 92.9% and 100%, respectively. In our series of 605 liver transplants, the incidence and mortality of HAT was 2.2% (13/605) and 53.8% (7/13), respectively.

Conclusions

Our study demonstrates the important role of CEUS in decision support for diagnosis and treatment of HAT after liver transplantation. When HAT is suspected by Doppler ultrasound, CEUS shall immediately be performed to elucidate its nature. A negative CEUS finding shall avoid invasive angiography. Such as, CEUS may alter the clinical workflow on HAT detection after liver transplantation.     

Anatomic variations of intrahepatic bile ducts in the general adult Egyptian population: 3.0-T MR cholangiography and clinical importance

Objective

To describe the anatomical variations occurring in intrahepatic bile ducts (IHDs) and their frequencies in general adult Egyptian population using 3.0-T MR cholangiography (MRC) as well as its clinical importance to reduce the biliary complications of hepatobiliary surgery.

Materials and methods

MRC was applied to a study group of 106 subjects (26 potential liver donors and 80 volunteers). Anatomical variations in IHDs were classified based on the variable insertion of right posterior hepatic bile duct (RPHD) using Huang classification.

Results

According to this classification, the frequencies of each type were as follows: Huang A1 (typical pattern): 63.2% (n = 67), Huang A2: 10.4% (n = 11), Huang A3: 17% (n = 18), Huang A4, 7.5% (n = 8), and Huang A5: 1.9% (n = 2). Total frequency for atypical types (i.e. A2, A3, A4 and A5) was 36.8%. No significant difference was detected in the distance between RPHD insertion to the junction of right and left hepatic duct in-between these Huang types. This distance was short (<1 cm) in 21 of subjects under Huang A classification. Twenty-one donors underwent intraoperative cholangiograms, of which twenty (95.2%) had similar classification in both intraoperative and MRC findings.

Conclusion

The incidence of variant biliary anatomy in general Egyptian population (36.8%) as well as the presence of Huang type A with short distance (<1 cm) between RPHD insertion and junction of right and left hepatic duct (19.8%) enhance the importance of MRC as a pre-operative tool before hepato-biliary surgical procedures to reduce post-operative biliary complications.     

The utility of MRCP in preoperative mapping of biliary anatomy in adult-to-adult living related liver transplant donors

PURPOSE: To assess the utility of magnetic resonance cholangiopancreatography (MRCP) in preoperative mapping of biliary anatomy in adult-to-adult living related liver transplant (LRLT) donors. MATERIALS AND METHODS: From 57 potential donors with preoperative MRCP, 27 cases (16 men, 11 women, age range 22-51 years, mean 37.2 years) underwent right lobe resection and had intraoperative cholangiography (IOC) for comparison. The MRCP and IOC reports were retrospectively reviewed in all 27 cases. The MRCP was performed on 1.5 Tesla MR magnets using breath-hold heavily T2-weighted sequences in axial/coronal thin sections, and variable-thickness rotating slabs. The accuracy of preoperative MRCP for biliary mapping in potential LRLT donors was analyzed compared to the IOC findings. RESULTS: Of 27 donors, 26 (96.3%) had MRCP which showed adequate information of central intrahepatic biliary anatomy. Of these, 19 had normal bifurcation confirmed by IOC, and single biliary anastomosis was created in the recipient at transplantation. MRCP correctly predicted 17 of 19 normal cases (sensitivity for normals: 89.5%). In seven donors with variant biliary anatomy, two separate biliary anastomoses were performed in the recipient. MRCP correctly predicted five of seven variants (sensitivity for variants: 71.4%). Overall, MRCP had an accuracy 84.6% (22/26). CONCLUSIONS: MRCP has potential in the preoperative assessment of nondilated bile ducts in LRLT donors, however further improvements are desired to increase its quality and accuracy.     

Pancreatic changes in patients with primary sclerosing cholangitis: MR cholangiopancreatography and MRI findings

Purpose

To evaluate the possible pancreatic changes and their frequencies in patients with primary sclerosing cholangitis (PSC) on MR cholangiopancreatography (MRCP), and conventional abdominal MRI.

Materials and Methods

Patient group consisted of 29 PSC (13 male, 16 female) cases, whereas cohort 1 consisted of 12 female patients with primary biliary cirrhosis, and cohort 2 consisted of 17 patients (6 male, 11 female) with non-immune chronic liver disease. Two radiologists retrospectively evaluated the MR examinations paying special attention to the pancreatic size (atrophy or enlargement), T1- and T2-signal intensity of the pancreas, focal pancreatic lesion, capsule-like rim, peripancreatic edema or fluid, fascial thickening, and pancreatic ducts (dilatation or narrowing). The results are expressed as percentages. Three groups were compared using Pearson chi-square test for each feature. However, only p-value for “dilatation of the pancreatic duct” was determined, whereas p-value could not be calculated because of the insufficient number of subjects/sequences for the other features.

Results

Twelve PSC patients (41.3%) had pancreatic abnormalities. The most common pancreatic changes in PSC patients were decreased T1-signal intensity (44%) and dilatation of the pancreatic duct (13.8%), respectively. Increased T2-signal intensity was also shown in 2 PSC patients (6.9%).

Conclusion

Even PSC patients without any sign of pancreatitis, can show MR changes in the pancreatic parenchyma or the pancreatic duct. The etiologies of these changes, and whether they are unique to PSC, are still controversial. Histopathological studies bringing light to these pancreatic changes are needed.