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MR Cholangiography for Evaluation of Hilar Branching Anatomy in Transplantation of the Right Hepatic Lobe from a Living Donor

¹ Department of Diagnostic Radiology, Yonsei University Health System, 134 Shinchon-dong, Seodaemoon-ku, Seoul 120-752, Republic of Korea.
² Institute of Gastroenterology, Yonsei University Health System, Seoul, Republic of Korea.
³ Department of Biostatistics, Yonsei University Health System, Seoul, Republic of Korea.
⁴ Department of Surgery, Yonsei University Health System, Seoul, Republic of Korea.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —46-year-old male liver donor with normal right hepatic duct. Anterior segmental, posterior segmental, right hepatic, and left hepatic ducts are well visualized in 2D T2 MR cholangiography (MRC) (thick-slap) (A), 3D T2 MRC (maximum-intensity-projection [MIP]) (B), and 3D contrast-enhanced T1 MRC (MIP) (C) images.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —46-year-old male liver donor with normal right hepatic duct. Anterior segmental, posterior segmental, right hepatic, and left hepatic ducts are well visualized in 2D T2 MR cholangiography (MRC) (thick-slap) (A), 3D T2 MRC (maximum-intensity-projection [MIP]) (B), and 3D contrast-enhanced T1 MRC (MIP) (C) images.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —46-year-old male liver donor with normal right hepatic duct. Anterior segmental, posterior segmental, right hepatic, and left hepatic ducts are well visualized in 2D T2 MR cholangiography (MRC) (thick-slap) (A), 3D T2 MRC (maximum-intensity-projection [MIP]) (B), and 3D contrast-enhanced T1 MRC (MIP) (C) images.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —35-year-old male liver donor with aberrant biliary anatomy. Two-dimensional T2 MR cholangiography (MRC) (A) and 3D T2 MRC (B) images show aberrant biliary anatomy with right posterior duct draining into left hepatic duct. Anterior (arrowhead, A, B, and D) and posterior segmental branches (arrow, A, B, and D) are well delineated in both sequences, but right segmental branches are not delineated on 3D contrast-enhanced T1 MRC (C) image. Intraoperative cholangiogram (D) confirmed aberrant biliary anatomy.

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —35-year-old male liver donor with aberrant biliary anatomy. Two-dimensional T2 MR cholangiography (MRC) (A) and 3D T2 MRC (B) images show aberrant biliary anatomy with right posterior duct draining into left hepatic duct. Anterior (arrowhead, A, B, and D) and posterior segmental branches (arrow, A, B, and D) are well delineated in both sequences, but right segmental branches are not delineated on 3D contrast-enhanced T1 MRC (C) image. Intraoperative cholangiogram (D) confirmed aberrant biliary anatomy.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —35-year-old male liver donor with aberrant biliary anatomy. Two-dimensional T2 MR cholangiography (MRC) (A) and 3D T2 MRC (B) images show aberrant biliary anatomy with right posterior duct draining into left hepatic duct. Anterior (arrowhead, A, B, and D) and posterior segmental branches (arrow, A, B, and D) are well delineated in both sequences, but right segmental branches are not delineated on 3D contrast-enhanced T1 MRC (C) image. Intraoperative cholangiogram (D) confirmed aberrant biliary anatomy.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —35-year-old male liver donor with aberrant biliary anatomy. Two-dimensional T2 MR cholangiography (MRC) (A) and 3D T2 MRC (B) images show aberrant biliary anatomy with right posterior duct draining into left hepatic duct. Anterior (arrowhead, A, B, and D) and posterior segmental branches (arrow, A, B, and D) are well delineated in both sequences, but right segmental branches are not delineated on 3D contrast-enhanced T1 MRC (C) image. Intraoperative cholangiogram (D) confirmed aberrant biliary anatomy.

View larger version (20K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Graphs show multiple comparisons of mean visualization scores and image quality for three MR cholangiography (MRC) techniques. White bars = 2D T2 MRC, light gray bars = 3D T2 MRC, dark gray bars = 3D contrast-enhanced T1 MRC, error bars indicate SD, asterisk indicates p < 0.05 in comparison of techniques. Branching ducts included bilateral first-order branches and right second-order branches. Overall ducts included a total of five segments. Graph shows mean visualization scores of common duct, branching ducts, and all ducts in three MR cholangiography techniques.

View larger version (16K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Graphs show multiple comparisons of mean visualization scores and image quality for three MR cholangiography (MRC) techniques. White bars = 2D T2 MRC, light gray bars = 3D T2 MRC, dark gray bars = 3D contrast-enhanced T1 MRC, error bars indicate SD, asterisk indicates p < 0.05 in comparison of techniques. Branching ducts included bilateral first-order branches and right second-order branches. Overall ducts included a total of five segments. Graph shows mean scores of image quality of each technique.

View larger version (34K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Multiple comparisons of mean accuracy and diagnostic confidence for four sets of MR cholangiography (MRC) imaging techniques. Technique 1 = 2D T2 MRC alone, technique 2 = combined set of 2D T2 MRC and 3D T2 MRC, technique 3 = combined set of 2D T2 MRC and 3D contrast-enhanced T1 MRC, and technique 4 = combined set of all three techniques. Error bars indicate SD; asterisk indicates p < 0.05 in comparison of techniques. No significant difference was observed within comparison of combined sets for both accuracy and diagnostic confidence. Graph shows mean accuracy of 2D MRC alone and three combined sets for prediction of ductal orifice number during right lobe harvesting.

View larger version (34K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Multiple comparisons of mean accuracy and diagnostic confidence for four sets of MR cholangiography (MRC) imaging techniques. Technique 1 = 2D T2 MRC alone, technique 2 = combined set of 2D T2 MRC and 3D T2 MRC, technique 3 = combined set of 2D T2 MRC and 3D contrast-enhanced T1 MRC, and technique 4 = combined set of all three techniques. Error bars indicate SD; asterisk indicates p < 0.05 in comparison of techniques. No significant difference was observed within comparison of combined sets for both accuracy and diagnostic confidence. Graph shows mean diagnostic confidence of 2D MRC alone and three combined sets for prediction of ductal orifice number during right lobe harvesting.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —30-year-old male liver donor who underwent single lumen acquisition during right lobe harvest. Two-dimensional T2 MR cholangiography (MRC) (A), maximum-intensity-projection (MIP) image of 3D T2 MRC (B), source image of 3D T2 MRC (C), MIP image of 3D contrast-enhanced T1 MRC (D), and source image of 3D contrast-enhanced T1 MRC (E) show normal anatomy in which junction of anterior segmental duct and posterior segmental duct forms right hepatic duct (arrow). All reviewers predicted that acquisition of single lumen would be possible during right lobe harvesting on sets of all four techniques. Intraoperative cholangiogram (F) confirmed normal anatomy (arrow), and acquisition of single lumen was performed.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —30-year-old male liver donor who underwent single lumen acquisition during right lobe harvest. Two-dimensional T2 MR cholangiography (MRC) (A), maximum-intensity-projection (MIP) image of 3D T2 MRC (B), source image of 3D T2 MRC (C), MIP image of 3D contrast-enhanced T1 MRC (D), and source image of 3D contrast-enhanced T1 MRC (E) show normal anatomy in which junction of anterior segmental duct and posterior segmental duct forms right hepatic duct (arrow). All reviewers predicted that acquisition of single lumen would be possible during right lobe harvesting on sets of all four techniques. Intraoperative cholangiogram (F) confirmed normal anatomy (arrow), and acquisition of single lumen was performed.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —30-year-old male liver donor who underwent single lumen acquisition during right lobe harvest. Two-dimensional T2 MR cholangiography (MRC) (A), maximum-intensity-projection (MIP) image of 3D T2 MRC (B), source image of 3D T2 MRC (C), MIP image of 3D contrast-enhanced T1 MRC (D), and source image of 3D contrast-enhanced T1 MRC (E) show normal anatomy in which junction of anterior segmental duct and posterior segmental duct forms right hepatic duct (arrow). All reviewers predicted that acquisition of single lumen would be possible during right lobe harvesting on sets of all four techniques. Intraoperative cholangiogram (F) confirmed normal anatomy (arrow), and acquisition of single lumen was performed.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —30-year-old male liver donor who underwent single lumen acquisition during right lobe harvest. Two-dimensional T2 MR cholangiography (MRC) (A), maximum-intensity-projection (MIP) image of 3D T2 MRC (B), source image of 3D T2 MRC (C), MIP image of 3D contrast-enhanced T1 MRC (D), and source image of 3D contrast-enhanced T1 MRC (E) show normal anatomy in which junction of anterior segmental duct and posterior segmental duct forms right hepatic duct (arrow). All reviewers predicted that acquisition of single lumen would be possible during right lobe harvesting on sets of all four techniques. Intraoperative cholangiogram (F) confirmed normal anatomy (arrow), and acquisition of single lumen was performed.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5E —30-year-old male liver donor who underwent single lumen acquisition during right lobe harvest. Two-dimensional T2 MR cholangiography (MRC) (A), maximum-intensity-projection (MIP) image of 3D T2 MRC (B), source image of 3D T2 MRC (C), MIP image of 3D contrast-enhanced T1 MRC (D), and source image of 3D contrast-enhanced T1 MRC (E) show normal anatomy in which junction of anterior segmental duct and posterior segmental duct forms right hepatic duct (arrow). All reviewers predicted that acquisition of single lumen would be possible during right lobe harvesting on sets of all four techniques. Intraoperative cholangiogram (F) confirmed normal anatomy (arrow), and acquisition of single lumen was performed.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5F —30-year-old male liver donor who underwent single lumen acquisition during right lobe harvest. Two-dimensional T2 MR cholangiography (MRC) (A), maximum-intensity-projection (MIP) image of 3D T2 MRC (B), source image of 3D T2 MRC (C), MIP image of 3D contrast-enhanced T1 MRC (D), and source image of 3D contrast-enhanced T1 MRC (E) show normal anatomy in which junction of anterior segmental duct and posterior segmental duct forms right hepatic duct (arrow). All reviewers predicted that acquisition of single lumen would be possible during right lobe harvesting on sets of all four techniques. Intraoperative cholangiogram (F) confirmed normal anatomy (arrow), and acquisition of single lumen was performed.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —38-year-old male liver donor who underwent dual-lumen acquisition during harvesting of right lobe. Right anterior and posterior segmental branches do not seem to be separated on 2D T2 MR cholangiography (MRC) (A) image. Two reviewers incorrectly interpreted that single lumen acquisition would be possible. However, maximum-intensity-projection (MIP) images of 3D T2 MRC (B) and 3D contrast-enhanced T1 MRC (C) depicted well absence of common right hepatic duct (arrowhead,B and C, right anterior segmental duct; arrow,B and C, right posterior segmental duct). Dual-lumen acquisition was performed during right lobe harvesting.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —38-year-old male liver donor who underwent dual-lumen acquisition during harvesting of right lobe. Right anterior and posterior segmental branches do not seem to be separated on 2D T2 MR cholangiography (MRC) (A) image. Two reviewers incorrectly interpreted that single lumen acquisition would be possible. However, maximum-intensity-projection (MIP) images of 3D T2 MRC (B) and 3D contrast-enhanced T1 MRC (C) depicted well absence of common right hepatic duct (arrowhead,B and C, right anterior segmental duct; arrow,B and C, right posterior segmental duct). Dual-lumen acquisition was performed during right lobe harvesting.

View larger version (97K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —38-year-old male liver donor who underwent dual-lumen acquisition during harvesting of right lobe. Right anterior and posterior segmental branches do not seem to be separated on 2D T2 MR cholangiography (MRC) (A) image. Two reviewers incorrectly interpreted that single lumen acquisition would be possible. However, maximum-intensity-projection (MIP) images of 3D T2 MRC (B) and 3D contrast-enhanced T1 MRC (C) depicted well absence of common right hepatic duct (arrowhead,B and C, right anterior segmental duct; arrow,B and C, right posterior segmental duct). Dual-lumen acquisition was performed during right lobe harvesting.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —21-year-old male liver donor with normal biliary anatomy. On 2D T2 MR cholangiography (MRC) image, right ductal anatomy is not well delineated. All three reviewers had relatively lower confidence.

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —21-year-old male liver donor with normal biliary anatomy. All three reviewers had relatively lower confidence, but all techniques combined showed relatively higher confidence grade in predicting single lumen acquisition: maximum-intensity-projection (MIP) image of 3D T2 MRC (B); source image of 3D T2 MRC (C); source image of 3D contrast-enhanced T1 MRC (D). Arrowhead indicates anterior segmental branch, short arrow indicates posterior segmental branch, and long arrow indicates right hepatic duct.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —21-year-old male liver donor with normal biliary anatomy. All three reviewers had relatively lower confidence, but all techniques combined showed relatively higher confidence grade in predicting single lumen acquisition: maximum-intensity-projection (MIP) image of 3D T2 MRC (B); source image of 3D T2 MRC (C); source image of 3D contrast-enhanced T1 MRC (D). Arrowhead indicates anterior segmental branch, short arrow indicates posterior segmental branch, and long arrow indicates right hepatic duct.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —21-year-old male liver donor with normal biliary anatomy. All three reviewers had relatively lower confidence, but all techniques combined showed relatively higher confidence grade in predicting single lumen acquisition: maximum-intensity-projection (MIP) image of 3D T2 MRC (B); source image of 3D T2 MRC (C); source image of 3D contrast-enhanced T1 MRC (D). Arrowhead indicates anterior segmental branch, short arrow indicates posterior segmental branch, and long arrow indicates right hepatic duct.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7E —21-year-old male liver donor with normal biliary anatomy. Intraoperative cholangiogram confirmed normal anatomy, and acquisition of single lumen was performed. Arrowhead indicates anterior segmental branch, short arrow indicates posterior segmental branch, and long arrow indicates right hepatic duct.

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