HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, V. S. Articles by Weinreb, J. C. Search for Related Content PubMed PubMed Citation Articles by Lee, V. S. Articles by Weinreb, J. C. Social Bookmarking                      What's this?

Volumetric Mangafodipir Trisodium-Enhanced Cholangiography to Define Intrahepatic Biliary Anatomy

¹ Department of Radiology, MRI, New York University Medical Center, 530 First Ave., HCC Basement, New York, NY 10016.
² Department of Surgery, New York University Medical Center, New York, NY 10016.

Received August 23, 2000; accepted after revision September 25, 2000.

 
Address correspondence to V. S. Lee.

Introduction

Top Introduction MR Imaging Technique References

 
The shortage of cadaveric livers for transplantation has led to the development of novel surgical techniques for adult-to-adult right lobe transplantation [1, 2]. One of the challenges of donor selection and surgical planning is the identification of anomalies of intrahepatic bile ducts. Like hepatic arterial anatomy, biliary anatomy is variable, and variants are seen in up to 45% of the population [3, 4]. The most typical variants are highly relevant when considering a right hepatectomy because these variants involve anomalous drainage of the lateral duct of the right lobe (draining segments VI and VII). In approximately 8-11% of the population, the right lateral duct drains directly into the junction between the right medial duct and the left hepatic duct (the so-called trifurcation pattern), and, even more problematic, in approximately 13% of the population, the right lateral duct drains into the left hepatic duct [3, 4]. A donor candidate having either of these variants can preclude performance of a single duct-to-duct biliary anastomosis in the transplant recipient [5], and thus, the risks of biliary complications for both the donor and the recipient may be considered too great for the transplantation to proceed. Until more experience with living donor liver transplantation has been accumulated, it seems prudent to have an accurate assessment of biliary tract anatomy for evaluation of a candidate's suitability for right lobe donation and for surgical planning.

State-of-the-art MR cholangiographic techniques typically rely on heavily T2-weighted turbo spin-echo techniques and have been shown to be highly accurate in the identification of biliary disease and in the detection of variant extrahepatic biliary anatomy relevant to laparoscopic cholecystectomy [6]. However, in our experience, the detection and definition of intrahepatic anatomic anomalies, particularly in nondilated systems, are often inadequate. An accurate, but invasive, alternative imaging technique—endoscopic retrograde cholangiopancreatography—is associated with a quantifiable morbidity, which makes its use as a routine screening procedure difficult to justify in otherwise healthy donor candidates.

Mangafodipir trisodium is a safe and approved hepatobiliary MR contrast agent [7] that is administered intravenously and causes T1 shortening as a result of the paramagnetic effects of the manganese metal ion. The manganese is excreted primarily via the biliary system and therefore can theoretically be used as a biliary contrast agent with T1-weighted MR imaging. Because biliary stasis in the setting of strictures or common duct stones reduces the excretion of biliary manganese after mangafodipir trisodium injection, the clinical use of this contrast agent with cholangiography has been limited [8]. However, for normal nonobstructed systems, we have observed visible biliary enhancement within 10 min of IV injection. We describe a new method for defining intrahepatic ductal anatomy in liver transplant donor candidates, using a combination of mangafodipir trisodium contrast material and high-resolution volumetric three-dimensional (3D) T1-weighted gradient-echo imaging of the liver.

MR Imaging Technique

Top Introduction MR Imaging Technique References

 
We studied 10 healthy transplant donor candidates. All patients were imaged on a 1.5-T scanner (Vision or Quantum; Siemens Medical Systems, Iselin, NJ) using our routine MR imaging protocol that includes T2-weighted short-tau inversion recovery turbo spin-echo imaging and unenhanced and gadopentetate dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ) contrast-enhanced axial T1-weighted gradient-echo imaging with a torso phased array coil. These images were used in the assessment of hepatic parenchymal disease and hepatic vascular anatomy.

Routine MR cholangiographic sequences were also performed and included axial and coronal half-Fourier acquisition single-shot turbo spin-echo images (TR/effective TE, infinite/62; refocusing angle, 140-160°; imaging matrix, 128-192 x 256; field of view, 300-375 mm with rectangular field of view depending on body habitus; slice thickness, 4 mm; number of slices per breath-hold, 15-20) and oblique coronal heavily T2-weighted turbo spin-echo images (2800/1100; flip angle, 150-180°; matrix, 240 x 256; field of view, 300-375 mm; section thickness, 20-60 mm with an optional rectangular field of view). All images were obtained during suspended respiration.

Subsequently, an IV injection of mangafodipir trisodium (Teslascan; Nycomed, Princeton, NJ) at a standard dose of 5 µmol/kg (0.1 mL/kg; maximum dose, 15 mL) was administered via a slow injection over 1-2 min followed by a 10-mL saline flush. From 10 to 15 min after injection, axial and coronal volumetric 3D spoiled gradient-echo acquisitions of the liver and biliary system were performed using two interpolated sequences with intermittent fat-suppression pulses. The first one was a higher resolution sequence that was performed coronally with limited coverage: TR/TE, 6.8/2.3; flip angle, 25-40°; matrix, 128-256 x 512; field of view, 350-450 mm (rectangular field of view depending on body habitus); and 24 partitions interpolated to 48 slices with a thickness of 1.5 mm or less. The second one was a lower resolution sequence that was performed axially to include the entire liver: TR/TE, 4.5/1.9; flip angle, 25-40°; matrix, 128-160 x 256; field of view, 300-375 mm using a rectangular field of view; and 80-112 partitions for a slice thickness of 2 mm or less [9]. Imaging time for all sequences was kept to less than 25 sec to facilitate breath-holding during the acquisition.

The imaging protocol was approved by our institutional review board, and informed consent was obtained from all patients.

The 3D image sets were viewed on a commercially available workstation (Virtuoso, Siemens Medical Systems; and Vitrea, Vital Images, Minneapolis, MN). Volume-rendering and maximum-intensity-projection displays are useful for evaluating the complex orthogonal relationships between the right lateral duct, which typically traverses the liver in the anteroposterior plane, and the right medial and left hepatic ducts, which typically lie in an oblique coronal plane (Figs. 1A,1B and 2A,2B,2C). Stereoscopic viewing of the 3D data sets (available on the Virtuoso workstation, Siemens) can be particularly helpful for visualization of 3D relationships in difficult cases.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —34-year-old healthy woman who was evaluated as potential right lobe liver transplant donor candidate. Coronal volume-rendered three-dimensional T1-weighted gradient-echo image (TR/TE, 6.8/2.3; flip angle, 25°) obtained after IV administration of mangafodipir trisodium depicts branching pattern of intrahepatic bile duct with low confluence of right lateral duct (straight arrow) and right medial duct (arrowhead) near origin of left hepatic duct (curved arrow). Identification of segment of right hepatic duct—no matter how short—can be crucial for surgical planning of right hepatectomy.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —34-year-old healthy woman who was evaluated as potential right lobe liver transplant donor candidate. Intraoperative contrast-enhanced MR cholangiogram confirms branching pattern of intrahepatic bile duct with low confluence of right lateral duct (straight arrow) and right medial duct (arrowhead) near origin of left hepatic duct (curved arrow). At surgery, 1-mm-long segment of right hepatic duct was found and proved to be adequate for single duct-to-duct biliary anastomosis in recipient. Donor underwent successful right hepatectomy and was discharged from hospital on seventh postoperative day.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —54-year-old healthy woman who was evaluated as potential right lobe liver transplant donor candidate. Conventional coronal heavily T2-weighted turbo spin-echo MR cholangiogram (TR/effective TE, 2800/1100) shows apparent confluence of right lateral duct (short arrow), right medial duct (arrowhead), and left hepatic duct (long arrow). On basis of this image alone, right lateral duct could be interpreted as draining into proximal left hepatic duct, a finding that would exclude this candidate from consideration as transplant donor at our institution because two separate biliary anastomoses in recipient are necessary.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —54-year-old healthy woman who was evaluated as potential right lobe liver transplant donor candidate. Coronal volume-rendered three-dimensional T1-weighted gradient-echo MR image (TR/TE, 6.8/2.3; flip angle, 25°) obtained after IV administration of mangafodipir trisodium depicts branching pattern of intrahepatic bile duct, with similar appearance to that on heavily T2-weighted images shown in A. Precise definition of biliary anatomy is limited with this projection. However, because volumetric images are obtained with nearly isotropic pixel size, images can be reconstructed from coronal projection in any obliquity to assist visualization. Note filling of cystic duct (arrow).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —54-year-old healthy woman who was evaluated as potential right lobe liver transplant donor candidate. Oblique coronal reconstruction of same image data set depicted in B. This projection better defines relationship between ducts by showing that right lateral duct (thick arrow) clearly drains into confluence of right medial duct (arrowhead) and left hepatic duct (thin arrow), corresponding to trifurcation pattern. Although this anatomy is considered challenging [5], patient has not been excluded as candidate for right lobe donation and is awaiting surgery. Note partial filling of gallbladder (G) in this patient with gallstones.

For the 10 patients examined so far, two independent MR radiologists have evaluated the conventional T2-weighted MR cholangiographic images and the mangafodipir trisodium-enhanced volumetric T1-weighted images for definition of biliary anatomy and the presence of anatomic variants [3, 4]. To date, only one patient (Fig. 1A,1B) has undergone right hepatectomy with intraoperative cholangiography. In this patient both the heavily T2-weighted coronal image and the mangafodipir trisodium-enhanced images predicted intraoperative findings accurately. Although an assessment of the accuracy of the method awaits further surgical confirmation, in our preliminary experience, we have observed that the mangafodipir trisodium-enhanced volumetric images of the liver can serve as a useful supplement to conventional T2-weighted MR cholangiographic images for the evaluation of right lobe donor candidates.

The high signal intensity of the biliary system after mangafodipir excretion produces excellent contrast when compared with the background liver parenchyma and hepatic vessels, the latter of which can be difficult to distinguish from bile ducts with some conventional T2-weighted MR cholangiographic methods. With two-dimensional T2-weighted images, the orthogonal relationships between the right medial duct, right lateral duct, left hepatic duct, and common hepatic duct can often be difficult to define with confidence (Fig. 2A,2B,2C). The use of volume-rendering algorithms for reconstruction of 3D data sets facilitates definition of these relationships for surgical planning. Transplantation surgeons at our institution review all cases using a 3D imaging workstation as part of the preoperative evaluation. The mangafodipir trisodium-enhanced 3D imaging method also provides improved resolution over that of conventional T2-weighted imaging by producing 3D images with a pixel size on the order of 1 x 2 x 1.5 mm. Given that the distinction between a normal pattern of biliary anatomy and biliary trifurcation may depend on differences in the position of the right lateral duct of less than 1 mm, image resolution can be critical for the accurate definition of biliary anatomy and, consequently, for the appropriate patient selection and exclusion (Fig. 2A,2B,2C).

Mangafodipir trisodium-enhanced T1-weighted MR imaging, particularly when performed using high-resolution volumetric T1-weighted imaging of the liver, may serve as a supplement to conventional MR cholangiographic methods; this method can facilitate the definition of intrahepatic bile duct anatomy in nonobstructed biliary systems such as that seen in healthy liver transplant donor candidates. It is hypothesized that this capacity will have a favorable impact on surgical results; however, studies to verify this hypothesis are needed. With our present protocol, both gadopentetate dimeglumine and mangafodipir trisodium contrast material are administered for evaluation of donor candidates to provide comprehensive evaluation of hepatic parenchymal and vascular anatomy as well as biliary anatomy, respectively. In the future, these studies could theoretically be performed with the use of a single contrast agent, such as a hepatobiliary gadolinium-based MR contrast agent, whereby dynamic T1-weighted imaging during bolus infusion can be used for evaluation of liver parenchyma and vascular anatomy and delayed imaging after biliary excretion can be used for cholangiography [10]. Investigational studies are warranted.

References

Top Introduction MR Imaging Technique References

 

1. Marcos A, Fisher RA, Ham JM, et al. Selection and outcome of living donors for adult to adult right lobe transplantation. Transplantation 2000;69:2410 -2415[Medline]
2. Fan S-T, Lo C-M, Liu C-L, et al. Safety of donors in live donor liver transplantation using right lobe grafts. Arch Surg 2000;135:336 -340[Abstract/Free Full Text]
3. Puente SG, Bannura GC. Radiological anatomy of the biliary tract: variations and congenital abnormalities. World J Surg 1983;7:271 -276[Medline]
4. Russell E, Yrizzary JM, Montalvo BM, Guerra JJ, Al-Refai F. Left hepatic duct anatomy: implications. Radiology 1990;174:353 -356[Abstract/Free Full Text]
5. Morgan GR, Lee V, Krinsky G, et al. Duct to duct biliary anastomosis with t-tube drainage in adult right lobe living donor liver transplantation without bile leaks. (abstr) Hepatology 2000;32:214A
6. Taourel P, Bret PM, Reinhold C, Barkun AN, Atri M. Anatomic variants of the biliary tree: diagnosis with MR cholangiopancreatography. Radiology 1996;199:521 -527[Abstract/Free Full Text]
7. Federle MP, Chezmar JL, Rubin DL, et al. Safety and efficacy of mangafodipir trisodium (MnDPDP) injection for hepatic MRI in adults: results of the U.S. multicenter phase III clinical trials (safety). J Magn Reson Imaging 2000;12:186 -197[Medline]
8. Mitchell DG, Alam F. Mangafodipir trisodium: effects on T2- and T1-weighted MR cholangiography. J Magn Reson Imaging 1999;9:366 -368[Medline]
9. Rofsky NM, Lee VS, Laub G, et al. Abdominal MR imaging with a volumetric interpolated breath-hold examination. Radiology 1999;212:876 -884[Abstract/Free Full Text]
10. Earls JP, Bluemke DA. New MR imaging contrast agents. Magn Reson Imaging Clin North Am 1999;7:255 -273

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				J. S. Lim, M.-J. Kim, S. Myoung, M.-S. Park, J.-Y. Choi, J.-S. Choi, and S. I. Kim MR Cholangiography for Evaluation of Hilar Branching Anatomy in Transplantation of the Right Hepatic Lobe from a Living Donor Am. J. Roentgenol., August 1, 2008; 191(2): 537 - 545. [Abstract] [Full Text] [PDF]

				S. K. An, J. M. Lee, K.-S. Suh, N. J. Lee, S. H. Kim, Y. J. Kim, J. K. Han, and B. I. Choi Gadobenate dimeglumine-enhanced liver MRI as the sole preoperative imaging technique: a prospective study of living liver donors. Am. J. Roentgenol., November 1, 2006; 187(5): 1223 - 1233. [Abstract] [Full Text] [PDF]

				J. S. Lim, M.-J. Kim, J. H. Kim, S. I. Kim, J.-S. Choi, M.-S. Park, Y. T. Oh, H. S. Yoo, J. T. Lee, and K. W. Kim Preoperative MRI of Potential Living-Donor-Related Liver Transplantation Using a Single Dose of Gadobenate Dimeglumine Am. J. Roentgenol., August 1, 2005; 185(2): 424 - 431. [Abstract] [Full Text] [PDF]

				D. B. Macdonald, M. A. Haider, K. Khalili, T. K. Kim, M. O'Malley, P. D. Greig, D. R. Grant, G. Lockwood, and M. S. Cattral Relationship Between Vascular and Biliary Anatomy in Living Liver Donors Am. J. Roentgenol., July 1, 2005; 185(1): 247 - 252. [Abstract] [Full Text] [PDF]

				Z. J. Wang, B. M. Yeh, J. P. Roberts, R. S. Breiman, A. Qayyum, and F. V. Coakley Living Donor Candidates for Right Hepatic Lobe Transplantation: Evaluation at CT Cholangiography--Initial Experience Radiology, June 1, 2005; 235(3): 899 - 904. [Abstract] [Full Text] [PDF]

				N. Hottat, C. Winant, T. Metens, N. Bourgeois, J. Deviere, and C. Matos MR Cholangiography with Manganese Dipyridoxyl Diphosphate in the Evaluation of Biliary-Enteric Anastomoses: Preliminary Experience Am. J. Roentgenol., May 1, 2005; 184(5): 1556 - 1562. [Abstract] [Full Text] [PDF]

				L. M. Fayad, I. R. Kamel, D. G. Mitchell, and D. A. Bluemke Functional MR Cholangiography: Diagnosis of Functional Abnormalities of the Gallbladder and Biliary Tree Am. J. Roentgenol., May 1, 2005; 184(5): 1563 - 1571. [Abstract] [Full Text] [PDF]

				H. K. Ryeom, B. H. Choe, J. Y. Kim, S. Kwon, C. W. Ko, H. M. Kim, S. B. Lee, and D. S. Kang Biliary Atresia: Feasibility of Mangafodipir Trisodium-enhanced MR Cholangiography for Evaluation Radiology, April 1, 2005; 235(1): 250 - 258. [Abstract] [Full Text] [PDF]

				J. S. Chen, B. M. Yeh, Z. J. Wang, J. P. Roberts, R. S. Breiman, A. Qayyum, and F. V. Coakley Concordance of Second-Order Portal Venous and Biliary Tract Anatomies on MDCT Angiography and MDCT Cholangiography Am. J. Roentgenol., January 1, 2005; 184(1): 70 - 74. [Abstract] [Full Text] [PDF]

				M.-S. Park, K. W. Kim, J.-S. Yu, M.-J. Kim, K. W. Kim, J. S. Lim, E.-S. Cho, D.-S. Yoon, T. K. Kim, S. I. Lee, et al. Early Biliary Complications of Laparoscopic Cholecystectomy: Evaluation on T2-Weighted MR Cholangiography in Conjunction with Mangafodipir Trisodium-Enhanced T1-Weighted MR Cholangiography Am. J. Roentgenol., December 1, 2004; 183(6): 1559 - 1566. [Abstract] [Full Text] [PDF]

				A. Ragozzino, R. De Ritis, A. Mosca, V. Iaccarino, and M. Imbriaco Value of MR Cholangiography in Patients with Iatrogenic Bile Duct Injury After Cholecystectomy Am. J. Roentgenol., December 1, 2004; 183(6): 1567 - 1572. [Abstract] [Full Text] [PDF]

				V. S. Lee, G. A. Krinsky, C. A. Nazzaro, J. S. Chang, J. S. Babb, J. C. Lin, G. R. Morgan, and L. W. Teperman Defining Intrahepatic Biliary Anatomy in Living Liver Transplant Donor Candidates at Mangafodipir Trisodium-enhanced MR Cholangiography versus Conventional T2-weighted MR Cholangiography Radiology, December 1, 2004; 233(3): 659 - 666. [Abstract] [Full Text] [PDF]

				C. S. Zuo, P. R. Seoane, J. Hu, P. P. Harnish, and N. M. Rofsky MR Imaging of the Stomach: Potential Use for Mangafodipir Trisodium-- A Study in Swine Radiology, July 1, 2004; 232(1): 160 - 163. [Abstract] [Full Text] [PDF]

				M. D. Bridges, G. R. May, and D. M. Harnois Diagnosing Biliary Complications of Orthotopic Liver Transplantation with Mangafodipir Trisodium-Enhanced MR Cholangiography: Comparison with Conventional MR Cholangiography Am. J. Roentgenol., June 1, 2004; 182(6): 1497 - 1504. [Abstract] [Full Text] [PDF]

				B. M. Yeh, R. S. Breiman, B. Taouli, A. Qayyum, J. P. Roberts, and F. V. Coakley Biliary Tract Depiction in Living Potential Liver Donors: Comparison of Conventional MR, Mangafodipir Trisodium-enhanced Excretory MR, and Multi-Detector Row CT Cholangiography--Initial Experience Radiology, March 1, 2004; 230(3): 645 - 651. [Abstract] [Full Text] [PDF]

				K. W. Kim, M.-S. Park, J.-S. Yu, J. P. Chung, Y. H. Ryu, S. I. Lee, K. S. Lee, S.-W. Yoon, and K.-H. Lee Acute Cholecystitis at T2-weighted and Manganese-enhanced T1-weighted MR Cholangiography: Preliminary Study Radiology, May 1, 2003; 227(2): 580 - 584. [Abstract] [Full Text] [PDF]

				V. Kapoor, M. S. Peterson, R. L. Baron, S. Patel, B. Eghtesad, and J. J. Fung Intrahepatic Biliary Anatomy of Living Adult Liver Donors: Correlation of Mangafodipir Trisodium--Enhanced MR Cholangiography and Intraoperative Cholangiography Am. J. Roentgenol., November 1, 2002; 179(5): 1281 - 1286. [Abstract] [Full Text] [PDF]

				K. M. Vitellas, A. El-Dieb, K. K. Vaswani, W. F. Bennett, J. Fromkes, C. Ellison, and J. G. Bova Using Contrast-Enhanced MR Cholangiography with IV Mangafodipir Trisodium (Teslascan) to Evaluate Bile Duct Leaks After Cholecystectomy: A Prospective Study of 11 Patients Am. J. Roentgenol., August 1, 2002; 179(2): 409 - 416. [Abstract] [Full Text] [PDF]

				R. C. Carlos, H. K. Hussain, J. H. Song, and I. R. Francis Gadolinium-Ethoxybenzyl-Diethylenetriamine Pentaacetic Acid as an Intrabiliary Contrast Agent: Preliminary Assessment Am. J. Roentgenol., July 1, 2002; 179(1): 87 - 92. [Abstract] [Full Text] [PDF]

				V. S. Lee, G. R. Morgan, L. W. Teperman, D. John, T. Diflo, P. V. Pandharipande, P. M. Berman, M. T. Lavelle, G. A. Krinsky, N. M. Rofsky, et al. MR Imaging as the Sole Preoperative Imaging Modality for Right Hepatectomy: A Prospective Study of Living Adult-to-Adult Liver Donor Candidates Am. J. Roentgenol., June 1, 2001; 176(6): 1475 - 1482. [Abstract] [Full Text] [PDF]

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, V. S. Articles by Weinreb, J. C. Search for Related Content PubMed PubMed Citation Articles by Lee, V. S. Articles by Weinreb, J. C. Social Bookmarking                      What's this?