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1
Department of Radiology—MRI, New York University Medical Center, 530
First Ave., New York, NY 10016.
2
Department of Surgery, New York University, New York, NY 10016.
Received October 13, 2000;
accepted after revision November 27, 2000.
Address correspondence to V. S. Lee.
Abstract
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SUBJECTS AND METHODS. Twenty-five consecutive donor candidates were examined at 1.5 T using a torso phased array coil with breath-hold T1- and T2-weighted imaging of the abdomen, MR cholangiography using T2-weighted turbo spin-echo imaging, and MR angiography and venography of the liver using two interpolated three-dimensional spoiled gradient-echo sequences (average dose of gadolinium contrast material, 0.17 mmol/kg). Images were interpreted for liver parenchymal and extrahepatic abnormalities; measurements of right and left lobe liver volumes; definition of hepatic arterial, portal venous, and hepatic venous anatomy; and definition of the biliary branching pattern. Findings were compared with those of conventional angiography in 13 patients, 11 of whom also had surgical findings for comparison.
RESULTS. Nine patients were excluded as candidates for donation on the basis of MR imaging findings that included parenchymal or extrahepatic abnormalities in five patients, vascular anomalies in two, and biliary anomalies in three. Two patients who did not undergo surgery underwent conventional angiography that confirmed MR angiographic findings except for a small (<2 mm) accessory left hepatic artery missed on MR imaging. Of the nine patients who underwent successful right hepatectomy, all MR imaging findings were corroborated intraoperatively. In two patients, right hepatectomy was aborted at laparotomy because of intraoperative cholangiography findings; in one of them, the biliary finding was unsuspected on MR imaging.
CONCLUSION. A comprehensive MR imaging examination has the potential to serve as the sole preoperative imaging modality for living adult-to-adult liver donor candidates provided improvements in definition of intrahepatic biliary anatomy can be achieved.
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Imaging findings that can disqualify a donor candidate include liver parenchymal disease and certain vascular and biliary anomalies. In a subset of these otherwise healthy individuals, unsuspected parenchymal abnormalities such as steatosis or insufficient liver volume, either in terms of transplanted tissue for the recipient or residual tissue for the donor, may be reasons for exclusion as donors. Several common anatomic variants, such as anomalous origin of the left portal vein from the right anterior portal vein or anomalous drainage of the right lateral bile duct into the left hepatic duct, can substantially increase the complexity of the surgical procedure [8] and, therefore, are also considered reasons for exclusion at our center. Preoperative identification of anomalous vascular or biliary anatomy not only can help the surgeons decide which donors are suitable candidates, but also, in those with favorable anatomy, can guide the safe harvesting of the right lobe from the donor and its transplantation to the recipient. For example, although large inferior accessory hepatic veins are not contraindications to surgery, the need for reimplantation of the veins in the recipient can be anticipated when they are identified preoperatively.
In the limited literature on this new procedure, complete preoperative imaging examination of the donor has typically included conventional or intraoperative sonography, cross-sectional imaging, conventional angiography, and intraoperative contrast-enhanced cholangiography [6, 11]. MR imaging has the potential to simplify the imaging protocol by providing in a single examination an assessment of liver parenchymal abnormalities such as steatosis [12, 13]; measurements of lobar liver volumes; and definition of arterial, portal venous, hepatic venous, and biliary anatomy. MR imaging is minimally invasive, and gadolinium-based contrast agents for MR angiography are safe for use in a screening examination.
The aim of our prospective study was to investigate the feasibility of MR imaging as the sole preoperative imaging test for examination of living adult-to-adult liver donor candidates.
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For MR cholangiography, breath-hold axial and coronal half-Fourier acquisition single-shot turbo spin-echo (HASTE) imaging and oblique coronal heavily T2-weighted thick-slab turbo spin-echo imaging were performed with the following sequence parameters: for HASTE imaging: TR/effective TE, infinite/63; refocusing pulse, 140-160°; slice thickness, 4 mm with no interslice gap; field of view, 325-400 mm; image matrix, 160 x 256 using a rectangular field of view according to body habitus; for heavily T2-weighted turbo spin-echo imaging: TR/effective TE, 2800/1100; refocusing pulse, 180°; either four 15-mm-thick slices with no interslice gap or one 60-mm-thick slice; field of view, 325-400 mm; and image matrix, 240 x 256.
For MR angiography, a coronal breath-hold three-dimensional (3D) interpolated spoiled gradient-echo sequence (TR/TE, 6.8/2.3; flip angle, 25°) was performed before and after 20-40 mL of IV gadopentetate dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ) with the arterial phase timed on the basis of a 1-mL test bolus of contrast material [14]. During the course of the study, the contrast dose was reduced from 40 mL (n = 8 patients) to 20 mL (n = 17 patients). The total dose of contrast material averaged 0.17 mmol/kg, and a power injector (Spectris; Medrad, Pittsburgh, PA) was used with an injection rate of 2 mL/sec. Sequence parameters were as follows: matrix, 195-225 x 512; field of view, 400-450 mm; slab thickness, 60-80 mm with 24 partitions interpolated to 48 for an effective slice thickness of 1.25-1.7 mm; and an intermittent fat-saturation pulse. A second 3D interpolated fat-suppressed spoiled gradient-echo sequence (TR/TE, 4.5/1.9; flip angle, 12°) was acquired in the axial plane and included coverage of the entire liver; this sequence is similar to a sequence that has recently been reported in the literature [15, 16]. This second 3D acquisition was also performed both before and after the administration of contrast material (in the equilibrium phase) and was used for evaluation of liver parenchyma and venous structures. Imaging parameters for the sequence were as follows: matrix, 128-160 x 256; field of view, 325-375 mm; slab thickness, 140-200 mm with 46-56 partitions interpolated to 92-112 for an effective slice thickness of 2 mm or less. All acquisition times were kept to less than 30 sec to facilitate breath-holding at end expiration. Total imaging times typically were 45 min or less.
All studies were evaluated by an MR fellowship-trained radiologist using a commercially available workstation (Virtuoso, Siemens; and Vitrea, Vital Images, Minneapolis, MN). Multiplanar reformating and 3D reconstructions using volume-rendering and maximum-intensity-projection algorithms were used in addition to the source images. The reconstructed 3D images were also viewed stereoscopically using the commercially available software of one workstation (Virtuoso). All MR imaging studies were performed before other imaging studies; therefore, the observers did not have information regarding correlative findings at the time of interpretation. Postprocessing time decreased with experience to approximately 30-45 min of physician time.
Images were interpreted for findings that we now briefly describe. Evaluation of liver parenchymal abnormalities included assessment of fatty infiltration on the basis of signal loss relative to spleen on opposed-phase T1-weighted gradient-echo images when compared with in-phase images [12, 13]. Detection and characterization of masses relied on T1- and T2-weighted imaging and dynamic contrast-enhanced T1-weighted imaging using interpolated 3D spoiled gradient-echo sequences. Calculation of right and left lobe volumes was performed by reconstructing axial 3D contrast-enhanced images into 1-cm-thick slices with no interslice gap. On each slice, regions of interest were manually drawn around the entire liver and around the right lobe, where the interlobar plane was defined as the longitudinal plane 1 cm to the right of the middle hepatic vein through the level of the gallbladder fossa. The sum of the cross-sectional areas from each slice was used to estimate total and right lobe liver volumes; the difference was used to estimate left lobe volumes. Weight was calculated on the basis of an estimated liver density of 1 g/mL. The weight of the right lobe was estimated from MR imaging to ensure that it would correspond to at least 1% of the recipient's body weight and leave the donor a left lobe liver volume corresponding to at least 0.5-0.6% of the donor's body weight.
Hepatic artery anatomy was classified according to Michels' system [17] by noting the origins of the right and left hepatic arteries and the presence of any accessory hepatic arteries. The presence and location of the origin of the middle hepatic artery, which supplies liver segment IV, were also noted. The length of the extrahepatic right hepatic artery was measured. Although the hepatic artery diameters were not measured, the relative sizes of all arteries supplying the liver were noted. Portal vein anatomy was characterized into patterns described in the literature and including the following: normal anatomy (bifurcation into normal right and left portal veins), trifurcation (origin of the left portal vein at the bifurcation of the right portal vein into anterior and posterior branches), and origin of the left portal vein from the right anterior portal vein branch [18, 19]. The presence of a normal right hepatic vein was noted. The locations and diameters of any accessory hepatic veins measuring greater than 2 mm in diameter were also recorded.
Biliary anatomy bifurcation patterns were characterized into patterns previously described in the literature [20, 21]. Most notably, emphasis was placed on discerning whether the right lateral duct (from posterior segments VI and VII) drained into the right hepatic duct (normal), into the junction of the right medial duct and the left main duct (trifurcation), or into the left hepatic duct. The presence and location of any accessory hepatic ducts were noted. Because our surgeons prefer a single duct-to-duct biliary anastomosis in the recipient, identification of two or more ducts draining the right lobe with separate orifices is considered a relative cause for exclusion of a donor candidate [22].
Conventional Angiography
The first 13 patients in our series also underwent conventional digital
subtraction angiography of the liver within 2 months of the MR imaging
examination (with subsequent operative confirmation of findings in nine
patients). After these 13 patients, the transplant surgery team elected not to
have donor candidates undergo conventional angiography routinely, instead
reserving the procedure for problematic cases only.
All studies were performed using a 5-French catheter via femoral access. Selective injections of the celiac artery and the superior mesenteric artery were performed, and delayed images were acquired for evaluation of portal vein anatomy. The pattern of hepatic artery anatomy was classified according to Michels' classification [17]. Attempts to discern portal vein anatomic variants were recognized as limited with frontal and oblique projections, and therefore only portal vein patency was assessed. All studies were performed and images interpreted without knowledge of the MR imaging results. The conventional angiograms were used as the reference standard for evaluating MR angiography. Surgical findings were also used to assess MR angiography results in the nine surgical patients.
Intraoperative Correlation and Data Interpretation
Before surgery, all patient studies were reviewed with the transplant team
at a multidisciplinary conference using the imaging workstation (Virtuoso)
with 3D rendering and stereoscopic viewing capabilities.
Eleven donor patients underwent laparotomy, at which intraoperative cholangiography was performed. Findings were used as a reference standard to assess the accuracy of MR cholangiography. In the nine patients who then underwent right hepatectomy, the MR definition of vascular anatomy was compared with surgical findings. The anatomy of the right hepatic artery and the presence of any accessory right arteries were recorded, as were the pattern of portal vein bifurcation and the presence of a normal right hepatic vein. All substantial inferior accessory veins encountered intraoperatively were noted, and vessels requiring reimplantation in the recipient were measured in their collapsed state after harvesting. Excised right lobes were also weighed in the operating room for all but the first of the nine patients. To compare the right lobe liver weights recorded intraoperatively with preoperative MR imaging estimates, correlation coefficients were calculated and mean differences computed.
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Parenchymal Findings
Abnormalities of the liver or extrahepatic organs were found at MR imaging
in eight patients (32%). Five patients had unsuspected liver lesions: three
patients had masses that were presumed to be focal nodular hyperplasia,
including one patient with multiple lesions in both lobes (Fig.
1A,1B,1C,1D);
one patient had a presumed hemangioma in the right lobe; and one had a simple
1-cm hepatic cyst in the right lobe. All presumed focal nodular hyperplasia
lesions were homogeneous in signal intensity on unenhanced images and showed
rapid arterial phase enhancement with near isointense signal on delayed
contrast-enhanced images. Of the patients with focal masses, only the patient
with multiple liver lesions was excluded on the basis of imaging findings
(Table 1); this patient also
had a small left lobe (362 g estimated on MR imaging).
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One patient had enlarged abdominal lymph nodes (Fig. 2) and was subsequently proven to have sarcoidosis at mediastinal lymph node biopsy. Her sister was also examined as a donor candidate; the sister's MR imaging study showed several tiny nonenhancing low-signal-intensity lesions in the liver that were later presumed to be granulomas because of her subsequent diagnosis of sarcoidosis (also based on lymph node biopsy). Both siblings were thus excluded as donors. Mild diffuse fatty infiltration was detected in one patient on the basis of decreased signal intensity of the liver relative to spleen on opposed-phase T1-weighted gradient-echo imaging when compared with in-phase imaging [12, 13]; the patient was subsequently excluded as a potential donor when additional liver function testing revealed newly elevated transaminase levels.
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In an additional patient who weighed 77 kg, no parenchymal lesions or disease was identified by MR imaging, but the candidate's left lobe liver volume measured 300 mL (for an approximate weight of 300 g) and was considered too small to allow a safe right hepatectomy.
Thus, five donor patients were excluded from transplantation on the basis of MR imaging evaluation of liver parenchymal and extrahepatic disease (Table 1).
Hepatic Artery Anatomy
Hepatic artery anatomy findings at MR imaging are shown in
Table 2. Most patients (17/25,
68%) were found to have normal hepatic artery anatomy (Fig.
3A,3B,3C),
although in three patients, the middle hepatic artery (supplying segment IV)
was observed to arise from the right hepatic artery (this variant is typically
also classified as normal or Michels' type I
[17]). None of these three
patients was excluded as a donor on the basis of this finding because the
origins of the middle hepatic artery were all proximal, near the origin of the
left hepatic artery, allowing a sufficiently long segment of right hepatic
artery distal to the middle hepatic artery for resection. The most common
arterial variants were an accessory left hepatic artery (n = 4, 16%)
and a replaced right hepatic artery (n = 3, 12%)
(Fig. 4). One patient had
anomalous origin of the common hepatic artery directly off the aorta with an
otherwise normal arterial branching pattern. None of the patients in our
series had dual blood supply to the right lobe; that is, no accessory right
hepatic arteries were identified.
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Contrast-enhanced angiography confirmed MR angiographic findings in 12 (92%) of 13 patients, including 10 of 11 patients with normal anatomy on MR angiography. In one patient, angiography showed a previously undetected accessory left hepatic artery smaller than 2 mm arising from the left gastric artery (Michels' type 5 [17]) in a candidate with otherwise normal arterial anatomy. One patient was found on MR imaging to have a separate origin of the common hepatic artery off the aorta. This finding was suspected on contrast angiography; however, distinction from an early origin of the common hepatic artery from the celiac trunk based on frontal and oblique projections was difficult. Celiac stenosis resulting from median arcuate ligament compression was found in one asymptomatic patient on both MR angiography and contrast-enhanced angiography; the patient subsequently underwent successful right hepatectomy without complications.
Portal Vein Anatomy
Portal vein anatomy was considered normal on MR imaging in 23 (92%) of 25
patients. One patient had trifurcation of the portal vein into the right
anterior, right posterior, and left main portal veins, and another had
anomalous origin of the left portal vein off the right anterior portal vein
branch (Fig.
3A,3B,3C).
Both patients were excluded on the basis of MR imaging alone. No other imaging
studies were performed in these patients.
In all nine patients who underwent right hepatectomy, preoperative MR imaging findings of normal portal vein anatomy were confirmed at surgery.
Hepatic Vein Anatomy
Accessory hepatic veins greater than 2 mm in diameter were identified in 13
(52%) of 25 patients on MR imaging; four patients had single accessory veins
that measured 5 mm or more in diameter (Fig.
1A,1B,1C,1D).
Of these, only one patient underwent right hepatectomy. The accessory vein in
this patient measured 8 mm on MR imaging (for an estimated circumference of 25
mm); the collapsed vessel diameter at hepatectomy measured 14 mm (for an
estimated circumference of 28 mm). The vessel was successfully reimplanted in
the transplant recipient. All accessory hepatic veins greater than 2 mm
detected on MR imaging were seen at surgery, although no other veins required
reimplantation; and, conversely, all accessory hepatic veins greater than 2 mm
at surgery were seen preoperatively.
All patients examined with MR imaging had a normal-appearing right hepatic vein; this finding was confirmed in all nine donors who underwent right heptatectomy.
Biliary Anatomy
Biliary variants were identified in 4 (16%) of 25 patients at MR imaging.
In one of these patients, the common hepatic duct trifurcated into two right
branches and one left hepatic duct (trifurcation pattern); and in two
patients, the right lateral duct drained into the left hepatic duct. One
patient had anomalous drainage of an accessory left hepatic duct into the
common hepatic duct. Of these patients, all but one were excluded as potential
donors on the basis of MR findings.
The patient with suspected biliary trifurcation was accepted as a donor because it was thought preoperatively that a common orifice to the right lateral and medial ducts could be obtained and used to perform a single duct-to-duct biliary anastomosis in the recipient. However, at laparotomy, intraoperative cholangiography showed insufficient right hepatic duct length to enable a single biliary anastomosis in the recipient without jeopardizing the donor's biliary system. Thus, surgery was aborted. In the second of the two patients in whom right hepatectomy was aborted, biliary anatomy was considered normal on MR imaging. At intraoperative cholangiography, anomalous drainage of the right lateral duct to the left duct was seen. When MR images were reviewed in retrospect with knowledge of the surgical findings, the aberrant right lateral duct was identified; preoperatively, it had been thought to be a left hepatic duct branch (Fig. 5A,5B).
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Predicted Right Lobe Weight
Predicted right lobe liver weights on MR imaging for the nine successful
donors averaged 984 g (± 129 g; range, 793-1226 g). Intraoperative
right lobe weights were measured in eight of nine patients. The correlation
coefficient between predicted and measured right lobe weights was 0.90, with
measured weights ranging from 735 to 1090 g. Predicted weights overestimated
measured weights by an average of 81 g (0-136 g), which corresponded to a
difference of 9% (range, 0-15%) of measured weight. In two patients,
transplant surgeons acknowledged reducing the volume of the right lobe excised
in order to preserve residual liver volumes in the donor, thereby knowingly
increasing the discrepancy between predicted and measured values.
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Our results are in agreement with literature supporting the use of MR angiography for the definition of hepatic artery anatomy [23]. In addition to defining accurately the origins of the main and accessory hepatic arteries in all patients except one missed accessory left hepatic artery, we were also able to identify the middle hepatic artery in most patients. Over the course of this study our MR angiography technique evolved, and the contrast dose was reduced from 40 to 20 mL. When compared with conventional angiography, our MR angiography technique was accurate in defining hepatic artery anatomy despite the reduction. By using a 512 imaging matrix for MR angiography, we could visualize intrahepatic arterial branches (Figs. 3A,3B,3C and 4). Nonetheless, the spatial resolution of MR imaging remains inferior to that of digital subtraction angiography. Also, given that MR imaging relies on IV injections rather than intraarterial injections of contrast material, it is not surprising that small hepatic artery branches remain more clearly seen with contrast-enhanced angiography. Despite these limitations, MR angiography has proven in our preliminary experience to be an accurate preoperative test for definition of right and left lobe arterial blood supply in liver donor candidates.
Reportedly found in 6-20% of the healthy population [18, 19], portal vein variants were identified in two patients (8%) in our series. The most common variants—portal trifurcation and origin of the left portal vein from the right anterior branch—require venous patching in the donor and additional anastomoses in the recipient that may increase the risk of operative complications [7]. Therefore, these portal vein variants have been considered reasons for exclusion in our center. Portal vein anatomy can be difficult to assess with multiplanar reformatting because of the orthogonal relationships between the main branches. In our experience, three-dimensional reconstructions with the option of stereoscopic viewing facilitated evaluation of the portal vein anatomy (Fig. 3A,3B,3C).
Many patients have small accessory hepatic veins that typically drain the inferior segments of the right lobe directly into the inferior vena cava. Most of these vessels measure less than 2 mm in diameter and do not require preservation with reimplantation at transplantation. One donor in our series had an accessory hepatic vein measuring 8 mm on MR imaging, and the vein was reimplanted in the recipient without complications. Preoperative MR imaging enabled surgeons to anticipate this additional component of the operation.
Of the MR cholangiographic methods used, we found coronal heavily T2-weighted turbo spin-echo and coronal half-Fourier single-shot turbo spin-echo imaging most helpful for evaluation of biliary anatomy; axial T2-weighted techniques were less useful. Common biliary variants—aberrant drainage of the right lateral duct into the left hepatic duct or at the level of the bifurcation (trifurcation) [20, 21]—were both considered by our surgeons to be contraindications to safe right hepatectomy in the donors. These variants require additional biliary anastomoses in the recipient that may lead to an increased risk of biliary complications [6, 7]. Surgical planning requires the distinction between a low right hepatic duct bifurcation and a trifurcation, because only the latter may complicate donation. In one patient in our series, anomalous drainage of a right lateral duct into the left hepatic duct was not identified preoperatively; in retrospect, it became clear that the anomalous duct had been incorrectly considered a left hepatic duct branch at MR cholangiography (Fig. 5A,5B). In a second candidate, the ductal system was thought to represent biliary trifurcation at MR imaging, and surgical candidacy was equivocal. Intraoperative cholangiography confirmed unfavorable trifurcation anatomy, and surgery was aborted.
For implementation of MR imaging as the sole preoperative imaging modality for living liver donor evaluation, improvements in MR cholangiography are clearly needed. Although the option exists for an accurate definition of biliary anatomy using preoperative endoscopic retrograde cholangiography, that procedure carries a substantial risk of morbidity [24]. Such a risk may be difficult to justify when the test is used as a screening tool in otherwise healthy donor candidates. However, in selected individuals with complex or questionable anatomy, endoscopic retrograde cholangiography may be justified before proceeding to laparotomy. A new approach to MR cholangiography relies on contrast agents that are excreted into the bile ducts for delineation of biliary anatomy using 3D T1-weighted imaging [25, 26]. This approach is being investigated, and other advances in MR cholangiography are anticipated.
Our measurements of liver volumes using MR imaging correlated well with intraoperative findings and are consistent with a previous published report [27]. Accurate measurement requires a clear understanding of the surgical planes used intraoperatively and can be performed by the surgeons directly on 3D workstations. With preoperative knowledge of lobar anatomy and volumes, surgeons also have the option of slightly modifying the surgical plane to ensure adequate transplanted tissue volumes for the recipient and residual liver volumes in the donor.
Studies of preoperative imaging of right lobe donor candidates are limited [6, 8, 11, 28]. Marcos et al. [6] described a preoperative examination that included MR imaging, conventional angiography, liver biopsy, and intraoperative cholangiography and sonography. In their series of 35 cases, they reported that they did not encounter any biliary variations that necessitated donor exclusion [6]. In a separate subsequent report describing their experience with 40 right lobe liver transplantations, the authors [8] described results in patients with anatomic variants that required additional surgical anastomoses and reconstructions. They recommended routine placement of biliary stents in recipients to reduce the otherwise high rate of serious biliary complications, which they reported to occur in 33% of patients when stents were not used. In our series, none of the nine transplant recipients suffered serious biliary complications with the use of a single duct-to-duct biliary anastomosis without stenting [22].
In their series of 22 living donors, Fan et al. [11] reported that all patients underwent preoperative CT (including CT volumetry for measurement of liver volumes), hepatic arteriography, and intraoperative cholangiography; in three patients, additional preoperative laparoscopy and liver biopsy were performed before laparotomy because of abnormal results of serum liver biochemistry or splenomegaly. The authors do not describe patients who were excluded as a result of preoperative imaging and also do not report any cases aborted as a result of intraoperative findings.
In a preliminary report using an MR imaging approach similar to ours to examine potential living liver donors, Goyen et al. [28] observed that of 17 donor candidates examined, eight were eliminated as donors on the basis of MR imaging findings. They also describe one patient in whom a right lateral duct was found intraoperatively that had not been visualized at MR cholangiography. Our results agree with their findings.
Our study has recognized limitations. First, our study sample is relatively small; therefore, not all anatomic variants were represented. For example, none of the patients in our series was identified on MR imaging or contrast-enhanced angiography or at surgery as having a dual arterial blood supply to the right lobe, and thus we did not assess the accuracy of MR imaging in identifying accessory right hepatic arteries. However, our preliminary results illustrate the spectrum of anatomic abnormalities that can play a role in the examination of living liver donor candidates. Our experience particularly highlights the importance of biliary variants in this population. Second, surgery and contrast-enhanced angiography provided confirmation in only a subset of all patients studied. For the remaining patients, no additional imaging was performed, primarily because of the reluctance of the transplant surgeons to subject otherwise healthy individuals to additional testing not deemed necessary. Therefore, our study cannot be used to assess potential false-positive findings with MR imaging. Finally, our surgeons were not kept unaware of MR imaging findings, thereby creating a potential source of bias in the use of operative findings to confirm MR imaging results.
We conclude that a comprehensive MR imaging approach can, in a single examination, evaluate liver parenchyma, extrahepatic abnormalities, and vascular and biliary anatomy, and define lobar volumes essential for surgical planning. In our series, in addition to MR imaging, conventional angiography was performed in the first 13 patients, and all surgical patients underwent intraoperative cholangiography. Conventional angiography is no longer routinely performed and is reserved only for problematic cases. On the basis of our preliminary results, MR imaging can potentially serve as the sole preoperative imaging test for living adult-to-adult liver donor candidates, provided improvements in definition of intrahepatic biliary anatomy, specifically regarding the right lateral duct branch, can be achieved.
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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]
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