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Original Report |
1 Department of Radiology, Division of Abdominal Imaging, University of
Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213.
2 Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
15213.
Received January 28, 2002;
accepted after revision May 10, 2002.
Address correspondence to V. Kapoor.
Abstract
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CONCLUSION. Mangafodipir trisodium—enhanced MR cholangiography accurately shows the biliary anatomy in the livers of donors. Noninvasive preoperative evaluation of the biliary anatomy in donor candidates is important for the detection of common anatomic variants that may require alternative graft-harvesting surgery.
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Recent case reports have suggested evaluating the biliary tract with mangafodipir trisodium—enhanced MR imaging [9]. The purpose of our study was to investigate the utility of MR cholangiography for adequately depicting the biliary anatomy of adult liver donors.
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MR Imaging
Preoperative mangafodipir trisodium—enhanced MR cholangiography was
performed in the eight living donors on a Signa LX 1.5-T MR scanner (General
Electric Medical Systems, Milwaukee, WI). In addition to mangafodipir
trisodium—enhanced MR cholangiography, the MR imaging protocol included
axial T1-weighted gradient-echo in-phase and T2-weighted respiratory-triggered
fat-suppressed fast spin-echo images. Fat-suppressed volumetric
three-dimensional (3D) T1-weighted coronal breath-hold spoiled gradient-echo
images of the biliary tract were obtained 5 min after IV injection of
mangafodipir trisodium (Teslascan; Nycomed Amersham, Princeton, NJ). The
standard dose of mangafodipir trisodium was 5 mmol/kg (0.1 mL/kg; maximal
dose, 15 mL), administered IV (duration, > 1 min). Scans were initiated 5
min after the injection, and two or three sets of volumetric 3D T1-weighted
coronal or oblique coronal images were obtained every 5-10 min. This timing
was based on our prior experience because, to our knowledge, no documented
studies on optimal timing exist. Scanning parameters included TR/TE, 4.7/1.2;
flip angle, 150°; field of view, 300-400 mm with a rectangular field of
view; matrix, 256 x 192 with 24-28 partitions and section thickness of 2
mm, interpolated to 48-56 slices at 1-mm intervals. Axial volumetric 3D
T1-weighted breath-hold spoiled gradient-echo images through the liver were
also obtained with imaging parameters similar to those of coronal images.
For donor evaluation, volume-rendered and maximum-intensity-projection reconstructions of the 3D image sets were performed and recorded on a workstation (Advantage Windows 4.0; General Electric Medical Systems) at the time of the initial examination. Recommendations regarding right versus left hepatectomy were typically discussed with transplantation surgeons before the surgery at the time of the MR examination. All images were available to the transplantation surgeons for interactive viewing on the workstation before surgery.
Complex orthogonal volume-rendered and maximum-intensity-projection views of the right and left hepatic ducts were retrieved for this study and viewed on the workstation. Two experienced MR radiologists unaware of the results of the intraoperative cholangiography evaluated the images to define by consensus the anatomy of the biliary tract. If consensus could not be reached, a third radiologist determined a majority opinion. The hepatic duct anatomy was classified as conventional or anomalous. Conventional anatomy was defined as ducts from Couinaud segments II, III, and IV joining to form the transverse left hepatic duct, ducts from segments VI and VII joining to form the right posterior branch and then draining into the right anterior branch to form the main right hepatic duct, and ducts from segments V and VIII joining to form the right anterior branch. The right posterior hepatic duct normally courses behind the right anterior branch to join at its left (medial) aspect to form the right hepatic duct. The main right and left hepatic ducts join to form the common hepatic duct. Any variation from the conventional anatomy was considered anomalous.
To reach consensus on the branching order of the hepatic ducts after mangafodipir trisodium—enhanced MR cholangiography, we viewed source, volume-rendered, and maximum-intensity-projection images of the hepatic ducts on the workstation. For our study, the first-order hepatic branch was defined at the bifurcation of the common hepatic duct; the second-order branch, at the bifurcation of the right and left hepatic ducts; and the third-order branch, at the bifurcation of the right anterior, right posterior, left lateral, and left medial hepatic ducts.
Surgery and Intraoperative Imaging
Conventional intraoperative cholangiography was performed before and after
partial hepatectomy in all eight donors. After open cholecystectomy and
ligation of the cystic duct, the common hepatic duct was cannulated.
Approximately 5-10 mL of ioversol (Optiray; Mallinckrodt, St. Louis, MO) was
hand injected with fluoroscopic guidance, and a minimum of two images before
resection and one image after resection were obtained in all donors. Although
surgical planning was based on preoperative imaging, the transplantation
surgeons made the final decision regarding the type of hepatectomy to perform
after reviewing the intraoperative cholangiograms.
We used the results of the intraoperative cholangiography as the gold standard for our study. Mangafodipir trisodium—enhanced MR cholangiography results were correlated with intraoperative cholangiography. Both radiologists reached a consensus in all cases without requiring a third investigator for a majority consensus.
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Two of these three donors underwent an extended left hepatectomy (segments I-IV)—one because of anomalous biliary anatomy (Fig. 2A,2B,2C) and the other because of anomalous biliary and arterial anatomy (an accessory right hepatic artery was arising from the superior mesenteric artery) (Fig. 3A,3B). Mangafodipir trisodium—enhanced MR cholangiography correctly identified conventional biliary anatomy in five donors and anatomic variants in three donors and was concordant with the intraoperative cholangiographic findings in eight (100%) of eight patients.
On mangafodipir trisodium—enhanced MR cholangiography, fourth-order branching patterns of the right hepatic duct were seen in four donors (three right anterior ducts and one right posterior hepatic duct); a third-order branching pattern was seen in eight donors (three anterior and five posterior); and a second-order branching pattern was seen in two donors (both right common ducts). On the left, fifth- and fourth-order branching patterns were seen in one donor each (both left lateral ducts); third-order branching patterns, in seven donors (three medial and four lateral ducts); and second-order branching patterns, in six donors (four medial; one each, lateral and left common hepatic ducts). The time interval between injection of mangafodipir trisodium and maximal distention of the hepatic ducts was not constant among the donors. As compared with the intraoperative cholangiography, mangafodipir trisodium—enhanced MR cholangiography did not show the hepatic bile ducts at the periphery of the liver, and the caliber of the contrast-filled ducts was less (physiologic distention on mangafodipir trisodium—enhanced MR cholangiography vs more distention due to injection under pressure during intraoperative cholangiogram). However, the ability of mangafodipir trisodium—enhanced MR cholangiography to depict central hepatic ducts was sufficient for preoperative planning.
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Helical CT cholangiography, MR cholangiography, endoscopic retrograde cholangiography, and percutaneous cholangiography have been used to evaluate the biliary tract in presurgical patients [7, 10, 11]. We assessed a noninvasive method to evaluate the biliary anatomy of liver donors using mangafodipir trisodium—enhanced MR cholangiography that was recently described by another group of researchers [9].
Mangafodipir trisodium is a contrast agent composed of a water-soluble chelate complex salt between a paramagnetic manganese (Mn+2) ion (II) and the ligand dipyridoxyl diphosphate, a vitamin B6 analogue [12]. After IV administration of mangafodipir trisodium, manganese from the dipyridoxyl diphosphate ligand is bound to plasma proteins and secreted with bile by the liver. Fifty-two to sixty-one percent is excreted through the gastrointestinal tract and approximately 14-20%, in the urine [12]. The Mn+2 ion results in shortening of the longitudinal (spin-lattice) or T1 relaxation time, with a concomitant increase in signal intensity of liver on T1-weighted images [13]. Mangafodipir begins to increase the intensity of the liver within 1-3 min of IV injection, with steady-state enhancement in about 5-10 min. Liver enhancement may be seen for up to 24 hr after mangafodipir administration. As the contrast agent is excreted into the bile ducts, there is a concomitant increase in the bile signal intensity on the short-TR sequences. In our experience, the signal intensity in the bile ducts peaks between 5-10 min and then decreases as contrast material accumulates in the gallbladder.
The incidence of biliary tract anatomy variants found in our series correlates with prior reports in the literature. Conventional biliary anatomy was the most common pattern, present in 62.5% of donors. Conventional hepatic biliary anatomy has been reported to occur in 57% of individuals in large studies [7, 11]. The most common biliary variants noted in these studies included the right posterior hepatic duct draining into the left hepatic duct (13-16%) and a trifurcation pattern (12%), with the right posterior hepatic duct draining to the junction of the right anterior and left hepatic ducts into the right (lateral) aspect of the right anterior hepatic duct. Less common variations included an aberrant right posterior hepatic duct draining directly into the common hepatic duct (4%) or into the cystic duct (2%) and accessory right (2%) or left hepatic ducts (1-2%). Some variants, (e.g., the trifurcation pattern) may preclude donor graft harvesting because of the significant increase in the risk of postoperative complications. One patient in our study had a short common right hepatic duct (Fig. 5A,5B,5C), which may be difficult to distinguish from the trifurcation pattern on conventional MR cholangiography.
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The accurate definition of a donor's biliary anatomy is crucial for the preoperative planning by the surgeons for the type of surgery—right versus left hepatectomy. Right hepatectomy was planned in six donors and an extended left hepatectomy, in two donors with anomalous biliary anatomies, on the basis of the preoperative findings of mangafodipir trisodium—enhanced MR cholangiography. As shown in Figures 2A,2B,2C and 3A,3B, two patients underwent different harvesting on the basis of preoperative imaging.
Conventional MR cholangiography has also been used for assessing the intrahepatic biliary anatomy in liver donors [4,5,6]. Two prior studies have shown limitations with conventional MR cholangiography in depicting biliary anatomy [4, 5]. Excellent contrast between the hepatic parenchyma and the mangafodipir trisodium—opacified ducts on T1-weighted images provides better definition of the biliary anatomy than that achieved on conventional MR cholangiography. The increased contrast also greatly aids in distinguishing bile ducts from hepatic vessels. The superior image resolution with the mangafodipir trisodium—enhanced 3D volumetric sequence (voxel size, 1.0 x 1.5 x 1.5 mm) is useful for delineating the smaller branches of the common, right, and left hepatic ducts and may help in patient selection or exclusion. Volume rendering, which is possible with the volumetric data sets from the 3D volumetric mangafodipir trisodium—enhanced studies, and the ability to view the images in multiple orthogonal planes (viewing options with MR cholangiography are limited because of the two-dimensional data set) are also helpful in evaluating the relationships of the right, left, and common hepatic ducts. One particular variant, the short right common hepatic duct simulating a trifurcation pattern, is particularly difficult to depict with conventional MR cholangiography. This variant was successfully delineated in one patient in our series (Fig. 5A,5B,5C). A larger series comparing mangafodipir trisodium—enhanced MR cholangiography and MR cholangiography is needed to determine the relative roles of these techniques in evaluating biliary anatomy. Like conventional MR cholangiography, mangafodipir trisodium—enhanced MR cholangiography allows gadolinium-enhanced imaging of hepatic arterial and venous anatomy during the same examination.
Although helpful as an aid for biliary mapping, mangafodipir trisodium—enhanced MR cholangiography has limitations. Compared with intraoperative cholangiography, mangafodipir trisodium—enhanced MR cholangiography does not reliably depict the peripheral branches of the intrahepatic bile ducts. However, the anatomy of the smaller peripheral branches in living liver donors is not necessary for planning donor graft surgery. It has been suggested that intraoperative cholangiography is inferior to MR cholangiography in complete depiction of the central, right, and left hepatic ducts because of limitations imposed by the surgical field [4], although we did not encounter this limitation on the intraoperative cholangiography in our series.
In conclusion, as correlated with intraoperative cholangiography, our study shows that mangafodipir trisodium—enhanced MR cholangiography accurately depicts living liver donor biliary anatomy. Noninvasive preoperative evaluation of the biliary anatomy in living liver donor candidates is important for detection of common biliary variants that may require alternative graft-harvesting surgery.
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