MR cholangiography of congenital biliary malformations in infancy

We presented MR cholangiography (MRC) of congenital biliary malformations in infancy. MRC was obtained during induced sleeping. In two cases of congenital dilation of bile duct, MRC revealed cystic or spindle dilatation of intra- and extra hepatic bile ducts. In one biliary atresia, MRC revealed the serpentine gall bladder and cystic dilatation of the extrahepatic bile duct without connection to the dilated hilar bile duct. MR cholangiography, which can be obtained noninvasively, is useful for the diagnosis and the preoperative assessment of congenital biliary malformations in infancy.     

Fibrotic stricture of the extrapancreatic biliary tract: a new complication of acute pancreatitis. Two cases

Two cases of fibrotic stricture of the extrapancreatic common bile duct were observed 3 and 5.5 months after severe acute alcoholic pancreatitis. The diagnosis was made by endoscopic retrograde cholangiography in both cases. Although colonic or ureteric stenosis have been reported after acute pancreatitis, this is the first report of extrapancreatic biliary stricture occurring after acute pancreatitis. The strictures could have arisen by either an enzymatic or ischemic mechanism. Outcome was favorable after surgical hepaticojejunostomy.     

Cardiac transplantation in patients aged 60 years or older

The indications and best technique for peroperative cholangiography during laparoscopic cholecystectomy remain unclear, but the operation has been associated with an increased use of preoperative endoscopic retrograde cholangiography. Cystic duct cholangiography, particularly in the hands of the trainee, can be time consuming, and bile duct injury may be caused by attempts to cannulate the cystic duct. This study analyses 113 consecutive patients undergoing peroperative cholangiography through the gallbladder, or cholecystocholangiography. It was successful in 92 (81.4%) patients, the procedure adding less than 10 min to the operating time. There were no cholangiogram-related complications. Common anatomical variations included both short and particularly wide cystic ducts. This information helps to minimize the risk of damage to the common bile duct. This study demonstrates that cholecystocholangiography is a safe, simple, and effective alternative to cystic duct cholangiography with virtually no "learning curve." It provides a "road-map" of biliary anatomy and identifies common bile duct stones prior to the commencement of dissection. Unsuccessful cholecystocholangiography does not preclude the use of cystic duct cholangiography later in the operation. Difficult anatomy is demonstrated prior to dissection. When unsuspected bile duct calculi necessitate open exploration, further laparoscopic dissection is avoided.     

Preoperative diagnosis of laparoscopic cholecystectomy. Is there an indication for routine intravenous cholangiography?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Common bile ductal carcinoma, hilar cholangiocarcinoma: evaluation with MR cholangiography

Recently, imaging of bile ductal carcinoma has been improved by new techniques such as MR cholangiography. Cancer invasion along the bile duct has been demonstrated by MR cholangiography. MR cholangiography will be useful for obtaining more detailed information in the diagnosis and staging of common bile ductal carcinoma, hilar cholangiocarcinoma.     

Mucinous biliary obstruction associated with a cystic adenocarcinoma of the pancreas

Obstruction of the biliary tree by large amounts of mucinous material is reported in a patient with a mucin-producing cystic adenocarcinoma of the pancreas invading the common bile duct. Although preoperative endoscopic retrograde cholangiography suggested bile duct invasion, mucinous obstruction, as in the previous cases in which it has been reported, was not suspected. Mucinous obstruction, although unusual, should be considered in patients with cystic carcinomas of the pancreas in the presence of jaundice or episodes of cholangitis.     

Value of intraoperative cholangiography in laparoscopic cholecystectomy

By introduction of laparoscopic cholecystectomy, an increase of accidental common bile duct injuries up to 1.2% has been reported. In the present study of 325 cholecystectomies we evaluated whether mandatory intraoperative cholangiography (IOC) can reduce the rate of accidental bile duct injuries or, at least, identify them early in order to make an adequate repair possible. In addition 163 patients underwent preoperative intravenous cholangiography (IVC). Both imaging techniques were compared with regard to their sensitivity in the detection of anatomic variations and stones of the extrahepatic bile duct system. Our results demonstrated a great advantage of the IOC. The IOC was feasible in 98.1% of the cases and presented a complete depiction of the extrahepatic bile duct system in 99.3%. IVCs showed the biliary system in 91.4% of the cases but without visualization of the cystic duct in 51.5% and the hepatic confluence in 16%. Anatomic variations of the bile duct system which consecutively influenced the operative management were found in additional 27.6% exclusively by IOC. 71.4% of bile duct stones were not detected by IVC. The intraoperative time consumption of IOC was unimportant. The x-ray-load was clearly lower by a factor of 3.5. There was no complication after IOC. In comparison, 6.1% of patients demonstrated an anaphylactic reaction by IVC. One common duct injury (0.3%) was detected intraoperatively by IOC and at the same operation treated without postoperative complications. In conclusion, we recommend an IOC in addition to a thorough preoperative ultrasound-examination. By this technique intraoperatively identified stones of the common bile duct can be sufficiently treated by postoperative endoscopic extraction and anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.     

Routine intraoperative cholangiography and its contribution to the selective cholangiographer

Routine intraoperative cholangiography (IOC) during cholecystectomy is controversial. In order to address this debate, we asked the following questions: What intraoperative information is provided to the surgeon? What IOC criteria or standards are necessary to observe this information? Between 1990 and 1993, 624 laparoscopic cholangiography (LC) cases were performed at Virginia Mason Hospital, during which 86% (535) of the patients underwent successfully performed IOCs. Each of these cholangiograms was sought, and 420 (78%) were reviewed by a radiologist and a surgeon. Specific items involved the presence or absence of filling defects, bile duct diameter, contrast leaks, flow into the duodenum, benign or malignant stricture, contrast in a portion of the pancreatic duct, and anomalous ducts. "Relevant findings" were defined as filling defects, stricture, leaks, and the following anomalous ducts: a bile duct from the right side of the liver entering near or into the cystic duct. The entire biliary tree was visualized in 86%, and the bifurcation was seen in 95% of the cases. Considering these deficiencies, we found a 10% incidence of filling defects. Anomalies were common in the biliary tree (39%), and knowledge of the presence of some of them are important for safe dissection (at least 4%). Also, at least 68 relevant findings would have been missed in 420 LC cases without IOC. If the IOC had not visualized the biliary tree proximal to the cystic duct, 30 of 68 or 44% of these findings would not have been observed. If an IOC is performed on a routine or selective basis, the study should visualize the entire biliary tree.     

Cholangiopancreatography with magnetic resonance. Clinical use of a new "inversion-recovery" sequence

This study was aimed at correlating the yield of a three-dimensional (3D) inversion-recovery (IR) turbo spin-echo MR cholangiopancreatography (MRCP) sequence with that of ERCP and PTC in the imaging of the normal and abnormal biliopancreatic tract. Thirty patients with suspected biliary and pancreatic diseases were examined with MRCP first and then with ERCP or PTC; they were also submitted to US, CT and conventional MR studies and in 5 of them CT cholangiography was also performed. Five patients were normal and 25 had various obstructive abnormalities: 5 patients had gallbladder stones, 8 common bile duct stones, 5 a cholangiocarcinoma and 7 an adenocarcinoma of the pancreatic head or papilla. MRCP was performed with a superconductive magnet at 0.5 T, with volumetric images on coronal planes acquired using an IR turbo SE sequence (TR 2500, TE 1000, TF 89, 4 NEX) with respiratory triggering and vascular presaturation. Segmental intrahepatic bile ducts were correctly depicted in all the patients with benign or malignant obstruction of the common bile duct, but with some respiratory artifacts. Common bile duct stones were correctly depicted in 7 of 8 patients, but studying also the single coronal slices. With this method, the stones were clearly demonstrated in 22 examined gallbladders. Neoplastic obstruction and the obstruction level were correctly identified in all patients. Pancreatic ducts were shown in normal patients and in 8 of 13 patients with neoplastic or lithiasic obstruction of the common bile duct mainly on the pancreatic head. ERCP was carried out successfully in 5 patients with common bile duct stones and in 7 patients with neoplastic obstruction; in the other cancer patients, PTC was necessary. To conclude, respiratory-triggered 3D IR turbo spin-echo MRCP is a noninvasive technique to study mostly biliary conditions which yields similar information to ERCP and PTC in a large number of patients. Moreover, this sequence can be used with midfield MR units to study the obstruction of the biliary and pancreatic ducts not only when invasive techniques fail, but also routinely.     

MR cholangiography: technical advances and clinical applications

Magnetic resonance (MR) cholangiography is a fast, accurate, noninvasive alternative to endoscopic retrograde cholangiography (ERC) in the evaluation of biliary tract disease. Technical improvements in imaging sequences (eg, half-Fourier rapid acquisition with relaxation enhancement) and use of phased-array coils allow high-quality imaging comparable to that available with ERC. In choledocholithiasis, common bile duct stones as small as 2 mm can be detected with MR cholangiography and appear as low-signal-intensity foci within the high-signal-intensity bile. MR cholangiography may help establish the diagnosis of malignant obstruction and is useful in the evaluation of patients in whom ERC was unsuccessful or incomplete. The role of MR cholangiography in the evaluation of intrahepatic duct disease continues to evolve. MR cholangiography plays a crucial role in evaluating postsurgical biliary tract alterations and can be used to demonstrate a variety of congenital anomalies of the biliary tract (eg, aberrant ducts, choledochal cysts, pancreas divisum). In addition, intentional or incidental imaging of the gallbladder with MR cholangiography can be used to identify calculi or help determine the presence and extent of neoplastic disease.     

Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study

A prospective, controlled, randomized trial was conducted in 275 patients with symptomatic gall stone disease, whose history, laboratory data or sonographical findings did not suggest common bile duct stones. Of these patients, 137 did not undergo intraoperative fluoroscopic cholangiography (IOC), but in the remaining 138 patients IOC was attempted. In 111 cases (80.4%) the biliary system was sufficiently visualized. In 3 patients (2.7%) calculi in the cystic or common bile duct were diagnosed, which would have been overlooked without IOC. IOC was false-positive in one case. One year after the operation the patients were asked to return for a follow-up examination. Three patients in the group without IOC had had symptomatic passage of a stone, and one had a common bile duct stone removed by endoscopic papillotomy. A retained stone was discussed as etiology for a pancreatitis in a fifth patient in this group. No patient sustained long-term sequelae from the retained common bile duct stones. None of the patients in the IOC group had evidence of cholangiolithiasis at follow-up. There was no difference between the study groups concerning the incidence of post-operative complications. The operations with IOC lasted significantly longer (92 +/- 31 min vs 77 +/- 28 min). According to our data and those published earlier, the additional financial and logistic expenditure associated with routine IOC is not justified. Patients with the preoperative suspicion of a common bile duct stone should have endoscopic bile duct clearance (ERCP and EPT) prior to cholecystectomy.     

Bile duct variations in partial liver transplantations from living-related donors

The aim of this paper was to present anatomic variations of bile ducts and their effect on the perioperative course of living-related donors in partial liver transplantations in children. Liver fragments for partial transplantation were harvested from 41 related donors. Segments II and III were harvested from 35 and segments II, III, and IV from 6 donors. During the procedure, cholangiography through cystic duct was performed revealing a normal anatomy of the bile ducts in 33 (80.5%) cases. The rest of the donors showed anatomic variations. There was only one case of complications related to the bile duct. The intraoperative diagnosis of anatomic variations allowed for safe partial liver harvesting.     

Laparoscopic intracorporeal ultrasound cystic duct length measurement: a new technique to prevent common bile duct injuries

The incidence of common bile duct injury remains high. Intracorporeal ultrasound mapping of cystic duct anatomy, prior to laparoscopic cholecystectomy (LC), may assist surgeons in avoiding common bile duct injuries. A technique for intraoperative intracorporeal predissection ultrasound imaging (IIPUI) of the cystic duct length was tested. During LC, gallbladder adhesions were lysed, and with the gallbladder retracted by grasping forceps, the ultrasound examination was performed. Using a 7.5-MHz articulating ultrasound probe, visualization of the extrahepatic biliary tree was obtained in five separate planes. Success in visualizing each plane, time for ultrasound examination, and predissection accuracy of cystic duct length measurement were recorded. Intraoperative cholangiography or direct measurement of the dissected cystic duct was used to determine accuracy of the ultrasound cystic duct length estimates. Forty-three patients underwent IIPUI during LC. The time required to perform the examination varied, with a range of 5 to 17 min (mean 9.5 min). Success of visualization in planes 1 through 5 was 44%, 95%, 98%, 98%, and 70%, respectively. The accuracy rate for cystic duct length ultrasound measurement was 87.1%. No complications related to the examination were observed. In this preliminary study, cystic duct length was determined by predissection intracorporeal ultrasound with a high level of accuracy. Predissection imaging may assist in preventing common bile duct injury during LC.     

Current status of surgical transduodenal papillotomy

The treatment of biliary lithiasis has changed during the past 20 years. Cholecystectomy remains the gold standard for cholelithiasis, but many options are available for calculi of the common bile duct. Among them are surgical open or laparoscopic choledochotomy, biliary-enteric anastomosis, transduodenal sphincterotomy (TDS), endoscopic sphincterotomy. With the aim to describe the current place of TDS, we reviewed the patients operated on in our department between 1976 and 1992. We found 78 patients with a mean age of 58 years (26-89 years). 34 (43%) of them had acute cholecystitis, with 26 being operated on urgently. 47 (60%) were jaundiced, 15 (19%) had pancreatitis and 12 (15%) had cholangitis before operation. Indications for TDS have been impacted stone or absence of progression of the contrast medium on intraoperative cholangiography in 71 patients (91%). 3 patients died (1 pulmonary embolism, 1 sepsis of pulmonary origin, 1 MOF syndrome complicating preoperative necrotizing pancreatitis). 30 patients (38%) had complications, of which 20 were directly related to TDS. Hemorrhage occurred in 4 cases, and resolved spontaneously without transfusion. Hyperamylasemia occurred in 17 instances, but clinical pancreatitis developed in only 1 case, with complete resolution. 1 duodenal fistula healed after conservative therapy. No death is attributable directly to TDS. Today, the importance of endoscopic sphincterotomy is increasing. This retrospective study shows that TDS, if performed with caution, does not increase the operative risks even in emergent operations. During surgical exploration of the common bile duct, TDS is indicated to remove an impacted stone, or as a bilio-enteric anastomosis if multiple stones are present with a thin common duct.(ABSTRACT TRUNCATED AT 250 WORDS)     

Chronic pancreatitis: a cause of cholestasis

The bile ducts were visualised using endoscopic retrograde cholangiopancreatography (ERCP), percutaneous or intravenous cholangiography in 38 patients with non-gallstone chronic pancreatitis. Stenosis of the intrapancreatic portion of the distal common bile duct was demonstrated in 11 patients. Ten of the 11 developed transient cholestasis during exacerbations of their chronic pancreatitis. In six cholestasis eventually persisted requiring surgical relief. Secondary biliary cirrhosis was present in one patient. No evidence of pancreatic carcinoma was found in the patients explored surgically. Ten of the patients are alive more than one year after diagnosis. Chronic pancreatitis was of alcoholic aetiology in 10 of the patients with biliary stenosis. Cholestasis and biliary stricture are common but poorly recognised complications of non-gallstone chronic pancreatitis, especially when pancreatitis is severe and due to alcohol.     

Case report: malignant haemobilia detected in the gallbladder--retrograde cholangiographic findings

Haemobilia caused by gallbladder cancer is a rare condition and cholangiography rarely detects gallbladder haemorrhage because cancer cells or blood clots obstruct the cystic duct. We describe a patient with haemobilia caused by gallbladder cancer, in whom retrograde cholangiography showed a cast-like filling defect in the common bile duct and, in addition, several string-like defects in the gallbladder. The string-like defects appeared to be streams of clotted blood flowing towards the common bile duct in this case of relatively minor haemorrhage.     

MR cholangiography in the examination of patients with biliary-enteric anastomoses

OBJECTIVE: The aim of our study was to determine the role of MR cholangiography in the noninvasive examination of patients with biliary-enteric anastomoses. SUBJECTS AND METHODS: Twenty-four patients (nine men and 15 women; mean age, 68.9 years old) with biliary-enteric anastomoses underwent MR cholangiography. We used a fat-suppressed three-dimensional turbo spin-echo sequence (3000/700 [TR/TE]; echo train length, 128) with no breath-hold, optimized with a 0.5-T magnet. Imaging studies were performed because of scheduled follow-up (five patients), persistent jaundice (six patients), cholangitis and abnormal liver function (eight patients), and a combination of transient jaundice, epigastric pain, and abnormal liver function (five patients). RESULTS: Image quality was graded from optimal to good in 21 (88%) of 24 cases and poor in three (13%) of 24 cases. The degree of bile duct dilatation was correctly assessed, with complete agreement between the two observers in all cases. MR cholangiography correctly showed bile duct irregularities in six of the eight patients with cholangitis (kappa = .59), anastomotic strictures in all 19 patients with strictures (kappa = .86), and 3- to 15-mm stones in nine of 10 patients (kappa = .95). A slight overestimation of the strictures occurred in four of the 19 cases with strictures. CONCLUSION: MR cholangiography is a reliable imaging technique for the examination of patients with biliary-enteric anastomoses.     

Selected versus routine use of intraoperative cholangiography during laparoscopic cholecystectomy

Routine use of intraoperative cholangiography during laparoscopic cholecystectomy is still widely advocated and standard in many departments, however, this is discussed controversially. We have developed a new diagnostic strategy to detect bile duct stones. The concept is based on an ultrasound examination and on a screening for the presence of six risk indicators of choledocholithiasis. 120 consecutive patients undergoing laparoscopic cholecystectomy were prospectively screened for the presence of six risk indicators of choledocholithiasis: history of jaundice; history of pancreatitis; hyperbilirubinemia; hyperamylasemia; dilated bile duct; unclear ultrasound findings. The sensitivity of ultrasound and of intraoperative cholangiography in diagnosing bile duct stones was also evaluated. For the detection of bile duct stones, the sensitivity was 77% for ultrasound and 100% for intraoperative cholangiography. 20% of all patients had at least one risk indicator. The presence of a risk indicator correlated significantly with the presence of choledocholithiasis (p < 0.01, chi-square-test). The negative predictive value of the total set of risk indicators was 100%. Following our diagnostic concept, we would have avoided 80% of intraoperative cholangiographies without missing a stone in the bile duct. This study lends further support to the view that the routine use of intraoperative cholangiography in patients undergoing laparoscopic cholecystectomy is not necessary.     

MR cholangiography in primary sclerosing cholangitis

OBJECTIVE: The purpose of this study was to evaluate the ability of MR cholangiography to reveal the characteristics of biliary abnormalities found in primary sclerosing cholangitis. CONCLUSION: Our results suggest that MR cholangiography could be useful in the diagnosis of primary sclerosing cholangitis. Slightly dilated peripheral bile ducts unconnected to the central ducts in several hepatic segments are a characteristic MR sign of primary sclerosing cholangitis. However, other studies are necessary to establish the usefulness of MR cholangiography in relation to other imaging techniques for evaluating primary sclerosing cholangitis.     

Choledocholithiasis after cholecystectomy

Concrements were found in the ducts of 172 patients subjected to secondary surgical interventions on bile ducts. The detailed analysis of the data failed to answer the question whether the stones could be formed immediately in the ducts without such conditions as a mechanical obstacle for the outflow of bile, the presence of foreign bodies and a big stump of the cystic duct. Such a formation of stones can take place in very few cases. The authors have shown that control cholangiography and especially choledochoscopy can reduce the danger to leave the stones in the ducts, but does not eliminate the danger completely. Nevertheless they think that now it is possible to lessen the indications for biliodigestive anastomoses in choledocholithiasis since the retained stones can be revealed within the first days after surgery and, as a rule, removed with instruments or by other methods using the drainage left in the ducts.