MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

Clinical outcomes of image-guided therapies in patients with adrenocortical carcinoma: a tertiary referral center retrospective study

BACKGROUND

Image-guided therapies (IGTs) are commonly used in oncology, but their role in adrenocortical carcinoma (ACC) is not well defined.

MATERIALS AND METHODS

A retrospective review of patients with ACC treated with IGTs. We assessed response to therapy using RECIST v1.1, time to next line of systemic therapy, disease control rate (DCR), local tumor progression-free survival (LTPFS), and complications of IGTs (based on the Common Terminology Criteria for Adverse Events [CTCAE] version 5.0).

RESULTS

Our cohort included 26 patients (median age 56 years [range 38-76]; n = 18 female) who had 51 IGT sessions to treat 86 lesions. IGTs modalities included cryoablation (n = 49), microwave ablation (n = 21), combined microwave and bland trans-arterial embolization (n = 8), bland trans-arterial embolization alone (n = 3), radio-embolization (n = 3), and radiofrequency ablation (n = 2). DCR was 81.4% (70 out of 86), of which 66.3% of tumors showed complete response, 18.6% showed progressive disease, 8.1% showed partial response, and 7.0% showed stable disease. LTPFS rates were 73% and 63% at 1 and 2 years, respectively. Fourteen lesions underwent re-ablation for incomplete response on initial treatment. Sixteen patients (61.5%) received new systemic therapy following IGTs, with a median time to systemic therapy of 12.5 months (95% CI: 8.6 months upper limit not reached). There was 1 reported CTCAE grade 3 adverse event (biloma) following IGT.

CONCLUSIONS

IGT use in properly selected patients with ACC is safe and associated with prolonged disease control and delay in the need for systemic therapy.

Magnetic Resonance Cholangiography Diagnosing Post-cholecystectomy Biliary Injuries

OBJECTIVE

This study aimed to determine the diagnostic performance of contrasted magnetic resonance cholangiography for detecting bile duct lesions following cholecystectomy.

MATERIALS AND METHODS

A retrospective case series study was conducted that included patients over 18 years of age with suspected bile duct injury after cholecystectomy, who underwent contrasted magnetic resonance cholangiography, and who also had endoscopic retrograde cholangiopancreatography, surgery, or subsequent clinical follow-up. The images were interpreted by two radiologists who assigned the type of lesion according to the Strasberg classification. Qualitative variables were represented by frequencies and proportions, while quantitative variables were described using measures of central tendency and dispersion. Sensitivity, specificity, and predictive values were assessed, along with interobserver variability, using the kappa index.

RESULTS

We included 20 patients with a median age of 51.5 years (interquartile range: 35), and 14 (70%) were women. In all 20 patients, lesions were identified on magnetic resonance cholangiography, of which 19 were confirmed with the gold standard for a positive predictive value of 100% (hepatobiliary-specific contrast agents) and 92% (extracellular contrast). The most frequent lesions were Strasberg E2 and E4 in five patients each. The kappa index was 1 in determining the presence or absence of bile duct injury and 0.9 in the Strasberg classification.

CONCLUSION

Contrasted magnetic resonance cholangiography is a method with high positive predictive value and almost perfect interobserver agreement for diagnosing bile duct lesions after cholecystectomy.

Extrahepatic abscess and dropped gallstones: a case report and a narrative review of an unusual delayed complication of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the most common minimally invasive abdominal surgery procedure performed in Western countries; it offers several advantages over laparotomy but still carries some risks, such as intraoperative spillage of bile and gallstones. Diagnosis of dropped gallstones could be challenging, it is frequently delayed, and this can lead to further complications such as abscesses formation.

METHODS

We report the history of a 51-year-old male with persistent dull abdominal pain in association to appetite loss, vomiting episodes and changes in regular bowel habits, a past medical history of laparoscopic cholecystectomy for biliary lithiasis (1.5 years earlier) and minimum elevation of inflammatory markers and gamma-GT values.

RESULTS

Ultrasound examination showed perihepatic stones and magnetic resonance imaging revealed the presence of multiple perihepatic abscesses, findings compatible with fibrotic-inflammatory phenomena from 'dropped gallstones'. A re-laparoscopy was then performed with an abscess collection containing multiple gallstones; a liver wedge resection was also required due to strong adhesions. At follow up, the patient had improved both on clinical and biochemical perspective.

CONCLUSION

Dropped gallstones are an underreported cause of morbidity and diagnostic dilemmas in subjects who underwent to laparoscopic cholecystectomy, in relation to infectious complications that can occur even several months or years after surgery. Imaging represents a valuable aid in the correct non-invasive diagnostic process, but proper awareness of this insidious condition is necessary. Surgeons and radiologists should always consider this eventuality in the differential diagnosis of a patient presenting with abdominal abscesses and history of cholecystectomy.

Comparison of the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy

OBJECTIVE

To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC).

METHODS

From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation.

RESULTS

The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05).

CONCLUSION

The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.

Imaging of the biliary tract

PURPOSE OF REVIEW

Magnetic resonance cholangiopancreatography (MRCP) has become the reference examination for the exploration of the biliary tract and has replaced endoscopic cholangiography for the analysis of the biliary tract because of its equivalent performance and its noninvasive character.

RECENT FINDINGS

Based on the International Primary Sclerosing Cholangitis (PSC) Study Group recommendations for MR imaging in PSC, two protocols can be distinguished for the imaging of biliary tract: a basic protocol and a more complete protocol. It is essential to know the main pitfalls in order not to wrongly describe biliary anomalies. In addition to the excellent performance of MR imaging with MRCP in analyzing the anatomy and the anomalies of the biliary tree, complementary techniques have recently been developed. Several MR prognostic factors have been described. New hepato-specific contrast agents are now available for assessment of the general and segmental liver function. MR Elastography and Diffusion-weighted MR sequences are accurate to evaluate the degree of hepatic fibrosis. Finally, images obtained in MRCP can be postprocessed by a software that will analyze and model the biliary tree in order to quantitatively evaluate the biliary system.

SUMMARY

Magnetic resonance imaging with its recent developments becomes by now an essential tool for the evaluation of biliary diseases.

Iatrogenic bile duct injuries after laparoscopic cholecystectomy: evaluation by MRCP before management

Background

Iatrogenic bile duct injuries are unusual but possibly associated with fatal complications with increased incidence since the introduction of laparoscopic cholecystectomy. Appropriate estimation of these injuries is essential for proper management. Imaging is vital for the initial diagnosis, extent assessment and consequently, treatment guidance of bile duct injury with an ideal outcome. In this study, MRCP was carried out in 37 cases (28 females and 9 males, age range from 19 to 58 years) with suspected BDI following laparoscopic cholecystectomy. MRCP images were assessed for bile duct transection injury, strictures, biliary leakage, and intrahepatic biliary radicles (IHBR) dilatation. In positive cases, Strasberg classification system was used with the definitive diagnosis was done regarding the surgical findings and/or findings on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC).

Results

Our study includes 37 cases with biliary injuries. On MRCP our cases were stratified regarding the Strasberg-Bismuth classification into five types (A to E). Most BDIs were type E2 (29.7%), followed by type E1 (18.9%), type A (16.2%), type E3 (10.8%), type E4 (8.2%), type C (5.4%), and type D and finally type E5 and B injuries with each one representing 2.7%. Twenty cases presented with biliary leakage and seventeen with bile duct obstruction, whether duct ligation or stricture.

Conclusion

MRCP is an essential imaging modality for assessment of iatrogenic BDIs enabling the radiologists to classify these injuries and helps to govern the management.

Radiologic findings of biliary complications post liver transplantation

Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.

Imaging of benign biliary pathologies

Pathologies of the biliary tree include a wide-spectrum of benign and malignant processes. The differential for benign disease includes congenital and acquired disease with variable prognosis and management pathways. Given the ability to mimic malignancy, benign processes are difficult to diagnose by imaging. Direct cholangiography techniques with tissue sampling are the gold standards for the diagnosis of benign and malignant biliary pathologies. Non-invasive imaging with ultrasound offers a first-line diagnostic tool while MRI/MRCP offers higher specificity for identifying underlying pathology and distinguishing from malignant disease. In this review, we focus on the imaging appearance of dilatation, cystic anomalies obstruction, inflammation, ischemia, strictures, pneumobilia, and hemobilia to help construct a differential for benign processes.