Gadoxetate Disodium-Enhanced Magnetic Resonance Cholangiography for the Noninvasive Detection of an Active Bile Duct Leak After Laparoscopic Cholecystectomy:

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

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

Hepatobiliary Scintigraphy-Role in Preliminary Diagnosis and Management of Biliary Tract Injuries

PURPOSE

This study was conducted to identify the role of hepatobiliary scintigraphy (HBS) in the management of biliary tract injuries.

METHODS

We retrospectively studied 54 patients (28 male and 26 female patients) aged 3 to 78 years with evidence of bile leak on HBS performed between January 2015 and October 2017. Following intravenous injection of Tc-mebrofenin, dynamic images were acquired for 30 minutes followed by static images until 24 hours. SPECT/CT was performed in patients with suspicion of bile leak on the planar images. Patients were classified as those with free intraperitoneal or localized bile leak. Any abdominal drain output was documented, and its statistical significance was assessed using Mann-Whitney U test. Subsequent management was also documented.

RESULTS

Of the 54 patients, 28 demonstrated free intraperitoneal bile leak and 26 localized leak on HBS. Thirty-four patients (24 with free intraperitoneal leak and 10 with localized leak) had an abdominal drain. Drain output was significantly higher in patients with free intraperitoneal leak compared with patients with localized leak (370 vs 78 mL/d per patient, P < 0.01). All patients with free intraperitoneal bile leak underwent interventional procedures such as endoscopic retrograde cholangiopancreatography and stenting or Roux-en-Y hepaticojejunostomy later on. Patients with localized bile leak were managed conservatively and were free of symptoms at 1-year follow-up.

CONCLUSIONS

Our findings indicate that, in addition to detecting biliary leak, HBS may be used to identify patients with localized bile leak (48% of patients in our study) who do not require active intervention.

Gd-EOB-DTP-enhanced MRC in the preoperative percutaneous management of intra and extrahepatic biliary leakages: does it matter?

Postoperative bile leakage is a common complication of abdominal surgical procedures and a precise localization of is important to choose the best management. Many techniques are available to correctly identify bile leaks, including ultrasound (US), computed tomography (CT) or magnetic resonance imaging (MRI), being the latter the best to clearly depict "active" bile leakages. This paper presents the state of the art algorithm in the detection of biliary leakages in order to plan a percutaneous biliary drainage focusing on widely available and safe contrast agent, the Gb-EOB-DPA. We consider its pharmacokinetic properties and impact in biliary imaging explain current debates to optimize image quality. We report common sites of leakage after surgery with special considerations in cirrhotic liver to show what interventional radiologists should look to easily detect bile leaks.

Peritoneal and pleural fluids may appear hyperintense on hepatobiliary phase using hepatobiliary MR contrast agents

AIM

To describe the effect of hepatobiliary-specific MR imaging contrast agent (HBCA) administration on the signal intensity of peritoneal and pleural fluid effusions on T1-weighted MR images.

MATERIALS AND METHODS

From October 2015 to May 2016 139 patients (mean 60±10 years old, 69 % males) with peritoneal or pleural effusions without biliary leakage who underwent HBCA-MRI (Gd-BOPTA or Gd-EOB-DTPA) at 1.5T and 3T were included from two centres. The fluid signal intensity was classified as hypo/iso/hyperintense before/after HBCA administration. The relative signal enhancement (RE) was calculated.

RESULTS

On hepatobiliary phase (HBP), peritoneal fluids appeared hyper/isointense in 88-100 % and pleural effusions in 100 % of the patients following Gd-BOPTA administration. All fluids remained hypointense following Gd-EOB-DTPA. The signal intensity of fluids increased with both HBCA but RE was significantly higher following Gd-BOPTA (p=0.002 to <0.001). RE was correlated with HBP acquisition time-point (r=0.42, p<0.001 and r=0.50, p=0.033 for peritoneal and pleural fluids).

CONCLUSION

The signal intensity of pleural and peritoneal fluids progressively increases following HBCA administration in the absence of biliary leakage. Due to its later hepatobiliary phase, this is more pronounced after Gd-BOPTA injection, leading to fluid hyperintensity that is not observed after Gd-EOB-DTPA injection.

KEY POINTS

• Fluids appear hyper/isointense on HBP in most patients after Gd-BOPTA injection. • Fluids remain hypointense on HBP after Gd-EOB-DTPA injection. • RE of fluids increases with time after liver-specific Gd injection. • RE of fluids is higher in patients with chronic liver disease.

Leakage of Hepaticojejunal Anastomosis: Reoperation

BACKGROUND

Leakage of a hepaticojejunal anastomosis is a rare event with potential major morbidity. Surgeons must be aware of the technical armamentarium and pitfalls in revisional surgery for hepaticojejunal anastomosis leakage.

METHODS

Review of the available literature and discussion of technical details based on experience and expert opinion.

RESULTS

Early bile leaks as well as failed interventional therapy are indications for reoperation. Almost all reports only mention rates of leakage as a secondary endpoint but do not report details of treatment and outcome. Few authors have compared outcome after reoperation versus interventional approaches in observational studies, with the latter resulting in lower morbidity. The complex and individual situation of the complication makes evidence-based argumentation difficult; this is why personal expert opinions have to be taken into account in this review. The technical aspects and pitfalls of revisional surgery are outlined but represent anecdotal evidence as comparative studies are lacking.

CONCLUSION

Bile leak after bilioenteric anastomosis is a rare condition that requires differentiated workup and therapy. Early leaks usually result from technical problems and are amenable to repair by reoperation. Reoperation technique can only be discussed on a low evidence level.

The Impact of Gd-Eob-Dtpa-Enhanced MR Cholangiography in Biliary Diseases: Comparison with T2-Weighted MR Cholangiopancreatography

BACKGROUND

Contrast enhanced magnetic resonance cholangiography is a novel technique and promising method in demonstrating biliary tree anatomy and evaluating biliary disorders. However, to date, there are a limited number of studies that have focused on the impact of this technique.

AIMS

We aimed to evaluate the additional role of contrast enhanced MR cholangiography (MRC) and compare contrast enhanced MRC with T2-weighted (w) magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of biliary disorders.

STUDY DESIGN

Diagnostic accuracy study.

METHODS

The T2w-MRCP and contrast enhanced MRC sequences of 31 patients whose gold standard test results were available were scored visually for the existence of pathological findings with regard to any of the biliary diseases. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) was used as the contrast agent. The correlation values were determined according to the statistical analysis made from those scores and the sensitivity, specificity and accuracy values of each sequence were detected as well.

RESULTS

We detected that the correlation values with gold standard methods of contrast enhanced MRC sequences were significantly higher than the ones of T2w-MRCP sequences. The correlation ratios of T2w-MRCP sequences were between 26 and 34%, while those for contrast enhanced MRC sequences were between 81 and 83% for the first reader and the correlation ratios of T2w-MRCP sequences were between 10 and 61%, whereas those of contrast enhanced MRC were between 79 and 81% for the second reader The mean sensitivity, specificity and accuracy values of T2w-MRCP sequences were 14.3-42.5%, 85-89.2% and 59.3-72.5%, respectively, while the mean sensitivity, specificity and accuracy values of contrast enhanced MRC sequences were 100%, 86.7% and 93.2-93.3%, respectively.

CONCLUSION

We suggest that obtaining of contrast enhanced MRC sequences in addition to the T2w-MRCP can be useful in the diagnosis of many diseases in relation with biliary tree.

Accumulation of Bile in the Gallbladder: Evaluation by means of Serial Dynamic Contrast-Enhanced Magnetic Resonance Cholangiography with Gadolinium Ethoxybenzyl Diethylenetriaminepentaacetic Acid

The aim of this study was to evaluate the process of biliary excretion of gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) into the biliary tract and to assess the accumulation patterns in the gallbladder using MR cholangiography obtained with Gd-EOB-DTPA which is a liver-specific hepatobiliary contrast agent. Seventy-five patients underwent Gd-EOB-DTPA enhanced MR imaging. Serial multiphasic hepatobiliary phase imaging was qualitatively reviewed to evaluate the process of the biliary excretion of contrast agent into the bile duct and the gallbladder. The accumulation pattern of contrast agent into gallbladder was classified into two groups (group 1 = orthodromic type and group 2 = delayed type). Furthermore, the results in differences of the presence of T1 hyperintense bile or sludge of gallbladder, gall stones, wall thickening of gallbladder, chronic liver disease, and liver cirrhosis between two groups were compared. Forty-eight of 75 patients (64%) were included in group 1, and remaining 27 (36%) were in group 2. The frequency of the presence of T1 hyperintense bile or sludge of gallbladder was significantly higher in patients with group 2 than that in patients with group 1 (P = 0.041). MR cholangiography obtained with Gd-EOB-DTPA showed that there may be an association between the biliary accumulation pattern in the gallbladder and the pathological condition.

Detection and localization of bile duct leaks after cholecystectomy using Gd-EOB-DTPA-enhanced MR cholangiography: retrospective study of 16 patients

OBJECTIVE

To determine if gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) cholangiography can detect and localize bile duct leaks in postcholecystectomy patients.

MATERIAL AND METHODS

Four blinded independent radiologists performed a retrospective review of 16 consecutive patients who underwent MR cholangiography with intravenous Gd-EOB-DTPA for the evaluation of possible biliary leak. Image quality, ductal opacification, and presence and location of any bile leak were evaluated. An independent observer determined the criterion standard using a consensus of all chart, clinical, and imaging findings.

RESULTS

All 6 bile leaks confirmed at endoscopic retrograde cholangiopancreatography were diagnosed by all reviewers (sensitivity, 100%). Of the 10 patients with no leak, only one reader incorrectly diagnosed a bile leak in a single case (specificity, 98%). The accuracy for detection of the site of leak with Gd-EOB-DTPA-enhanced MR cholangiography was 80%.

CONCLUSION

Gadolinium-EOB-DTPA-enhanced MR can detect bile leaks with a high sensitivity and specificity.

Magnetic resonance imaging of the pediatric pancreaticobiliary system

Magnetic resonance cholangiopancreatography (MRCP) is an extremely useful tool for evaluating a wide variety of disorders affecting the pancreaticobiliary system in neonates/infants, children, and adolescents. This imaging technique has numerous distinct advantages over alternative diagnostic modalities, such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography, including its noninvasive nature and lack of ionizing radiation. Such advantages make MRCP the preferred first-line method for advanced imaging the pediatric pancreaticobiliary tree, after ultrasonography. This article presents a contemporary review of the use of MRCP in the pediatric population, including techniques, indications, and the imaging appearances of common and uncommon pediatric disorders.

Non-invasive detection of biliary leaks using Gd-EOB-DTPA-enhanced MR cholangiography: comparison with T2-weighted MR cholangiography

Objective

To evaluate the added role of T1-weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance cholangiography (MRC) compared with T2-weighted MRC (T2w-MRC) in the detection of biliary leaks.

Methods

Ninety-nine patients with suspected biliary complications underwent routine T2w-MRC and T1w contrast-enhanced (CE) MRC using Gd-EOB-DTPA to identify biliary leaks. Two observers reviewed the image sets separately and together. MRC findings were compared with those of surgery and percutaneous transhepatic cholangiopancreatography. The sensitivity, specificity and accuracy of the techniques in identifying biliary leaks were calculated.

Results

Accuracy of locating biliary leaks was superior with the combination of Gd-EOB-DTPA-enhanced MRC and T2w-MRC (P < 0.05).The mean sensitivities were 79 % vs 59 %, and the mean accuracy rates were 84 % vs 58 % for combined CE-MRC and T2w-MRC vs sole T2w-MRC. Nineteen out of 21 patients with biliary-cyst communication, 90.4 %, and 12/15 patients with post-traumatic biliary extravasations, 80 %, were detected by the combination of Gd-EOB-DTPA-enhanced MRC and T2w-MRC images, P < 0.05.

Conclusions

Gd-EOB-DTPA-enhanced MRC yields information that complements T2w-MRC findings and improves the identification and localisation of the bile extravasations (84 % accuracy, 100 % specificity, P < 0.05). We recommend Gd-EOB-DTPA-enhanced MRC in addition to T2w-MRC to increase the preoperative accuracy of identifying and locating extravasations of bile.

Key Points

• Magnetic resonance cholangiography (MRC) does not always detect bile leakage and cysto-biliary communications.

• Gd-EOB-DTPA-enhanced MRC helps by demonstrating extravasation of contrast material into fluid collections.

• Gd-EOB-DTPA-enhanced MRC also demonstrates the leakage site and bile duct injury type.

• Combined Gd-EOB-DTPA-enhanced and T2w-MRC can provide comprehensive information about biliary system.

• Gd-EOB-DTPA-enhanced MRC is non-invasive and does not use ionising radiation.

[Biliodigestive anastomosis: indications, complications and interdisciplinary management]

Techniques for biliodigestive anastomoses are a frequent indication in primary surgical interventions. Moreover, they are required to manage secondary complications of hepatobiliary surgery. Evidence for the management of complications following biliodigestive anastomoses is low. Biliodigestive anastomoses can be performed as hepaticojejunostomy, hepatojejunostomy/portoenterostomy and hepaticoduodenostomy using running or single stitch suture techniques. Complication management in the hands of experienced hepatopancreatobiliary surgeons should consider a time delay to the primary operation and an interdisciplinary surgical and/or endoscopic or radiologic interventional approach. The therapy may be protracted and requires repeated critical reflection of the particular complication.

Early phase detection of bile leak after hepatobiliary surgery: value of Gd-EOB-DTPA-enhanced MR cholangiography

PURPOSE

To assess the value of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MR cholangiography for the detection of bile leaks after hepatobiliary surgery.

METHODS

Twenty-three patients with symptoms suggestive of bile leak underwent conventional fat-suppressed T1- and T2-weighted MR cholangiography followed by Gd-EOB-DTPA-enhanced MR cholangiography using gradient-echo (GRE) T2-weighted sequences and fat-suppressed T1-weighted 3D gradient-echo sequences 20 min after an intravenous bolus of Gd-EOB-DTPA. The results of Gd-EOB-DTPA-enhanced MR cholangiography correlated with clinical findings, surgical repair, and the results of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography.

RESULTS

The results of Gd-EOB-DTPA-enhanced MR cholangiography were negative in 13 patients (cholecystectomy 5, liver transplantation 2, liver resection for focal lesions 2, cholangiocarcinoma 1, and partial hepatectomy after liver injury 1). In 10 patients in whom bile leaks were detected, this complication occurred after liver resection for focal lesions in 3, cholecystectomy in 4, liver transplantation in 2, and liver resection for intrahepatic cholangiocarcinoma in 1. The diagnostic accuracy of Gd-EOB-DTPA-enhanced MR for the detection or exclusion of bile leaks was 100%.

CONCLUSIONS

Gd-EOB-DTPA-enhanced MR cholangiography is a highly reliable technique for the detection of bile leaks after hepatobiliary surgery and may avoid the use of other, potentially risky invasive diagnostic techniques.

Use of magnetic resonance imaging contrast agents in the liver and biliary tract

This article presents an overview of liver and biliary contrast agents including their mechanisms of action, dosage and elimination, current clinical indications, and potential future uses.

Hepatobiliary MR imaging with gadolinium-based contrast agents

The advent of gadolinium-based "hepatobiliary" contrast agents offers new opportunities for diagnostic magnetic resonance imaging (MRI) and has triggered great interest for innovative imaging approaches to the liver and bile ducts. In this review article we discuss the imaging properties of the two gadolinium-based hepatobiliary contrast agents currently available in the U.S., gadobenate dimeglumine and gadoxetic acid, as well as important pharmacokinetic differences that affect their diagnostic performance. We review potential applications, protocol optimization strategies, as well as diagnostic pitfalls. A variety of illustrative case examples will be used to demonstrate the role of these agents in detection and characterization of liver lesions as well as for imaging the biliary system. Changes in MR protocols geared toward optimizing workflow and imaging quality are also discussed. It is our aim that the information provided in this article will facilitate the optimal utilization of these agents and will stimulate the reader's pursuit of new applications for future benefit.

Targeted MRI contrast agents for pediatric hepatobiliary disease

New options are available for the magnetic resonance imaging (MRI) assessment of pediatric hepatobiliary disease. This article describes the potential utility for MRI with contrast agents tailored for hepatobiliary imaging. MRI contrast agents that preferentially target the liver may be helpful in characterizing liver masses and bile duct abnormalities in select children. The imaging approach is noninvasive and relatively rapid to perform. It also provides anatomic and functional information and is a radiation-free alternative to other imaging strategies. This relatively new imaging procedure is placed in the context of more established imaging modalities. The pharmacokinetics, technical considerations, and potential applications of these hepatobiliary-specific contrast agents also are discussed.

Contrast-enhanced MR cholangiography (MRCP) with GD-EOB-DTPA in evaluating biliary complications after surgery

PURPOSE

We assessed the usefulness of contrast-enhanced magnetic resonance cholangiography (CE-MRC) with liver-specific contrast agent in evaluating the biliary tree after hepatic surgery.

MATERIALS AND METHODS

A total of 142 patients with suspected biliary complications after liver surgery underwent hepatobiliary MR before and after administration of gadolinium ethoxy benzylic diethylenetriamine pentaacetic acid (Gd-EOB-DTPA). Unenhanced MR cholangiopancreatography (MRCP) and postcontrast MRC were obtained in all patients. Blinded image evaluation and semiquantitative analysis comparing MRCP and CE-MRC were performed by two experienced radiologists.

RESULTS

In all cases, optimal postcontrast visualisation of the biliary tract was obtained. In 22 patients, a postsurgical biliary complication was confirmed. MRCP detected 64% of lesions, but in 36% of cases, an alteration was only suspected but not clearly defined. CE-MRC allowed definite diagnosis in 100% of cases.

CONCLUSIONS

Hepatobiliary-specific contrast agents allow for accurate and extensive study of biliary tract alterations, especially in assessing postsurgical complications.