Hepatobiliary scintigraphy for the assessment of biliary strictures after pediatric liver transplantation

Hepatobiliary Scintigraphy to Evaluate Biliary Complications of Pediatric Liver Transplantation: An Account of an Experience

INTRODUCTION

 Hepatobiliary scintigraphy (HS) is a noninvasive imaging technique whose use in the follow-up of liver transplantation has not been duly documented. The main objective of this study is to describe the experience of using this technique to detect biliary complications in pediatric patients following liver transplantation.

MATERIALS AND METHODS

 A retrospective, observational, and descriptive study involving 86 pediatric patients who had undergone liver transplantation between 2013 and 2018. Of the 86, 31 had undergone at least one HS during their postoperative period.

RESULTS

 A total of 45 studies were performed on 31 patients (36% of the patients undergoing transplantation during that time period). Patient ages ranged from 5 to 204 months (mean = 50 months). A total of 22 transplants (71%) were from living donors and 9 (29%) were from cadaveric donors. Of the 45 studies, 22 were positive for biliary complications, and all of them had an impact on clinical decision-making. The remaining 23 studies were negative. Of these 23, 19 continued under medical treatment and the other four underwent an additional intervention with positive surgical outcomes in all cases. All scintigraphy studies revealed hepatocellular dysfunction and cholestasis.

CONCLUSION

 The HS is a useful, noninvasive, and diagnostic procedure for the early diagnosis of biliary complications that may impact the evolution of disease in liver transplant patients. It allows the treating physician to make a more informed decision regarding expectant management, surgical management, or a less invasive course of action for transplantation complications.

Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques

In pediatric liver transplantation, bile duct complications occur with a greater incidence than vascular anastomotic dysfunction and represent a major source of morbidity and mortality. While surgical re-anastomosis can reduce the need for retransplantation, interventional radiology offers minimally invasive and graft-saving therapies. The combination of small patient size and prevailing Roux-en-Y biliary enteric anastomotic techniques makes endoscopic retrograde cholangiopancreatography difficult if not impossible. Expertise in percutaneous management is therefore imperative. This article describes post-surgical anatomy, pathophysiology and noninvasive imaging of biliary complications. We review percutaneous techniques, focusing heavily on biliary access and interventions for reduced liver grafts. Subsequently we review the results and adverse events of these procedures and describe conditions that masquerade as biliary obstruction.

Hepatobiliary scintigraphy in the study of complications in adult patients after liver transplant. Description of the experience

OBJECTIVE

To show the experience of the use of hepatobiliary scintigraphy in patients with suspected complications after liver transplantation in a high complexity centre.

MATERIAL AND METHOD

Retrospective, observational and descriptive study. All consecutive adult patients with liver transplantation between January 2013 and February 2018 were included, with one or more hepatobiliary scintigraphy during the early or late postoperative period. A total of 58 studies were analyzed in 38 patients (22 men and 16 women). Mean age: 48 years. In 34/38: cadaverous donor (89%), and in 4 (11%): a living donor. Demographic data and relevant information regarding the transplant were obtained, and the result was related to the surgical findings to determine the correlation between them. The influence of the test on the final clinical decisions was evaluated.

RESULTS

Findings: 9 scans (14%) were normal, 36 studies were negative, and 21 were positive for biliary complications. Of the total of 58 studies, 50 (86%) had impact on the clinical behaviour of observation or intervention. All the patients with findings of biliary complications (21/21; 100%) had clinical repercussion since 18/21 patients were taken to invasive studies or treatments, and 3/21 patients continued in medical management for findings of non-surgical biliary complications. In 14/18 patients taken to studies or procedures, correlation was found with the scintigraphic study. In 24/36 (66%) of patients with negative scintigraphy, an impact on clinical behaviour was found.

CONCLUSION

Hepatobiliary scintigraphy is a simple, non-invasive, reliable, current and available form for the early study of biliary complications in patients with liver transplantation. Important hepatocellular dysfunction should be taken into account as a frequent cause of false negative studies.

Hepatic gadoxetic acid uptake as a measure of diffuse liver disease: Where are we?

MRI has emerged as the most comprehensive noninvasive diagnostic tool for focal liver lesions and diffuse hepatobiliary disorders. The introduction of hepatobiliary contrast agents, most notably gadoxetic acid (GA), has expanded the role of MRI, particularly in the functional imaging of chronic liver diseases, such as nonalcoholic fatty liver disease (NAFLD). GA-enhanced MRI (GA-MRI) may help to distinguish between the two subgroups of NAFLD, simple steatosis and nonalcoholic steatohepatitis. Furthermore, GA-MRI can be used to stage fibrosis and cirrhosis, predict liver transplant graft survival, and preoperatively estimate the risk of liver failure should major resection be undertaken. The amount of GA uptake can be estimated, using static images, by the relative liver enhancement, hepatic uptake index, and relaxometry of T1-mapping during the hepatobiliary phase. On the contrary, the hepatic extraction fraction and liver perfusion can be measured on dynamic imaging. Importantly, there is currently no clear consensus as to which of these MR-derived parameters is the most suitable for assessing liver dysfunction. This review article aims to describe the current role of GA-enhanced MRI in quantifying liver function, primarily in diffuse hepatobiliary disorders.

LEVEL OF EVIDENCE

3 J. Magn. Reson. Imaging 2017;45:646-659.

Accuracy of Hepatobiliary Scintigraphy after Liver Transplantation and Liver Resection

Background and Aims. Biliary complications are the most frequent complications after common liver surgeries. In this study, accuracy of hepatobiliary scintigraphy (HBS) and impact of hyperbilirubinemia were evaluated. Methods. Between November 2007 and February 2016, 131 patients underwent hepatobiliary scintigraphy after having liver surgery. 39 patients with 42 scans after LTX (n = 13) or hepatic resection (n = 26) were evaluated in the study; 27 were male, with mean age 60 years. The subjects underwent hepatobiliary scintigraphy with Tc-99m labeled Mebrofenin. The results were compared to ERCP as gold standard performed within one month after HBS. We calculated sensitivity, specificity, PPV, and NPV. We compared LTX patients to patients with other liver surgeries. Furthermore the influence of hyperbilirubinemia on HBS scans was evaluated. Results. HBS always provided the correct diagnosis in cases of bile leak in the liver-resected group (14/14). Overall diagnostic accuracy was 76% (19/25) in this group and 54% (7/13) in the LTX group. False negative (FN) diagnoses occurred more often among LTX patients (p = 0.011). Hyperbilirubinemia (>5 mg/dL) significantly influenced the excretion function of the liver, prolonging HBS's time-activity-curve (p = 0.001). Conclusions. Hepatobiliary scintigraphy is a reliable tool to detect biliary complications, but reduced accuracy must be considered after LTX.

Recurrent cholangitis by biliary stasis due to non-obstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy: report of a case

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

Hepatobiliary scintigraphy for the assessment of biliary stricture after pediatric living donor liver transplantation for hepaticojejunostomy reconstruction: the value of the excretion rate at 60 min

HBS is performed to determine the presence of biliary stricture after liver transplantation. We focused on the Ex-60 after an intravenous injection of tracer during HBS. The aim of this study was to review the cutoff values for the diagnosis of biliary stricture by HBS after pediatric LDLT. We analyzed 114 HBS studies using (99m) Tc-PMT in 80 cases after pediatric LDLT. HBS was performed three months after LDLT on a routine basis and/or was performed when ultrasonography and blood test findings indicated biliary stricture. A ROC curve analysis was performed to identify the cutoff value for the correlation between Ex-60 and biliary stricture. The Ex-60 (mean ± s.d.) in the cases diagnosed as having biliary stricture and in normal subjects were 49.1 ± 20.2% vs. 78.0 ± 9.7% (p < 0.01), respectively. As a result of an ROC curve analysis of the Ex-60, the recommended cutoff value to diagnose biliary stricture was set at 69.2% (sensitivity 87.0%, specificity 81.8%). In cases where the Ex-60 by (99m) Tc-PMT HBS is <69.2%, it is recommended that further treatment for biliary stricture should be provided.

Hepatobiliary scintigraphy for detecting biliary strictures after living donor liver transplantation

AIM: To investigate the diagnostic accuracy of hepatobiliary scintigraphy (HBS) in detecting biliary strictures in living donor liver transplantation (LDLT) patients.

METHODS: We retrospectively reviewed 104 adult LDLT recipients of the right hepatic lobe with duct-to-duct anastomosis, who underwent HBS and cholangiography. The HBS results were categorized as normal, parenchymal dysfunction, biliary obstruction, or bile leakage without re-interpretation. The presence of biliary strictures was determined by percutaneous cholangiography or endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS: In 89 patients with biliary strictures, HBS showed biliary obstruction in 50 and no obstruction in 39, for a sensitivity of 56.2%. Of 15 patients with no biliary strictures, HBS showed no obstruction in 11, for a specificity of 73.3%. The positive predictive value (PPV) was 92.6% (50/54) and the negative predictive value (NPV) was 22% (11/50). We also analyzed the diagnostic accuracy of the change in bile duct size. The sensitivity, NPV, specificity, and PPV were 65.2%, 27.9%, 80% and 95%, respectively.

CONCLUSION: The absence of biliary obstruction on HBS is not reliable. Thus, when post-LDLT biliary strictures are suspected, early ERCP may be considered.