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Anastomotic biliary stricture with lithiasis. A: Axial T2-weighted image shows dilation of the biliary system with concomitant stones (yellow arrow); B: Axial T1-weighted image confirms the presence of stones in the biliary tract (yellow arrow); C: Maximum intensity projections of 3D thin-slab fast spin-echo T2-weighted images (obtained using different thicknesses) demonstrate the dilation of the both intra-and extra-hepatic (pre-and post-anastomotic) biliary tract with a stricture of the iuxta-papillary choledocho (white arrow); the presence of two stones at the level of the hepatic bifurcation (yellow arrow) is also well appreciable; D: On coronal single-shot T2-weighted images (at different levels) is also better appreciable a stricture at the anastomotic site (red arrow); E: Endoscopic retrograde cholangiography confirms the presence of strictures and stones in the pre-anastomotic biliary tract; F: Stones were endoscopically removed and strictures were treated by stenting as shown on different projection images.
Source publication
Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these adverse events is heavily influenced by the type of anastomosis during surgery. The low specificity of clinical and biologic findings...
Contexts in source publication
Context 1
... conventional T2-weighted MR cholangiography the presence of pneumobilia is an element that can com- promise the correct diagnosis of lithiasis. The differential diagnosis between stones and pneumobilia is usually performed on axial T2-weighted sequences. Calculi are generally identified as endoluminal areas of signal void surrounded by high intensity of bile in the dependent portion of the duct (Figure 5), whereas pneumobilia is typically characterized by low signal intensity in the non- dependent portion of the bile duct [19] (Figure 6). Besides, on conventional T2-weighted MRC flow artifacts are sometimes observed in the central portion of chole- dochal duct as thin area of low signal intensity [58] . These flow artifacts are not commonly recognized on contrast- enhanced T1-weighted MR cholangiography, that may be helpful in providing an increased diagnostic confidence in the differential diagnosis between stones and pneu- mobilia. Furthermore, Kinner et al [59] showed that adding non-enhanced T1-weighted sequences to conventional T2-weighted MRCP the diagnostic performance of MRI for the diagnosis of biliary cast syndrome after OLT is significantly improved since biliary cast is hyperintense on T1-weighted images (Figure ...
Context 2
... at the level of the surgical anastomosis that can be associated or not with dilatation of the pre-anas- tomotic biliary tract [48] (Figure 4). T1-and T2-weighted images in the axial plane show a regular thickening of A: Axial T2-weighted image shows dilation of the biliary system with concomitant stones (yellow arrow); B: Ax- ial T1-weighted image confirms the presence of stones in the biliary tract (yellow arrow); C: Maximum intensity projections of 3D thin-slab fast spin-echo T2-weighted images (obtained using different thicknesses) demonstrate the dilation of the both intra-and extra-hepatic (pre-and post-anastomotic) biliary tract with a stricture of the iuxta-papillary choledocho (white arrow); the presence of two stones at the level of the hepatic bifurcation (yellow arrow) is also well appreciable; D: On coronal single-shot T2-weighted images (at different levels) is also better appreciable a stricture at the anastomotic site (red arrow); E: Endoscopic retrograde cholangiography confirms the presence of strictures and stones in the pre-anastomotic biliary tract; F: Stones were endoscopically removed and strictures were treated by stenting as shown on different projection images. the anastomotic biliary wall with a typical ring-shaped hypointensity [48] . Besides, calculi can be appreciable in the pre-anastomotic biliary tract ( Figure ...
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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 p...
Citations
... The diagnosis is pathologically established by a lack of visible bile ducts in more than 50% of examined portal tracts. However, a diagnosis of vanishing bile duct syndrome may be suggested on cholangiography by a paucity of or disappearance of small intrahepatic bile ducts (Fig. 12) [60]. Excretion of hepatobiliary contrast may be absent owing to the concomitant intrahepatic cholestasis [6]. ...
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.
Graphical abstract
... 42 43 The proposed pathogenesis of VBDS with acute cellular rejection is a T cell response against bile duct cells, leading to destructive cholangitis, severe ductopaenia, and portal tracts without bile ducts. 44 VBDS with chronic rejection is still not fully understood, but some studies suggest macrophage activation which leads to histological features of lobular hepatitis, marked hepatocyte apoptosis, and small bile duct injury. [45][46][47] Acute and chronic rejection may occur as a result of cytomegalovirus (CMV) infection, medications (eg, Open access sertraline), and ischaemic cholangitis as the instigating event. ...
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
... Biliary leaks typically occur in the early phase after transplantation and are most common at the anastomosis or site of T-tube insertion [31]. Although biliary ductal dilation or a biloma may be visualized with ultrasound, MR cholangiopancreatography is the best non-invasive imaging test for evaluating biliary complications and is enhanced by the use of biliary contrast agents [32]. Hepatobiliary scintigraphy may also be helpful to diagnose biliary leakage. ...
Simultaneous liver-kidney transplantations (SLKTs) are increasing in incidence, and the en bloc surgical approach is associated with a unique spectrum of vascular complications. En bloc SLKTs have a common arterial supply from the celiac axis and post-operative assessment with Doppler ultrasound can help to localize vascular lesions as either proximal in the shared arterial supply or distal in the organ-specific arteries. Venous complications predominantly include thrombosis or stenosis of the portal vein, hepatic veins, renal vein, or IVC, but have a much lower incidence. Radiologists familiar with the post-operative anatomy and complications can provide meaningful and accurate assessment to help direct clinical care. The purpose of this article is to provide a targeted review of SLKT, review the post-surgical anatomy associated with en bloc SLKT, and review the imaging evaluation of vascular complications associated with SLKT.
... Since first liver transplantation (LT) was performed by Starzl and colleagues in 1963 1 , LT became the gold standard therapy for patients with many liver disease, including end stage chronic liver disease, primary or metastatic liver cancer, metabolic liver diseases and acute liver failure 1 . Living donor liver transplantation (LDLT) is an effective treatment choice, especially in areas where deceased grafts are in short supply [1][2][3] . LT can be accompanied by various complications, including vascular (stenosis or thrombosis of the hepatic artery, portal, hepatic, or inferior cava vein), biliary (stenosis, bile leaks, bilioma), and other clinical complications (abscess, hematoma, neoplasm, cirrhosis, rejection). ...
Objective:
To evaluate whether gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhanced magnetic resonance imaging (MRI), the measurements of quantitative and qualitative parameters on hepatobiliary phase images can predict the risk of postoperative complications in patients underwent living donor liver transplantation (LDLT) PATIENTS AND METHODS: We obtained Gd-EOB-DTPA-enhanced 3 Tesla MRI before living donor hepatectomy in donors (donor group; n=30) and after LDLT in their recipients (recipient group; n=30). MRIs were evaluated in terms of quantitative and qualitative variables. Quantitative parameters included relative liver enhancement value, biliary signal intensity value, and muscle signal index value. Qualitative parameters included visual evaluation of the liver and biliary enhancement on hepatobiliary phase images. Patients were followed up for postoperative biliary and vascular complications and divided according to the presence and absence of complications. The relationship between MRI parameters and postoperative complications was statistically analyzed.
Results:
The mean relative liver enhancement values, mean biliary signal values, and muscle signal index were significantly lower in recipients with postoperative complications than those in donors and recipients without complications (p < 0.001). Visual assessments of liver enhancement and biliary signal were also significantly different in recipients with postoperative complications than that in donors and recipients without complications (p < 0.001).
Conclusions:
Quantitative and qualitative MRI parameters obtained by Gd-EOB-DTPA-enhanced MRI on hepatobiliary phase images may potentially become a reliable tool for the assessment of the risk for postoperative complications after LDLT.
... Biliary complications are common following liver transplant and most are identified in the first 6-12 months after transplant [7,[37][38][39]. Biliary complications are encountered in up to 30% of transplants, and include stricture, biliary leak, cholangitis, sphincter of Oddi dysfunction and stone disease [37,40]. When reconnecting the biliary tree, the preferred anastomosis is created as an end-to-end choledochocholedochostomy preserving the sphincter of Oddi and thereby reducing the risk of cholangitis. ...
... There are two types of biliary strictures, anastomotic strictures (AST) and non-anastomotic strictures (NAS). AST are more common in living donor transplants and at bilioenteric anastomoses (Fig. 16) [39][40][41]. Early AST may be a result of surgical technique or size mismatch of the donor and recipient ducts, whereas late-onset AST is thought to be due fibrosis [7,38]. ...
... Treatment is first attempted with endoscopic retrograde cholangiopancreatography (ERCP) with stenting or percutaneous drainage (Fig. 17) [39]. On the other hand, NAS are usually multifocal, longer in length and located in the intrahepatic ducts or at the confluence of the hepatic ducts [40,42,43]. The most common cause of NAS is ischemia in the setting of hepatic artery thrombosis or stenosis (Fig. 18). ...
Liver transplantation has become a definitive treatment for patients with end-stage liver disease and those meeting Milan criteria for hepatocellular carcinoma. The morbidity and mortality associated with liver transplantation continues to decrease thanks to refinements in surgical technique, immunosuppression, and imaging. In particular, imaging plays a vital role by facilitating early detection of post-operative complications and enabling prompt treatment. Post-operative complications that lead to graft failure and patient morbidity/mortality can be generally categorized as vascular, biliary, parenchymal, and malignant. Vascular complications include stenosis and thrombosis of the hepatic artery, portal vein, and inferior vena cava; hepatic artery pseudoaneurysm; arteriovenous fistula; and celiac stenosis. Biliary abnormalities include strictures, bile leak, obstruction, recurrent disease, and infection. While imaging is not primarily utilized to diagnose allograft rejection, it plays an important role in excluding mechanical causes of graft dysfunction that can mimic rejection. Ultrasound is routinely performed as the first-line imaging evaluation for the detection and follow-up of early and delayed complications. Cholangiography and magnetic resonance cholangiopancreatography are useful in detecting and characterizing biliary complications. Computed tomography is often used to further evaluate abnormal findings on ultrasound or for the characterization of post-operative fluid collections. The aim of this review is to discuss and illustrate the imaging findings of complications associated with liver transplantation and their role in facilitating treatment.
... Cholangiography is the gold standard for diagnosis but is limited by its invasiveness. MRCP has demonstrated comparable diagnostic accuracy [14][15][16][17], however, it is not cost-effective and has limited availability for liver recipients who needs repeated, non-invasive, convenient imaging modality for follow up. ...
... Our results are consistent with the previous studies regarding MRCP findings of BS. MRCP appearance of NAS were characterized by multiple stenoses and skip dilatations of intrahepatic bile ducts, and lengthy stricture and wall thickening of hilar bile duct [16,[27][28][29][30][31]. AS typically presents as focal luminal narrowing at the biliary anastomosis with or without pre-anastomotic dilatation of the biliary system [17,32]. ...
Purpose
To evaluate the role of ultrasonography (US) in differentiating anastomotic biliary strictures (AS) and non-anastomotic biliary strictures (NAS) after orthotopic liver transplantation (OLT).
Method
This retrospective study included 1259 OLT recipients between 2005−2018. Seventy-six with anastomotic strictures (AS) and 103 with non-anastomotic strictures (NAS) were analyzed. The reference standard was cholangiography. The sensitivity, specificity, accuracy of US was evaluated.
Results
There were significant differences between AS and NAS groups (p < 0.001) for skipped and irregular dilatation of intrahepatic bile duct and visualization of hilar biliary lumen. The better US imaging feature for NAS was poorly visualized and non- visible hilar bile duct luminal contour. The sensitivity, specificity and accuracy were 94.2 %, 84.2 % and 88.9 % respectively. Combined two predictors greatly increased the specificity to 93.4 % while diminished its sensitivity and accuracy.
Conclusion
US is useful and efficient to differentiate AS and NAS after OLT.
... The protocol for MRCP included radial 2D single shot breath-hold and 3D turbo spin echo T2-weighted sequences. IC was defined as the development of biliary anomalies, excluding biliary anastomotic strictures and recurrent sclerosing cholangitis, such as (1) extra-or intrahepatic ductal strictures; (2) extra-or intrahepatic ductal dilatations; (3) intrahepatic biloma; (4) complete biliary destruction, with irregular dilatation of the entire biliary tree and presence of biliary casts [23][24][25] (Fig. 2A-F). To confirm that patients were properly screened and reduce a possible observation bias, all survivors were recalled to undergo both DUS and MRCP, the former to assess HA patency, and the latter to evaluate the presence of biliary anomalies. ...
Purpose
To evaluate long-term arterial patency and abnormalities of bile ducts in patients that had endovascular treatment for arterial complications after liver transplantation (LT).
Materials and Methods
Between 2004 and 2014, 1048 LTs were consecutively performed in our institution and 53 patients (42 men; age range 19–69) were diagnosed and treated by endovascular techniques for arterial complications such as stenosis, thrombosis, dissection or kinking of the hepatic artery (HA). Radiological and surgical data were retrospectively analyzed, and survivors were contacted to undergo follow-up Doppler ultrasound (DUS) of the HA and magnetic resonance cholangiopancreatography.
Results
The primary technical success of endovascular treatment was 94% (n = 50). The patency rate of HA at 5-year was 81%. After a median follow-up of 58 months, 17 patients (32%) developed radiological features of ischemic cholangiopathy (IC), including 7 patients with abnormal DUS and 10 with normal DUS. Patients who presented with complications of the HA in the first 3 months after LT developed IC more frequently (42%) than others (12%) (p = 0.028). No other factor was associated with the development of IC.
Conclusion
IC was more often observed when HA complication occurred within the first 3 months after LT. The presence of IC was not excluded by a normal DUS during follow-up.
... After preliminary acquisition of T1-and T2-weighted sequences in the axial plane, two different MRC sequences are conventionally performed: 1) breath-hold, thick-collimation (40-60 mm), 2D SS-FSE T2-weighted sequence utilizing coronal/coronal oblique projections; 2) respiratory-triggered, thin-collimation (2.4 mm thk/-1.2 mm) 3D FRFSE T2-weighted sequence in the coronal plane, providing numerous single thin partitions as a source for multiplanar and volumetric reconstructions [32][33][34]. ...
... Using MRC, most of ITBL show a lengthy stricture that frequently involves the right and left hepatic ducts and the hepatic bifurcation, which is a prevalent localization for ischemic injures after OLT [41]. Another characteristic MR feature of ITBL is represented by wall thickening of the graft extra-hepatic biliary ducts, that can be associated to biliary sludge, stones or casts formation [34,40]. All these biliary findings can be better demonstrated at 3.0-T device [50] (Fig. 11). ...
Orthotopic liver transplantation is the treatment of choice in adult patients with endstage liver disease. Survival of both graft and patient has progressively improved over time due to improvements in surgical and medical treatment. However, post-transplant complications still have a significant impact on morbidity and mortality associated with transplant surgery. The most common adverse events of the graft include vascular arterial and venous stenosis and thrombosis, biliary leakage, strictures, stones and parenchymal complications hepatitis virus C infection, HCC recurrence, liver abscesses. The diagnosis of these adverse events is often challenging because of the low specificity of clinical and biologic findings. Different diagnostic algorithms have been proposed for the detection of graft complications and, in this setting, radiological evaluation plays a key role in differential diagnosis of graft complications and the exclusion of other adverse events. Ultrasound examination is established the first-line method of identifying adverse events in liver transplant recipients but a normal or a technically unsatisfactory study cannot exclude the presence of biliary, vascular and/or parenchymal complications. In these circumstances, before planning any treatment, multi-detector CT and/or MR imaging and MR cholangiography should be performed for the evaluation of vascular structures, biliary system, liver parenchyma and fluid collections. The aim of this review is to illustrate the role and state-of-the-art of non-invasive cross-sectional imaging techniques in the diagnosis and management of complications which primarily affect the graft in patients after liver transplantation.
... After exclusion of both vascular and parenchymal conditions that could justify the manifestation, magnetic resonance cholangio-pancreatography (MRCP) or even a cholangiogram through a T-tube are considered the diagnostic standard for biliary tract complications [9] . Invasive approaches, such as endoscopic retrograde cholangiography (ERC) or percutaneous trans-hepatic cholangiography (PTC) should be considered treatment options rather than diagnostic tools. ...
The clinical outcome of patients receiving liver trans plantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these con ditions lead to markedly reduction in morbidity and mortality. Therapeutic gold standard is represented by conservative approaches, both endoscopic and percutaneous, based on the type of biliary reconstruction, the local availability of the procedures and specific expertise. In patients with previous transplantation, the difficult biliary access and the possible presence of concomitant complications (mainly strictures) further restrict the efficacy of the endoscopic and percutaneous treatments; on the other hand, surgery should generally be avoided because of the even increased morbidity and mortality due to technical and clinical issues. Here we review the most common biliary complications occurring after liver transplantation and discuss available treatment options including future perspectives such as endoscopic ultrasoundguided biliary access in patients with Roux enY choledochojejunostomy or extracorporeal shock wave lithotripsy for difficult stones.
... This is a recently emerged technique that is useful for delineating the anatomy of biliary-enteric anastomoses and detecting biliary complications, for example, biliary strictures, intraductal stones, and bile duct leakages, and it may provide additional functional information in grading biliary obstructions. 19 A future study, using these agents, could show optimising results and be of additional value, although comparative studies between T2-weighted MRCP and T1-weighted contrast-enhanced MR cholangiography which actually have proven this in a large patient group are scarce. [20][21][22] In addition, Duarte et al 23 described the use of pineapple juice with gadopentetate dimeglumine as a promising contrast-enhancing agent in the evaluation of the biliary tree. ...
Background: Nonanastomotic biliary strictures (NAS) remain a frequent complication after orthotopic liver transplantation (OLT). The aim of this study was to evaluate whether magnetic resonance cholangiopancreatography (MRCP) could be used to detect NAS and to grade the severity of biliary strictures.
Methods: In total, 58 patients after OLT from 2 Dutch transplantation centers in whom endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography and MRCP were performed within less than 6 months apart were included in the study. Of these patients, 41 had NAS and 17 were without NAS based on endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography and follow-up. Four radiologists—2 from each center—used an adapted validated classification—termed “Leiden Biliary Stricture Classification” “(LBSC)—to evaluate the MRCP examinations independently. In this classification, NAS severity is assessed in 4 hepatobiliary regions. Interobserver agreement of the severity score for each region was calculated with the κ statistics.
Results: Optimal cutoff value of the LBSC to detect the presence of NAS with MRCP was calculated at 3 points or greater for all readers. Applying this cutoff sensitivity for each reader was greater than 90%, with a specificity of 50% to 82%, positive predictive value of 86% to 91%, and negative predictive value of 80% to 100%. The MRCP performance was better in evaluation of the intrahepatic than of the extrahepatic bile ducts. The additional value of MRCP for grading severity of NAS was limited.
Conclusions: The MRCP with the LBSC is a reliable tool to detect or exclude NAS after OLT. Currently, MRCP cannot be used to reliably grade the severity of these strictures.
