Original Contribution
Evaluating Biliary Anatomy and Variations in Living Liver Donors by a New Technique: Three-Dimensional Contrast-Enhanced Ultrasonic Cholangiography

https://doi.org/10.1016/j.ultrasmedbio.2010.05.001Get rights and content

Abstract

Accurate assessment of the biliary anatomy is important for the safety of liver donors in living donor liver transplantation (LDLT). We evaluated the biliary anatomy and variations of 12 living liver donors with 3-D contrast-enhanced ultrasonic cholangiography (3-D CEUSC) by injecting microbubble contrast agents into the common hepatic ducts intraoperatively. Two radiologists assessed the diagnostically adequate, delineation of biliary branch orders, visibility scores (grades 0 to 3) and anatomical patterns of the intrahepatic biliary tree by consensus. The results were compared with findings on intraoperative cholangiography (IOC) and surgery. 3-D CEUSC successfully demonstrated the spatial structure of the intrahepatic biliary tree in all 12 donors. The maximum branching order of intrahepatic bile ducts displayed on 3-D CEUSC was the fifth order in the right lobe and fourth order in the left lobe of the liver, respectively. The visibility scores of the first-order (3.00 ± 0.00) and second-order (2.67 ± 0.69) branches were significantly (p < 0.001) higher than that of the third-order (1.98 ± 1.13) branches, whereas visibility scores of the second-order (2.88 ± 0.34) and third-order (2.44 ± 1.01) branches in the right lobe were significantly (p = 0.040 and p < 0.001, respectively) higher than those in the left lobe (2.46 ± 0.88 and 1.33 ± 0.99). The 3-D CEUSC images of the 12 donors were diagnostically adequate for evaluating the biliary anatomy. Normal biliary pattern in nine donors and biliary variations in three donors were confirmed by both IOC and surgical findings. 3-D CEUSC may be a potential alternative to IOC in the evaluation of biliary anatomical variation before graft harvesting in LDLT. (E-mail: [email protected])

Introduction

Living donor liver transplantation (LDLT) has been accepted as the most effective alternative to overcome the shortage of deceased donor liver grafts (Brown, 2008, Graziadei, 2007, Gridelli and Remuzzi, 2000, Russo and Brown, 2004). The success of LDLT requires a full understanding of liver anatomy including the vascular and biliary systems. More than 42% of the population have anatomical variations of the biliary tree (Puente and Bannura 1983). Evaluation of the biliary anatomy is important for surgical planning of biliary anastomosis and precluding unsuitable potential liver donors in LDLT (Lee et al., 2001, Marcos et al., 2000). Postoperative complications can be fatal if the biliary variations are not detected before graft harvesting. Accurate and safe imaging techniques to evaluate the biliary anatomy are currently the subject of research and development.

Conventional ultrasound is sensitive in detecting dilated bile ducts. However, it is limited in demonstrating nondilated biliary system. Newly developed contrast-enhanced ultrasound (CEUS) with intracavitary administration of ultrasound contrast agent (UCA) can depict nondilated intrahepatic biliary tract (Robert et al. 2006). Because ultrasound is the most common imaging modality used in LDLT to delineate the hepatic veins, simultaneous scanning of both the intrahepatic vascular and biliary structures would be beneficial. We previously reported a new technique—three-dimensional contrast-enhanced ultrasonic cholangiography (3-D CEUSC) using intrabiliary injection of UCA—to display the normal spatial structure of the intrahepatic biliary tree in a living liver donor (Xu et al. 2009). On the basis of previous successful practice, the objective of this study is to determine the efficacy of 3-D CEUSC in LDLT for demonstrating biliary anatomy and variations in a larger group of living liver donors.

Section snippets

Subjects

From June 2008 through June 2009, 27 consecutive potential donors for adult LDLT were evaluated at our institute. Fifteen candidates were excluded because of preoperative detection of contraindications. The remaining 12 subjects (10 male, 2 female; age range: 21 to 48 y, mean 28.90 y) were enrolled as donors and underwent resection of the right lobe of the liver. The study was approved by the institutional ethics review board and was in compliance with the Helsinki Declaration. Written informed

Demonstration of biliary anatomy

The biliary trees from the common hepatic ducts to various intrahepatic branch orders were successfully displayed on 3-D CEUSC in all 12 donors (Fig. 1). The 3-D CEUSC images in 12 donors were all diagnostically adequate. The maximum branching order of intrahepatic bile ducts was the fifth order in the right lobe and fourth order in the left lobe of the liver, respectively (Table 1). By varying the angles, overlapped intrahepatic biliary branches on conventional 2-D IOC were well seen on the

Discussion and Summary

CEUS has been successfully used for depicting the microvasculature by intravenous injection of UCA (Claudon et al. 2008). Recently, intracavitary administration of UCA was also applied to delineate ureters and bile ducts (Ascenti et al., 2004, Claudon et al., 2008, Darge and Riedmiller, 2004, Ignee et al., 2009, Lanzani et al., 2009, Mao et al., 2010, Robert et al., 2006, Xu et al., 2009). Nondilated intrahepatic bile ducts are usually not visible on conventional ultrasound because of their

Acknowledgments

We thank Dr. Margaret Pui for her editorial assistance in the preparation of this manuscript.

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