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Intrahepatic Biliary Anatomy of Living Adult Liver Donors: Correlation of Mangafodipir Trisodium—Enhanced MR Cholangiography and Intraoperative Cholangiography

¹ Department of Radiology, Division of Abdominal Imaging, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213.
² Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213.

Received January 28, 2002; accepted after revision May 10, 2002.

 
Address correspondence to V. Kapoor.

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. The purpose of our study was to assess the usefulness of mangafodipir trisodium—enhanced MR cholangiography for evaluating intrahepatic biliary anatomy of adult living liver donors and to correlate the results with intraoperative cholangiography.

CONCLUSION. Mangafodipir trisodium—enhanced MR cholangiography accurately shows the biliary anatomy in the livers of donors. Noninvasive preoperative evaluation of the biliary anatomy in donor candidates is important for the detection of common anatomic variants that may require alternative graft-harvesting surgery.

Introduction

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A growing demand for liver transplantation with a concomitant shortage of cadaveric livers has increased the prevalence of adult living-donor liver transplantation. Ensuring the safety of donors is critical, and strict evaluation and selection protocols have been suggested [1]. Traditionally, left lateral segment transplantation has been advocated in children, and transplantation of either the right lobe or the left lobe with or without the caudate lobe, has been advocated in adults because of the larger graft size required by adult recipients [2]. CT and MR imaging before surgery play significant roles in evaluating donors, including selection of the right versus left lobe of the liver for graft harvesting. Imaging has been used for assessing the liver volume and venous, arterial, and biliary anatomy and to diagnose steatosis or other diseases in the donor liver that may preclude the donation [3,4,5,6,7,8]. Endoscopic retrograde percutaneous CT cholangiography and MR cholangiography have been used to delineate the biliary anatomy and its anatomic variants [7,8,9,10,11].

Recent case reports have suggested evaluating the biliary tract with mangafodipir trisodium—enhanced MR imaging [9]. The purpose of our study was to investigate the utility of MR cholangiography for adequately depicting the biliary anatomy of adult liver donors.

Materials and Methods

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Patients
Medical records of patients who had transplantation from March through October 2001 were reviewed to identify 11 patients who underwent adult-to-adult living-donor liver transplantation at our institution. Eight of these liver donors (three women and five men; age range, 19-57 years; mean, 38 years) were referred for preoperative mangafodipir trisodium—enhanced MR cholangiography and composed the study group. The eight donors were referred for mangafodipir trisodium—enhanced MR cholangiography on the basis of the surgeon's preference, and the other three, for MR cholangiography with no preselection. The medical records and imaging studies of these donors were retrospectively reviewed and recorded after transplantation. The interval between mangafodipir trisodium—enhanced MR cholangiography and surgery was less than 4 weeks for all donors.

MR Imaging
Preoperative mangafodipir trisodium—enhanced MR cholangiography was performed in the eight living donors on a Signa LX 1.5-T MR scanner (General Electric Medical Systems, Milwaukee, WI). In addition to mangafodipir trisodium—enhanced MR cholangiography, the MR imaging protocol included axial T1-weighted gradient-echo in-phase and T2-weighted respiratory-triggered fat-suppressed fast spin-echo images. Fat-suppressed volumetric three-dimensional (3D) T1-weighted coronal breath-hold spoiled gradient-echo images of the biliary tract were obtained 5 min after IV injection of mangafodipir trisodium (Teslascan; Nycomed Amersham, Princeton, NJ). The standard dose of mangafodipir trisodium was 5 mmol/kg (0.1 mL/kg; maximal dose, 15 mL), administered IV (duration, > 1 min). Scans were initiated 5 min after the injection, and two or three sets of volumetric 3D T1-weighted coronal or oblique coronal images were obtained every 5-10 min. This timing was based on our prior experience because, to our knowledge, no documented studies on optimal timing exist. Scanning parameters included TR/TE, 4.7/1.2; flip angle, 150°; field of view, 300-400 mm with a rectangular field of view; matrix, 256 x 192 with 24-28 partitions and section thickness of 2 mm, interpolated to 48-56 slices at 1-mm intervals. Axial volumetric 3D T1-weighted breath-hold spoiled gradient-echo images through the liver were also obtained with imaging parameters similar to those of coronal images.

For donor evaluation, volume-rendered and maximum-intensity-projection reconstructions of the 3D image sets were performed and recorded on a workstation (Advantage Windows 4.0; General Electric Medical Systems) at the time of the initial examination. Recommendations regarding right versus left hepatectomy were typically discussed with transplantation surgeons before the surgery at the time of the MR examination. All images were available to the transplantation surgeons for interactive viewing on the workstation before surgery.

Complex orthogonal volume-rendered and maximum-intensity-projection views of the right and left hepatic ducts were retrieved for this study and viewed on the workstation. Two experienced MR radiologists unaware of the results of the intraoperative cholangiography evaluated the images to define by consensus the anatomy of the biliary tract. If consensus could not be reached, a third radiologist determined a majority opinion. The hepatic duct anatomy was classified as conventional or anomalous. Conventional anatomy was defined as ducts from Couinaud segments II, III, and IV joining to form the transverse left hepatic duct, ducts from segments VI and VII joining to form the right posterior branch and then draining into the right anterior branch to form the main right hepatic duct, and ducts from segments V and VIII joining to form the right anterior branch. The right posterior hepatic duct normally courses behind the right anterior branch to join at its left (medial) aspect to form the right hepatic duct. The main right and left hepatic ducts join to form the common hepatic duct. Any variation from the conventional anatomy was considered anomalous.

To reach consensus on the branching order of the hepatic ducts after mangafodipir trisodium—enhanced MR cholangiography, we viewed source, volume-rendered, and maximum-intensity-projection images of the hepatic ducts on the workstation. For our study, the first-order hepatic branch was defined at the bifurcation of the common hepatic duct; the second-order branch, at the bifurcation of the right and left hepatic ducts; and the third-order branch, at the bifurcation of the right anterior, right posterior, left lateral, and left medial hepatic ducts.

Surgery and Intraoperative Imaging
Conventional intraoperative cholangiography was performed before and after partial hepatectomy in all eight donors. After open cholecystectomy and ligation of the cystic duct, the common hepatic duct was cannulated. Approximately 5-10 mL of ioversol (Optiray; Mallinckrodt, St. Louis, MO) was hand injected with fluoroscopic guidance, and a minimum of two images before resection and one image after resection were obtained in all donors. Although surgical planning was based on preoperative imaging, the transplantation surgeons made the final decision regarding the type of hepatectomy to perform after reviewing the intraoperative cholangiograms.

We used the results of the intraoperative cholangiography as the gold standard for our study. Mangafodipir trisodium—enhanced MR cholangiography results were correlated with intraoperative cholangiography. Both radiologists reached a consensus in all cases without requiring a third investigator for a majority consensus.

Results

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All eight donors underwent hepatectomy (right hepatectomy, segments V-VIII, n = 6; extended left hepatectomy, segments I-IV, n = 2). At surgery, five donors (62.5%) had conventional biliary anatomies (Fig. 1A,1B). The right posterior duct drained Couinaud segments VI and VII, and the right anterior duct drained segments V and VIII. In three others, one (12.5%) each of the following variants was identified: right posterior duct draining into the left hepatic duct (Fig. 2A,2B,2C); aberrant right posterior duct draining segment VI directly into the common hepatic duct (Fig. 3A,3B); and an accessory left hepatic duct (Fig. 4A,4B).

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —49-year-old living male liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows right posterior (dorsocaudal) hepatic duct (single straight arrow) joining right anterior (cranioventral) hepatic duct (short double arrowheads) to form right hepatic duct (long arrowhead). Left hepatic duct (double arrows) joins right hepatic duct to form common hepatic duct (curved arrow). Intraoperative cholangiogram (B) confirms findings on mangafodipir trisodium—enhanced MR cholangiography (A).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —49-year-old living male liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows right posterior (dorsocaudal) hepatic duct (single straight arrow) joining right anterior (cranioventral) hepatic duct (short double arrowheads) to form right hepatic duct (long arrowhead). Left hepatic duct (double arrows) joins right hepatic duct to form common hepatic duct (curved arrow). Intraoperative cholangiogram (B) confirms findings on mangafodipir trisodium—enhanced MR cholangiography (A).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —36-year-old living female liver donor who underwent left hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows right posterior hepatic duct (single straight arrow) joining left hepatic duct (double arrows), the most common variant of biliary duct anatomy. Right anterior hepatic duct (arrowhead) drains into common duct (curved arrow). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiography (A). Intraoperative cholangiogram (C) after left hepatectomy shows resected margin of left hepatic duct.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —36-year-old living female liver donor who underwent left hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows right posterior hepatic duct (single straight arrow) joining left hepatic duct (double arrows), the most common variant of biliary duct anatomy. Right anterior hepatic duct (arrowhead) drains into common duct (curved arrow). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiography (A). Intraoperative cholangiogram (C) after left hepatectomy shows resected margin of left hepatic duct.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —36-year-old living female liver donor who underwent left hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows right posterior hepatic duct (single straight arrow) joining left hepatic duct (double arrows), the most common variant of biliary duct anatomy. Right anterior hepatic duct (arrowhead) drains into common duct (curved arrow). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiography (A). Intraoperative cholangiogram (C) after left hepatectomy shows resected margin of left hepatic duct.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —51-year-old living female liver donor who underwent left hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows aberrant right posterior duct draining segment VI (straight arrow) joining common hepatic duct (curved arrow). This variant is unfavorable for right lobe harvesting because additional biliary anastomosis is required in recipient, with increased risk of recipient biliary complications. Donor also had accessory right hepatic artery arising from superior mesenteric artery; this variant made harvesting of right lobe unfavorable. Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiogram (A).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —51-year-old living female liver donor who underwent left hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows aberrant right posterior duct draining segment VI (straight arrow) joining common hepatic duct (curved arrow). This variant is unfavorable for right lobe harvesting because additional biliary anastomosis is required in recipient, with increased risk of recipient biliary complications. Donor also had accessory right hepatic artery arising from superior mesenteric artery; this variant made harvesting of right lobe unfavorable. Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiogram (A).

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —57-year-old living female liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows accessory left hepatic duct (short straight arrow) draining directly into common hepatic duct (curved arrow). Right posterior (double arrows) and anterior (long arrow) ducts join to form right hepatic duct (arrowhead). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiogram (A).

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —57-year-old living female liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows accessory left hepatic duct (short straight arrow) draining directly into common hepatic duct (curved arrow). Right posterior (double arrows) and anterior (long arrow) ducts join to form right hepatic duct (arrowhead). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiogram (A).

Two of these three donors underwent an extended left hepatectomy (segments I-IV)—one because of anomalous biliary anatomy (Fig. 2A,2B,2C) and the other because of anomalous biliary and arterial anatomy (an accessory right hepatic artery was arising from the superior mesenteric artery) (Fig. 3A,3B). Mangafodipir trisodium—enhanced MR cholangiography correctly identified conventional biliary anatomy in five donors and anatomic variants in three donors and was concordant with the intraoperative cholangiographic findings in eight (100%) of eight patients.

On mangafodipir trisodium—enhanced MR cholangiography, fourth-order branching patterns of the right hepatic duct were seen in four donors (three right anterior ducts and one right posterior hepatic duct); a third-order branching pattern was seen in eight donors (three anterior and five posterior); and a second-order branching pattern was seen in two donors (both right common ducts). On the left, fifth- and fourth-order branching patterns were seen in one donor each (both left lateral ducts); third-order branching patterns, in seven donors (three medial and four lateral ducts); and second-order branching patterns, in six donors (four medial; one each, lateral and left common hepatic ducts). The time interval between injection of mangafodipir trisodium and maximal distention of the hepatic ducts was not constant among the donors. As compared with the intraoperative cholangiography, mangafodipir trisodium—enhanced MR cholangiography did not show the hepatic bile ducts at the periphery of the liver, and the caliber of the contrast-filled ducts was less (physiologic distention on mangafodipir trisodium—enhanced MR cholangiography vs more distention due to injection under pressure during intraoperative cholangiogram). However, the ability of mangafodipir trisodium—enhanced MR cholangiography to depict central hepatic ducts was sufficient for preoperative planning.

Discussion

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A steady increase in the number of patients in need of liver transplantation in the United States and a scarcity of cadaveric livers have led to a rise in adult-to-adult right lobe transplantation as an alternative to cadaveric liver transplantation. The living donors are healthy individuals, and ensuring their safety is of paramount importance. In addition to other clinical and anatomic information, depiction of the biliary tract anatomy before graft harvesting is crucial for the transplantation surgeon. Preoperative diagnosis of biliary tract anatomic variants with screening imaging tests may allow for better preoperative surgical planning and avert unnecessary surgery in donors with potentially unsuitable anatomies, thereby decreasing complications in the donors and recipients. Obtaining the information about the biliary anatomy only at surgery with intraoperative cholangiography would result in an increase in the number of surgeries that may need to be aborted because of the donor's anomalous biliary anatomy and an increase in postoperative complications because of biliary anomalies that may not be apparent on intraoperative cholangiography.

Helical CT cholangiography, MR cholangiography, endoscopic retrograde cholangiography, and percutaneous cholangiography have been used to evaluate the biliary tract in presurgical patients [7, 10, 11]. We assessed a noninvasive method to evaluate the biliary anatomy of liver donors using mangafodipir trisodium—enhanced MR cholangiography that was recently described by another group of researchers [9].

Mangafodipir trisodium is a contrast agent composed of a water-soluble chelate complex salt between a paramagnetic manganese (Mn⁺²) ion (II) and the ligand dipyridoxyl diphosphate, a vitamin B₆ analogue [12]. After IV administration of mangafodipir trisodium, manganese from the dipyridoxyl diphosphate ligand is bound to plasma proteins and secreted with bile by the liver. Fifty-two to sixty-one percent is excreted through the gastrointestinal tract and approximately 14-20%, in the urine [12]. The Mn⁺² ion results in shortening of the longitudinal (spin-lattice) or T1 relaxation time, with a concomitant increase in signal intensity of liver on T1-weighted images [13]. Mangafodipir begins to increase the intensity of the liver within 1-3 min of IV injection, with steady-state enhancement in about 5-10 min. Liver enhancement may be seen for up to 24 hr after mangafodipir administration. As the contrast agent is excreted into the bile ducts, there is a concomitant increase in the bile signal intensity on the short-TR sequences. In our experience, the signal intensity in the bile ducts peaks between 5-10 min and then decreases as contrast material accumulates in the gallbladder.

The incidence of biliary tract anatomy variants found in our series correlates with prior reports in the literature. Conventional biliary anatomy was the most common pattern, present in 62.5% of donors. Conventional hepatic biliary anatomy has been reported to occur in 57% of individuals in large studies [7, 11]. The most common biliary variants noted in these studies included the right posterior hepatic duct draining into the left hepatic duct (13-16%) and a trifurcation pattern (12%), with the right posterior hepatic duct draining to the junction of the right anterior and left hepatic ducts into the right (lateral) aspect of the right anterior hepatic duct. Less common variations included an aberrant right posterior hepatic duct draining directly into the common hepatic duct (4%) or into the cystic duct (2%) and accessory right (2%) or left hepatic ducts (1-2%). Some variants, (e.g., the trifurcation pattern) may preclude donor graft harvesting because of the significant increase in the risk of postoperative complications. One patient in our study had a short common right hepatic duct (Fig. 5A,5B,5C), which may be difficult to distinguish from the trifurcation pattern on conventional MR cholangiography.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —19-year-old living male liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows biliary anatomy closely resembling trifurcation pattern that is typically difficult to diagnose on conventional T2-weighted MR cholangiography. Short right hepatic duct (long arrow) joins left hepatic duct (short arrow) to form common hepatic duct (arrowhead). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiography (A). Intraoperative cholangiogram (C) after right hepatectomy shows left (short arrow) and common (arrowhead) hepatic ducts.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —19-year-old living male liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows biliary anatomy closely resembling trifurcation pattern that is typically difficult to diagnose on conventional T2-weighted MR cholangiography. Short right hepatic duct (long arrow) joins left hepatic duct (short arrow) to form common hepatic duct (arrowhead). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiography (A). Intraoperative cholangiogram (C) after right hepatectomy shows left (short arrow) and common (arrowhead) hepatic ducts.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C. —19-year-old living male liver donor who underwent right hepatectomy. Three-dimensional volumetric maximum-intensity-projection mangafodipir trisodium—enhanced MR cholangiogram (A) shows biliary anatomy closely resembling trifurcation pattern that is typically difficult to diagnose on conventional T2-weighted MR cholangiography. Short right hepatic duct (long arrow) joins left hepatic duct (short arrow) to form common hepatic duct (arrowhead). Intraoperative cholangiogram (B) confirms finding on mangafodipir trisodium—enhanced MR cholangiography (A). Intraoperative cholangiogram (C) after right hepatectomy shows left (short arrow) and common (arrowhead) hepatic ducts.

The accurate definition of a donor's biliary anatomy is crucial for the preoperative planning by the surgeons for the type of surgery—right versus left hepatectomy. Right hepatectomy was planned in six donors and an extended left hepatectomy, in two donors with anomalous biliary anatomies, on the basis of the preoperative findings of mangafodipir trisodium—enhanced MR cholangiography. As shown in Figures 2A,2B,2C and 3A,3B, two patients underwent different harvesting on the basis of preoperative imaging.

Conventional MR cholangiography has also been used for assessing the intrahepatic biliary anatomy in liver donors [4,5,6]. Two prior studies have shown limitations with conventional MR cholangiography in depicting biliary anatomy [4, 5]. Excellent contrast between the hepatic parenchyma and the mangafodipir trisodium—opacified ducts on T1-weighted images provides better definition of the biliary anatomy than that achieved on conventional MR cholangiography. The increased contrast also greatly aids in distinguishing bile ducts from hepatic vessels. The superior image resolution with the mangafodipir trisodium—enhanced 3D volumetric sequence (voxel size, 1.0 x 1.5 x 1.5 mm) is useful for delineating the smaller branches of the common, right, and left hepatic ducts and may help in patient selection or exclusion. Volume rendering, which is possible with the volumetric data sets from the 3D volumetric mangafodipir trisodium—enhanced studies, and the ability to view the images in multiple orthogonal planes (viewing options with MR cholangiography are limited because of the two-dimensional data set) are also helpful in evaluating the relationships of the right, left, and common hepatic ducts. One particular variant, the short right common hepatic duct simulating a trifurcation pattern, is particularly difficult to depict with conventional MR cholangiography. This variant was successfully delineated in one patient in our series (Fig. 5A,5B,5C). A larger series comparing mangafodipir trisodium—enhanced MR cholangiography and MR cholangiography is needed to determine the relative roles of these techniques in evaluating biliary anatomy. Like conventional MR cholangiography, mangafodipir trisodium—enhanced MR cholangiography allows gadolinium-enhanced imaging of hepatic arterial and venous anatomy during the same examination.

Although helpful as an aid for biliary mapping, mangafodipir trisodium—enhanced MR cholangiography has limitations. Compared with intraoperative cholangiography, mangafodipir trisodium—enhanced MR cholangiography does not reliably depict the peripheral branches of the intrahepatic bile ducts. However, the anatomy of the smaller peripheral branches in living liver donors is not necessary for planning donor graft surgery. It has been suggested that intraoperative cholangiography is inferior to MR cholangiography in complete depiction of the central, right, and left hepatic ducts because of limitations imposed by the surgical field [4], although we did not encounter this limitation on the intraoperative cholangiography in our series.

In conclusion, as correlated with intraoperative cholangiography, our study shows that mangafodipir trisodium—enhanced MR cholangiography accurately depicts living liver donor biliary anatomy. Noninvasive preoperative evaluation of the biliary anatomy in living liver donor candidates is important for detection of common biliary variants that may require alternative graft-harvesting surgery.

References

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