Published online before print May 8, 2003, 10.1148/radiol.2281020740
(Radiology 2003;228:246-250.)
© RSNA, 2003
Vascular and Interventional Radiology |
Relationship between Left Biliary Duct System and Left Portal Vein: Evaluation with Three-dimensional Portocholangiography1
Akihiro Cho, MD,
Shinichi Okazumi, MD,
Youshin Yoshinaga, MD,
Yukika Ishikawa, MD,
Munemasa Ryu, MD and
Takenori Ochiai, MD, PhD
1 From the Department of Academic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba 260-0856, Japan (A.C., S.O., Y.Y., Y.I., T.O.); and Department of Surgery, Chiba Prefectural Sawara Hospital, Japan (M.R.). Received June 19, 2002; revision requested August 21; revision received October 10; accepted December 19. Address correspondence to A.C. (e-mail: cho@maple.ocn.ne.jp).
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ABSTRACT
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PURPOSE: To investigate the relationship between the left biliary duct system and the left portal vein by using in vivo analysis of the human liver with three-dimensional portocholangiography.
MATERIALS AND METHODS: Twenty-seven patients underwent helical computed tomography during both arterial portography and cholangiography. Three-dimensional portocholangiograms were reconstructed to evaluate the relationship between the left biliary duct system and the left portal vein, in particular the umbilical portion.
RESULTS: In 16 (59%) patients, segment II and III ducts united just above the umbilical portion or laterally to it, and the segment IV duct joined medially to the umbilical portion. In eight (30%) patients, segment III and IV ducts united medially to the umbilical portion and the segment II duct joined at a point close to the hepatic hilum. In three (11%) patients, three ducts from segments II–IV united at a position immediately medial to the umbilical portion.
CONCLUSION: Three types of left bile duct anatomy were seen in relation to the left portal vein.
© RSNA, 2003
Index terms: Bile duct radiography, 76.122 • Bile ducts, anatomy, 76.92 • Bile ducts, CT, 76.12112, 76.12115, 76.12117 • Bile ducts, neoplasms, 76.321 • Portal vein, anatomy, 957.92 • Portal vein, CT, 957.12912
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INTRODUCTION
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Surgical resection is the only treatment that offers hope of a cure for biliary tract malignancies, and improved diagnostic and surgical procedures have allowed aggressive surgical approaches to hilar cholangiocarcinoma (1–5). However, the complex anatomy of the portal and biliary systems, in particular the hepatic hilum, still causes difficulties with curative resection. To safely and satisfactorily excise the hepatic hilum, the anatomy of both the portal and the biliary systems and their interrelationships must be understood. In addition, reduced-organ liver transplantation techniques have increased the supply of pediatric donor organs and reduced pretransplantation complications, as well as death (6), but biliary complications occur in approximately 15% of reduced-organ liver transplantation grafts (7,8). This relatively high incidence of biliary complications may be due to not only inherent technical failures but also an incomplete understanding of the surgical anatomy of the left bile duct system as applied to the creation of a left lateral segment graft (9).
Advances in helical computed tomography (CT) have allowed the reconstruction of accurate and realistic three-dimensional (3D) images from arbitrary angles, and the reconstruction of images facilitates comprehension of the complex anatomic structures of the hepatic hilum (10–12). By providing an accurate 3D map of the liver and its vasculature, 3D images are a useful adjunct for surgical planning in living-donor liver transplantation, and 3D images may reduce postoperative complications (13–15). The aim of the present study was to investigate the relationship between the left biliary duct system and the left portal vein by means of in vivo analysis of the human liver by using 3D portocholangiography.
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MATERIALS AND METHODS
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Patients
Between April 1999 and December 2001, 71 consecutive patients with malignant hepatobiliary or pancreatic tumors underwent CT during arterial portography at Chiba Prefectural Sawara Hospital, Japan. Of these 71 patients, 27 patients (10 men, 17 women; age range, 41–81 years; mean age, 65.9 years) who had undergone percutaneous transhepatic biliary drainage because of obstructive jaundice were included in the study population. Our 27 participants had the following types of cancer: bile duct cancer (n = 13), pancreatic cancer (n = 8), gallbladder cancer (n = 5), and cancer of the Vater ampulla (n = 1). In seven of 27 patients, two biliary catheters were placed in each of the right and left hepatic ducts because the hepatic confluence was separated into double units as a result of the cancer. In the remaining 20 patients, a single biliary catheter was placed at the common duct because biliary obstruction was distal to the hepatic confluence. For preoperative diagnosis of cancer extension, direct cholangiography through biliary catheters had been performed, and the volumes of contrast material necessary to display the entire biliary tree with fluoroscopy in each patient were recorded. The study protocol was approved by the institutional review board, and written informed consent was obtained from all patients before starting the procedure.
CT Imaging
All studies were performed with a commercially available helical CT scanner (Somatom Plus 4; Siemens, Erlangen, Germany). A 5-F catheter was positioned in the superior mesenteric artery, and the patient was transferred to the CT room. We first injected the previously confirmed volumes (range, 12–20 mL; mean, 17.2 mL per patient) of iohexol (Omnipaque; Daiichi, Tokyo, Japan), 300 mg of iodine per milliliter, diluted at a ratio of 1:10 with saline through biliary catheters to achieve biliary opacification and then performed CT during arterial portography cephalocaudally with a single breath-hold helical technique by using collimation of 3 mm, table movement of 3 mm/sec (scanning time per section, 1 second; pitch, 1), and contiguous 1-mm image reconstruction. For CT during arterial portography, 90 mL of iohexol (300 mg of iodine per milliliter) diluted to one-half concentration with saline was injected at a rate of 3 mL/sec into the superior mesenteric artery during CT scanning of the entire liver. The scanning delay after the start of iohexol injection into the superior mesenteric artery was 20 seconds (12). Neither serious nor minor complications occurred during or after procedures in all patients. Our method of dilution of the biliary and arterial contrast was successful in uniformly differentiating the biliary from the portal system on the 3D renderings in all patients.
Image Processing and Analysis
The CT data were downloaded to an independent workstation equipped with software for perspective volume rendering (3D Virtuoso, Siemens; Plug’n View ZEUS, Azemoto, Tokyo, Japan). With this software, 3D portocholangiograms were reconstructed. Segmentation of the liver and biliary and portal systems used in this study was based on the system of Couinaud (16). The original consecutive transverse CT images and 3D portocholangiograms were interpreted independently in a separate blinded fashion by two authors (A.C., Y.I.) with 12 and 7 years experience, respectively, who assessed the bifurcation pattern of the left main portal vein, the biliary ductal branches forming the left hepatic duct, and the relationship between the left portal and biliary systems. Discrepancies were resolved with consensus.
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RESULTS
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Bifurcation Pattern of the Left Main Portal Vein
Analysis of 3D portocholangiograms revealed only one structural design of the left portal system: The left main portal vein bifurcated into the segment II portal branch and the umbilical portion; then the umbilical portion bifurcated into the segment IV portal branch and the segment III portal branch.
Biliary Ductal Branches That Formed Left Hepatic Duct
In contrast with the left portal vein, three distinct types of left bile duct anatomy were detected (Table). Type 1 anatomy was characterized by the union of the segment II and III ducts to form a single left lateral segmental duct, with one or two segment IV ducts joining to form the left hepatic duct (Fig 1a). This type was seen in 16 (59%) of 27 patients. Type 2 anatomy was characterized by a common trunk of segment III and IV ducts that received a segment II duct to form the left hepatic duct (Fig 1b). This type was seen in eight (30%) of 27 patients. Type 3 anatomy was characterized by the union of segment II–IV ducts to immediately form the left hepatic duct (Fig 1c). This type was seen in three (11%) of 27 patients.
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Figure 1a. Diagrams show three variants of left biliary (B) and portal (P) systems. B2 = segment II bile duct, B3 = segment III bile duct, B4 = segment IV bile duct, P2 = segment II portal branch, P3 = segment III portal branch, P4 = segment IV portal branch, UP = umbilical portion. (a) Type 1 variant. Segment II and III ducts unite just above or laterally to umbilical portion; segment IV duct then joins medially to umbilical portion. (b) Type 2 variant. Segment III and IV ducts unite medially to umbilical portion; segment II duct then joins close to the hepatic hilum. (c) Type 3 variant. Three ducts from segments II-IV immediately unite medially to umbilical portion. Left main portal vein bifurcates into the segment II portal branch and the umbilical portion; the umbilical portion then bifurcates into the segment IV and segment III portal branches.
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Figure 1b. Diagrams show three variants of left biliary (B) and portal (P) systems. B2 = segment II bile duct, B3 = segment III bile duct, B4 = segment IV bile duct, P2 = segment II portal branch, P3 = segment III portal branch, P4 = segment IV portal branch, UP = umbilical portion. (a) Type 1 variant. Segment II and III ducts unite just above or laterally to umbilical portion; segment IV duct then joins medially to umbilical portion. (b) Type 2 variant. Segment III and IV ducts unite medially to umbilical portion; segment II duct then joins close to the hepatic hilum. (c) Type 3 variant. Three ducts from segments II-IV immediately unite medially to umbilical portion. Left main portal vein bifurcates into the segment II portal branch and the umbilical portion; the umbilical portion then bifurcates into the segment IV and segment III portal branches.
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Figure 1c. Diagrams show three variants of left biliary (B) and portal (P) systems. B2 = segment II bile duct, B3 = segment III bile duct, B4 = segment IV bile duct, P2 = segment II portal branch, P3 = segment III portal branch, P4 = segment IV portal branch, UP = umbilical portion. (a) Type 1 variant. Segment II and III ducts unite just above or laterally to umbilical portion; segment IV duct then joins medially to umbilical portion. (b) Type 2 variant. Segment III and IV ducts unite medially to umbilical portion; segment II duct then joins close to the hepatic hilum. (c) Type 3 variant. Three ducts from segments II-IV immediately unite medially to umbilical portion. Left main portal vein bifurcates into the segment II portal branch and the umbilical portion; the umbilical portion then bifurcates into the segment IV and segment III portal branches.
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Relationship between Left Portal and Biliary Systems
The orientation in which the left lateral ducts crossed the umbilical portion cranially and the left biliary ducts coursed superior to the transverse portion was constant. In all 16 patients with type 1 anatomy, segment II and III ducts united just above or lateral to the umbilical portion; then the segment IV duct joined medially to the umbilical portion (Figs 1a, 2). In two (13%) of 16 patients with type 1 anatomy, the segment IV duct joined at a point close to the hepatic hilum (Fig 3). In all eight patients with type 2 anatomy, segment III and IV ducts united medially to the umbilical portion; then the segment II duct joined at a point close to the hepatic hilum (Figs 1b, 4). In both patients with type 3 anatomy, three ducts from segments II–IV united medially to the umbilical portion (Figs 1c, 5).
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Figure 2a. Bile duct cancer in two patients. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1. (a) Three-dimensional portocholangiogram obtained in a 78-year-old woman shows caudocranial view of portobiliary systems. Segment II and III ducts united (thick arrow) lateral to umbilical portion (thin arrow); then, segment IV duct (arrowhead) joined medially to umbilical portion. (b) Three-dimensional portocholangiogram obtained in a 50-year-old man shows craniocaudal view of portobiliary systems. Segment II and III ducts united (thick arrow) just above umbilical portion (thin arrow); then, segment IV duct (arrowhead) joined medially to umbilical portion.
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Figure 2b. Bile duct cancer in two patients. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1. (a) Three-dimensional portocholangiogram obtained in a 78-year-old woman shows caudocranial view of portobiliary systems. Segment II and III ducts united (thick arrow) lateral to umbilical portion (thin arrow); then, segment IV duct (arrowhead) joined medially to umbilical portion. (b) Three-dimensional portocholangiogram obtained in a 50-year-old man shows craniocaudal view of portobiliary systems. Segment II and III ducts united (thick arrow) just above umbilical portion (thin arrow); then, segment IV duct (arrowhead) joined medially to umbilical portion.
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Figure 3. Bile duct cancer in a 56-year-old man. Three-dimensional portocholangiogram shows craniocaudal view of portobiliary systems. Segment IV duct joined at a point close to the hepatic hilum. Arrow points to umbilical portion. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1.
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Figure 4a. Bile duct cancer in a 74-year-old woman. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1. (a) Three-dimensional portocholangiogram shows caudocranial view of portobiliary systems. Left lateral ducts crossed umbilical portion (thin arrow) cranially, and left biliary duct (thick arrow) coursed anterior to transverse portion. (b) Three-dimensional portocholangiogram shows craniocaudal view of portobiliary systems. Segment III and IV ducts united medially to umbilical portion (arrow); then segment II duct and segment I duct (B1) joined close to hepatic hilum.
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Figure 4b. Bile duct cancer in a 74-year-old woman. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1. (a) Three-dimensional portocholangiogram shows caudocranial view of portobiliary systems. Left lateral ducts crossed umbilical portion (thin arrow) cranially, and left biliary duct (thick arrow) coursed anterior to transverse portion. (b) Three-dimensional portocholangiogram shows craniocaudal view of portobiliary systems. Segment III and IV ducts united medially to umbilical portion (arrow); then segment II duct and segment I duct (B1) joined close to hepatic hilum.
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Figure 5a. Bile duct cancer in a 65-year-old woman. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1. (a) Three-dimensional portocholangiogram shows caudocranial view of portobiliary systems. Two segment IV ducts joined (arrow) medially to umbilical portion. (b) Three-dimensional portocholangiogram shows craniocaudal view of portobiliary systems. Segments II-IV immediately united (arrow) medially to umbilical portion.
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Figure 5b. Bile duct cancer in a 65-year-old woman. D = dorsal direction, V = ventral direction. Other keys are the same as for Figure 1. (a) Three-dimensional portocholangiogram shows caudocranial view of portobiliary systems. Two segment IV ducts joined (arrow) medially to umbilical portion. (b) Three-dimensional portocholangiogram shows craniocaudal view of portobiliary systems. Segments II-IV immediately united (arrow) medially to umbilical portion.
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DISCUSSION
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The portal and biliary anatomy of the left lobe of the liver has been thoroughly analyzed by using ex vivo acrylic corrosion casts and cadaveric dissections, which have recently contributed to technical developments in liver surgery (9,16–18). In a review of 100 liver autopsy specimens, Healey and Schroy (17) described that the segment II and III ducts united to form the left lateral duct, which was then joined by a segment IV duct, in 67% of these specimens. They also described that segment III and IV ducts united to form the common trunk, which was then joined by a segment II duct, in 25% of the specimens. Reichert et al (9) reported that segment IV joined the left lateral duct formed by segment II and III ducts in 55% of autopsy specimens, two parallel ducts from segment IV joined the left lateral duct in 30%, segment IV and III ducts united to form the common trunk that was then joined by a segment II duct in 10%, and segment II–IV ducts immediately united to form the left hepatic duct in 5%.
Findings of our radiologic study indicated that segment IV ducts joined the left lateral duct in 59% of patients, that segment II ducts joined the common trunk of segment III and IV ducts in 30%, and that segment II–IV ducts immediately united in 11%. Both the anatomic and radiologic findings were similar. However, discrepancies between corrosion casts and the in vivo liver may have made interpretation of hepatic anatomy difficult and were often the cause of serious misinterpretation in the preoperative diagnosis (19). In fact, discrepancies between anatomic and radiologic study findings with respect to the relationship between the left biliary duct system and the umbilical portion were noted. Healey and Schroy (17) described the union of segment II and III bile ducts in the umbilical fissure in 50% of autopsy specimens, to the left of the umbilical fissure in 42%, and to the right of the umbilical fissure in 8%. Reichert et al (9) reported that the left lateral duct originated at the umbilical fissure in 5% of specimens, to the right of the umbilical fissure in 50%, and to the left of the umbilical fissure in 45%.
In contrast, Russell et al (20), in a review of 838 cholangiograms and 15 liver autopsy specimens, described that the segment II and III bile ducts joined immediately lateral to the plane of the falciform ligament in most patients. Findings in the present study indicated that segment II and III bile ducts united just above or lateral to the umbilical portion in 59%. The assumed explanation for these discrepancies is that the entire vasculature shifts in such a way that the umbilical portion is located farther laterally than in the physiologic state when the corrosion cast of the liver is placed on the table with posterior surface facing downward. However, comprehension of the relationship between the left biliary duct system and the umbilical portion on only routine cholangiograms and portograms is extremely difficult. Cheng et al (21), in a review of 210 cholangiograms and hepatic arterial portograms, reported that the intrahepatic portal vein and bile duct had the same anatomic classification in 83.33%. In contrast, the findings of the present study indicated that the left portal and biliary system had the same ramification (type 2) in only 30%. According to the results of the present study, in all patients with type 1 anatomy, segment II and III ducts united just above or laterally to the umbilical portion; in all patients with types 2 and 3 anatomy, segment II and III ducts united medially to the umbilical portion; and in all patients regardless of type, segment IV ducts joined medially to the umbilical portion.
In conclusion, although our study is limited in that there is no actual standard for the findings, and we will attempt to compare both radiologic and surgical findings in a future study, we consider recognition of this vascular anatomy to be clinically important not only for the preoperative evaluation of patients with hilar cholangiocarcinoma but also for reduced-organ liver transplantation. If the left biliary ramification is confirmed, the relationship between the left biliary duct system and the left portal vein, in particular the umbilical portion, can be easily predicted.
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FOOTNOTES
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Abbreviation: 3D = three-dimensional
Author contributions: Guarantor of integrity of entire study, A.C.; study concepts and design, A.C.; literature research, A.C., S.O.; clinical studies, A.C., Y.Y., Y.I.; data acquisition and analysis/interpretation, A.C., Y.I.; manuscript preparation and editing, A.C., S.O.; manuscript definition of intellectual content, A.C., M.R.; manuscript revision/review, A.C., S.O., T.O.; manuscript final version approval, A.C., M.R., T.O.
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TOP
ABSTRACT
INTRODUCTION
