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Published online before print April 15, 2005, 10.1148/radiol.2353040424
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(Radiology 2005;235:899-904.)
© RSNA, 2005

Gastrointestinal Imaging

Living Donor Candidates for Right Hepatic Lobe Transplantation: Evaluation at CT Cholangiography—Initial Experience1

Zhen J. Wang, MD, Benjamin M. Yeh, MD, John P. Roberts, MD, Richard S. Breiman, MD, Aliya Qayyum, MB, BS and Fergus V. Coakley, MD

1 From the Departments of Radiology (Z.J.W., B.M.Y., R.S.B., A.Q., F.V.C.) and Surgery (J.P.R.), University of California San Francisco, Box 0628, C-324C, 505 Parnassus Ave, San Francisco, CA 94143-0628. From the 2003 RSNA Annual Meeting. Received March 3, 2004; revision requested May 14; revision received July 6; accepted August 5. Address correspondence to B.M.Y. (e-mail: ben.yeh@radiology.ucsf.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To retrospectively evaluate computed tomographic (CT) cholangiography in the depiction of second-order biliary tract anatomy in living donor candidates for right hepatic lobe transplantation.

MATERIALS AND METHODS: Human research committee approval was obtained, informed consent was not required, and the study was compliant with the Health Insurance Portability and Accountability Act. The authors identified all living right-lobe liver donor candidates who underwent CT cholangiography at their institution between October 2001 (when CT cholangiography was introduced at the institution) and March 2003 (n = 62). There were 41 men (mean age, 36 years; range, 18–55 years) and 21 women (mean age, 40 years; range, 22–55 years). Two readers in consensus rated quality of second-order bile duct visualization at CT cholangiography on a four-point scale (0, not seen; 3, excellent visualization) and noted the presence of variant second-order biliary tract branching anatomy. CT cholangiography findings were compared with those at surgery in subjects who underwent right hepatic lobe retrieval (n = 24). In addition, adult donors who underwent right hepatic lobe retrieval between January 2000 and March 2003 (29 men, mean age, 35 years [range, 20–52 years]; 18 women, mean age, 38 years [range, 23–54 years]) were identified. Numbers of donors who underwent intraoperative cholangiography before and after the introduction of CT cholangiography were compared by using the Fisher exact test.

RESULTS: The mean second-order bile duct score at CT cholangiography was 2.9 (range, 2–3). Of 24 subjects who underwent right lobe retrieval, biliary tract anatomy determined at CT cholangiography was concordant with findings at surgery in 23 (96%). Variant second-order branching anatomy was seen in 13 subjects (54%) at surgery; one variant branch was missed at CT cholangiography. Of 47 subjects who underwent right hepatic lobe retrieval, significantly fewer subjects required conventional intraoperative cholangiography after the introduction of CT cholangiography (three of 24 subjects [12%]) than before (23 of 23 subjects; P < .0001).

CONCLUSION: CT cholangiography accurately depicts biliary tract anatomy in living donor candidates for right hepatic lobe transplantation, and donors who undergo preoperative CT cholangiography are unlikely to need conventional intraoperative cholangiography.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Living donor right-lobe liver transplantation is an important therapeutic option for adult patients who need to undergo liver transplantation (1,2). The preoperative assessment of living liver donor candidates includes evaluation of second-order biliary tract anatomy because variant anatomy is seen in up to 45% of the population (3,4). Variant second-orderbiliary tract anatomy affects the surgical approach and biliary anastomotic technique and may preclude liver donation (5,6). Although endoscopic retrograde cholangiography is the standard test for defining biliary anatomy, it is invasive and has a major complication rate of 1.4%–3.2% (7,8). The noninvasive evaluation of the biliary tract with computed tomographic (CT) cholangiography has shown promising results in small series (9,10). Therefore, we undertook this study to retrospectively evaluate CT cholangiography in the depiction of second-order biliary tract anatomy in living donor candidates for right hepatic lobe transplantation.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
This was a retrospective single-institution study approved by our Committee on Human Research. Patient informed consent was not required. Our study was compliant with the Health Insurance Portability and Accountability Act. CT cholangiography has been described in reports of studies in the United States (11–13) and has been used extensively in Asia (14–19) and Europe (10,20–22). In addition, intravenous iodipamide meglumine (Cholografin; Bracco Diagnostics, Princeton, NJ) is approved by the U.S. Food and Drug Administration for imaging of the biliary tract. For these reasons, our Committee on Human Research did not require its approval for use of this agent in clinical examinations of the biliary tract.

One radiologist (Z.J.W.) retrospectively identified all consecutive CT cholangiograms obtained at our institution in living donor candidates for right-lobe liver transplantation between October 2001 (when CT cholangiography was introduced at our institution) and March 2003. There were 62 donor candidates: 41 men with a mean age of 36 years (range, 18–55 years) and 21 women with a mean age of 40 years (range, 22–55 years). There was no statistically significant difference in mean age between men and women (P = .15, unpaired two-sample t test). Twenty-four of these 62 patients subsequently underwent right hepatic lobe retrieval. The surgeons performing transplantation were aware of all findings at CT cholangiography before surgery. In this series, no patients were excluded from liver donation on the basis of biliary duct anatomy as seen at CT cholangiography. Intraoperative cholangiography was performed at the discretion of the surgeons when confirmation of biliary anatomy was believed to be necessary.

One radiologist (Z.J.W.) also identified all adult donors at our institution who underwent right hepatic lobe retrieval between January 2000 (the start of adult living related liver transplantation) and March 2003 (n = 47). Subjects included 29 men with a mean age of 35 years (range, 20–52 years) and 18 women with a mean age of 38 years (range, 23–54 years). There was no statistically significant difference in mean age between men and women (P = .41, unpaired two-sample t test).

The first author (Z.J.W.) recorded the need for conventional intraoperative cholangiography before and after the introduction of CT cholangiography to see whether the existence of CT cholangiography had any effect on the frequency of conventional intraoperative cholangiography. Before the introduction of CT cholangiography at our institution, intraoperative cholangiography was routinely performed to define biliary anatomy before right hepatic lobe retrieval. The medical records of all 62 patients who underwent CT cholangiography were reviewed by one radiologist (Z.J.W.) to identify any potential donors who were excluded from liver donation because of a biliary anatomic variant demonstrated at CT cholangiography. Surgeons were aware of the results of CT cholangiography before surgery, and intraoperative cholangiography was performed at the discretion of the surgeon.

CT Cholangiographic Technique
All 62 patients underwent multi–detector row CT evaluation of the hepatic vascular anatomy, liver volume, and liver parenchyma immediately before undergoing CT cholangiography. Our CT cholangiographic technique was heterogeneous because it was evolved over time. CT scans obtained before February 2002 (n = 8) were obtained with a four–detector row unit (high-speed mode, LightSpeed LX/i; GE Medical Systems, Milwaukee, Wis), and scans obtained during or after February 2002 (n = 54) were obtained with a 16–detector row unit (Lightspeed; GE Medical Systems). The first author estimated the average dose of CT cholangiography by multiplying the dose length product value recorded from the scanner console by multipliers specific to the abdomen according to the method outlined by Jessen et al (23). The estimated dose for a CT cholangiogram is about 7.6 mSv. The average dose for an intraoperative cholangiogram is similar to that for an abdominal radiograph, which has been reported in the literature to have a dose equivalent of 0.6–1.7 mSv (24).

No oral contrast material was administered for CT cholangiography. Before the administration of cholangiographic contrast material, each subject received 25 mg of intravenous diphenhydramine (Benadryl; Pfizer, New York, NY). In subjects examined before January 2003 (n = 41), we also administered intravenous morphine sulfate (Abbott Laboratories, Chicago, Ill; 0.04 mg per kilogram of body weight) to contract the sphincter of Oddi (25–27) and possibly improve biliary distention. However, because the image quality of the CT cholangiograms did not improve with intravenous morphine administration (B.M.Y., unpublished data, November 2001), the remaining subjects (n = 21) were not given morphine. Twenty milliliters of iodipamide meglumine 52% (Cholografin; Bracco Diagnostics) diluted in 80 mL of normal saline was infused over 30 minutes.

The liver was imaged during a single breath hold 15 minutes after the completion of infusion. Section thickness, gantry rotation time, and table-top speed were 1.25 mm, 0.8 per second, and 13.5 mm/sec for the 16–detector row scanner and 2.5 mm, 0.8 per second, and 15 mm/sec for the four–detector row scanner, respectively. All subjects were observed for reactions to contrast material from the start of contrast material injection until the end of the CT examination (about 55 minutes). Two minor reactions occurred: One patient developed mild wheezing and one developed scattered urticaria. These reactions resolved without specific treatment within 15 minutes of onset.

Image Processing and Interpretation
The field of view of the source images was 360–440 mm, with a pixel size of 0.7–0.9 mm. CT scans were reconstructed at a reduced field of view (250–300 mm) and at intervals of 1.25 mm (n = 8, four–detector row CT scanner) or 0.625 mm (n = 54, 16–detector row CT scanner). Volumetric images were then reconstructed on a dedicated three-dimensional workstation (Advantage for Windows 4.0 or 3.1; GE Medical Systems)by using maximum intensity projection and volume-rendered techniques. Two radiologists (B.M.Y. and F.V.C., with 2 and 7 years, respectively, of subspecialty experience with CT of the liver), who were unaware of findings at clinical and other imaging examinations, reviewed by consensus all source and reconstructed CT images on a picture archiving and communication system workstation (Impax; Agfa, Mortsel, Belgium). Although these two radiologists were involved in the interpretation of some of the CT cholangiograms at the time they were obtained, they were unaware of the surgical findings when they were reviewing images for this study. Second-order biliary branches were scored by using a four-point scale, as follows: 0, not seen; 1, faintly seen; 2, well seen but the confluence or a portion of the biliary branch segment is not seen; and 3, excellent visualization from proximal commencement to distal confluence.

Second-order biliary tract anatomy was classified as conventional or variant. In conventional anatomy, the right posterior duct (which drains Couinaud segments VI and VII) joins the right anterior duct (which drains Couinaud segments V and VIII) to form the right hepatic duct, which then joins the left hepatic duct (which is formed by ducts draining Couinaud segments II, III, and IV) (3). All other anatomic configurations were considered variant.

Comparisons
In the 24 subjects who underwent CT cholangiography and right hepatic lobe retrieval, the biliary anatomy shown at CT cholangiography was compared with surgical findings. The comparison was done by one radiologist (Z.J.W.). The number of subjects in whom intraoperative cholangiography was necessary was compared for the 47 patients undergoing right hepatic lobe retrieval before and after the introduction of CT cholangiography.

Statistical Analysis
The proportion of subjects who underwent intraoperative cholangiographic assessment of second-order biliary anatomy was compared for the donors who undergoing right hepatic lobe retrieval before and after the introduction of CT cholangiography by using the Fisher exact test. A P value of less than .05 was considered indicative of a statistically significant difference. Statistical analysis was performed by using Stata software package version 7.0 (Stata, College Station, Tex).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
The mean second-order biliary branch visualization score was 2.9 (range, 2–3). Second-order biliary tract branching anatomy determined at CT cholangiography is summarized in the Table. Examples of CT cholangiograms are shown in Figures 1 and 2.


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  		Second-Order Biliary Branch Anatomy at CT Cholangiography

 


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  		Figure 1. Oblique coronal volume-rendered CT cholangiogram (image acquired with 1.25-mm section thickness) in a 41-year-old man examined for potential right hepatic lobe donation. Conventional branching anatomy of the bile ducts is seen. In particular, the right posterior branch (second-order branch) is fully visible (arrow).

 


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  		Figure 2a. Images in a 45-year-old woman examined for potential liver donation. (a) Coronal volume-rendered CT cholangiogram (image acquired with 2.5-mm section thickness) shows a right posterior biliary branch (arrow) inserting into the common hepatic duct. (b) Intraoperative cholangiogram shows similar second-order biliary branch (arrow) anatomy.

 


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  		Figure 2b. Images in a 45-year-old woman examined for potential liver donation. (a) Coronal volume-rendered CT cholangiogram (image acquired with 2.5-mm section thickness) shows a right posterior biliary branch (arrow) inserting into the common hepatic duct. (b) Intraoperative cholangiogram shows similar second-order biliary branch (arrow) anatomy.

 
Variant second-order biliary tract anatomy was seen at CT cholangiography in 27 (44%) of the 62 subjects (Table). Of the 24 subjects who underwent right hepatic lobe retrieval, second-order biliary branch anatomy as determined at CT cholangiography was concordant with findings at surgery in 23 (96%) subjects. Twelve (50%) of these 24 subjects had variant second-order biliary branch anatomy seen at CT and confirmed with surgery, and the variants consisted of aberrant insertion of the right posterior duct into the common hepatic duct (n = 6), aberrant insertion of the right posterior duct into the left main duct (n = 3), trifurcation of the common hepatic duct (n = 2), or insertion of an accessory right anterior duct into the common hepatic duct (n = 1).

In one subject, an aberrant right duct insertion was missed at CT cholangiography (Fig 3). Two right-sided second-order biliary branches separated by less than 1 mm of tissue were found in this subject at surgery. The CT cholangiogram had been obtained with 2.5-mm-thick sections.



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  		Figure 3. Coronal maximum intensity projection CT cholangiogram (image acquired with 2.5-mm section thickness) in a 43-year-old man examined for potential liver donation. Although the image shows conventional anatomy, two right-sided biliary branches separated by less than 1 mm of tissue were found at surgery.

 
Among all 47 adult living donors who underwent right hepatic lobe retrieval at our institution since the start of adult living related liver transplantation in January 2000, significantly fewer subjects required conventional intraoperative cholangiography after the introduction of CT cholangiography (three of 24 subjects [12%]) than before the introduction of CT cholangiography (23 of 23 subjects [100%]; P < .0001) (Fig 4). Of the three subjects who underwent intraoperative cholangiography after CT cholangiography, all three had variant second-order biliary tract branching anatomy, and the subtype of anatomic variants was identical as determined at CT and conventional cholangiography. It is at the transplant surgeon’s discretion whether to perform intraoperative cholangiography after CT cholangiography. Two of the three subjects underwent intraoperative cholangiography in November 2001, within 1 month of the introduction of CT cholangiography. The third subject underwent intraoperative cholangiography in November 2002. This subject was determined to have conventional biliary anatomy at the initial interpretation of the CT cholangiogram. However, further review of the CT cholangiogram immediately before surgery revealed variant anatomy with aberrant insertion of the right posterior duct into the left main duct.



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  		Figure 4. Diagram shows the number of living right-lobe liver donors who underwent intraoperative cholangiography before and after the introduction of CT cholangiography at our institution. Before the introduction of CT cholangiography, all 23 donors underwent intraoperative cholangiography for the assessment of second-order biliary tract anatomy. After the introduction of CT cholangiography, only three of 24 donors underwent intraoperative cholangiography.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
We found that CT cholangiography enables consistently good-to-excellent visualization (mean second-order biliary branch visualization score of 2.9 on a scale of 0–3) of second-order biliary branches in living liver donor candidates. Among the 24 subjects who underwent right hepatic lobe retrieval and CT cholangiography, second-order biliary branch anatomy as determined with CT cholangiography was concordant with intraoperative findings in 23 (96%) subjects. In the discordant case, an aberrant right biliary branch insertion was missed at CT cholangiography. At surgery, two right-sided second-order bile ducts were found, separated by less than 1 mm of tissue. This biliary tract anatomic variant was not visible at CT cholangiography, possibly because of limited resolution in the z-axis or slight respiratory blurring. The use of thinner sections and shorter scanning times may be useful for evaluating biliary branching variants when bile ducts run close together. Larger patient series, however, are needed to address this important issue.

We also found, by using the Fisher exact test, that the use of conventional intraoperative cholangiography decreased significantly after the introduction of CT cholangiography: Intraoperative cholangiograms were obtained in all 23 (100%) subjects who underwent right hepatic lobe retrieval at our institution before the introduction of CT cholangiography but in only three of 24 (12%) subjects thereafter. In two of those three subjects, intraoperative cholangiography was performed in November 2001 (within 1 month of the introduction of CT cholangiography) and may partially reflect the surgeons’ initial lack of familiarity with this test. In the third subject, intraoperative cholangiography was performed as a result of the discrepancies in the initial interpretation of the CT cholangiogram before surgery. The decrease in the need for intraoperative cholangiography likely reflects the diagnostic quality of CT cholangiography and the increasing familiarity and confidence of our transplant surgeons with this test. It is possible that a reduction in the rate of intraoperative cholangiography decreases the surgery time, potentially improving donor outcome. However, because of improvements in surgical approach and increasing surgical experience with right hepatic lobe retrieval during the study period, we did not evaluate surgery time as an endpoint in this study.

The high prevalence of variant biliary anatomy in our study (27 of 62 subjects [44%] who underwent CT cholangiography and 13 of 24 subjects [54%] who underwent right hepatic lobe retrieval) is in agreement with that in previous reports (3,4) and underscores the importance of preoperative biliary imaging in living donor candidates for right-lobe liver transplantation. Reports of previous studies have described the use of CT cholangiography in the evaluation of living potential liver donors. Cheng et al (9) reported results in 16 living potential liver donors, 10 of whom had confirmation of CT cholangiographic findings with either endoscopic retrograde cholangiography or conventional intraoperative cholangiography. Schroeder et al (10) also reported excellent results in 16 living potential liver donors with multi–detector row CT cholangiography, but only four had intraoperative confirmation of CT cholangiographic biliary tract anatomic findings.

In addition to providing a consistent and accurate depiction of biliary tract anatomy, multi–detector row CT cholangiography offers several other advantages in the preoperative evaluation of living liver donor candidates. CT cholangiography is minimally invasive and simple to perform. The image data enable visualization of the biliary anatomy, as well as the relationship between bile ducts and hepatic vasculature, and can be readily reformatted into three-dimensional displays (10). CT angiography and liver parenchyma evaluation can be performed on the same day.

Intravenous cholangiography is rarely performed in North America, owing in part to the perceived high risk of contrast material reactions (28,29). In several recent studies of CT cholangiography, however, minor contrast material reactions were encountered in only 1%–3% of patients, a rate similar to that with conventional intravenous contrast material–enhanced CT (30–33). No major reactions were noted. The low frequency and mild reactions in these studies may reflect the use of slow contrast material infusion rates as well as intravenous administration of diphenhydramine before imaging (12,30). In our series of 62 living donors, only two reactions occurred; both were minor and self-limiting. However, attention to potential contrast material reaction in future studies is important to ensure patient safety.

An alternative technique, oral CT cholangiography, does not appear to be a sufficiently robust alternative to intravenous CT cholangiography for determining second-order biliary tract anatomy (13). In several centers, magnetic resonance (MR) cholangiography has been used in the preoperative evaluation of the biliary tract in potential liver donors (34–36). The spatial resolution of MR cholangiography is lower than that of CT cholangiography and does not allow for consistent visualization of the biliary system in living liver donors (6,36,37), even when a combination of conventional and excretory MR cholangiography is used (38).

There are several limitations to this study. This was a single-institution retrospective study. Of the 62 subjects who underwent preoperative CT cholangiography, 24 had surgical confirmation of the second-order biliary anatomy; we do not have independent confirmation of biliary branching anatomy in the other subjects. Because of the small number of subjects who underwent imaging with 2.5-mm-thick sections (n = 8), we did not study whether section thickness had an effect on accuracy in cases of closely spaced parallel bile ducts. Future studies with larger patient series are needed to address whether thinner sections and faster scanning may further improve accuracy in such cases.

In conclusion, CT cholangiography accurately depicts biliary tract anatomy in living donor candidates for right hepatic lobe transplantation, and donors who undergo preoperative CT cholangiography are unlikely to need conventional intraoperative cholangiography.


   FOOTNOTES
 
Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, Z.J.W., B.M.Y.; study concepts, Z.J.W., B.M.Y., F.V.C.; study design, Z.J.W., B.M.Y., F.V.C., J.P.R.; literature research, Z.J.W., B.M.Y.; clinical studies, B.M.Y., F.V.C., R.S.B., A.Q.; data acquisition, Z.J.W., B.M.Y.; data analysis/ interpretation, Z.J.W., B.M.Y., F.V.C.; statistical analysis, Z.J.W., B.M.Y.; manuscript preparation, Z.J.W., B.M.Y., F.V.C., J.P.R.; manuscript definition of intellectual content, Z.J.W., B.M.Y., F.V.C.; manuscript editing, revision/review, and final version approval, Z.J.W., B.M.Y., A.Q., R.S.B., F.V.C.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 

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B. M. Yeh, F. V. Coakley, A. C. Westphalen, B. N. Joe, C. E. Freise, A. Qayyum, R. A. McTaggart, and J. P. Roberts
Predicting Biliary Complications in Right Lobe Liver Transplant Recipients according to Distance between Donor's Bile Duct and Corresponding Hepatic Artery
Radiology, January 1, 2007; 242(1): 144 - 151.
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S. K. An, J. M. Lee, K.-S. Suh, N. J. Lee, S. H. Kim, Y. J. Kim, J. K. Han, and B. I. Choi
Gadobenate dimeglumine-enhanced liver MRI as the sole preoperative imaging technique: a prospective study of living liver donors.
Am. J. Roentgenol., November 1, 2006; 187(5): 1223 - 1233.
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