The Guidance Impact of Preoperative Magnetic Resonance Cholangiopancreatography on Laparoscopic Cholecystectomy

Anatomic Variations of the Cystic Duct in Magnetic Resonance Cholangiopancreatography in Shiraz: A Cross-Sectional Study

BACKGROUND

Anatomic variations of the cystic duct (CD) are commonly encountered. Being aware of these variants will reduce complications subsequent to surgical, endoscopic, or percutaneous procedures. Magnetic resonance cholangiopancreatography (MRCP) is the least invasive and the most reliable modality for biliary anatomy surveys. This study aimed to determine the prevalence of cystic duct variations in the Iranian population.

METHODS

In this retrospective cross-sectional study, MRCP images of 350 patients referred to Shiraz Faraparto Medical Imaging and Interventional Radiology Center from October 2017 to October 2018 were reviewed. The CD course and insertion site to the extrahepatic bile duct (EHBD) was determined and documented in 290 cases. Descriptive statistics and Chi square test were applied for data analysis via SPSS software.

RESULTS

About 77% of cases revealed the classic right lateral insertion to the middle third of EHBD. The insertion of CD to the upper third and the right hepatic duct was 10%, and the insertion to the medial aspect of the middle third of EHBD from anterior or posterior was noted to be about 7.6%. From 2.8% of insertions to the lower third, 1% demonstrated parallel course, and finally, 0.3% of cases presented short CD.

CONCLUSION

CD variations are relatively common, and MRCP mapping prior to the hepatobiliary interventions could prevent unexpected consequences.

Impacts on outcomes and management of preoperative magnetic resonance cholangiopancreatography in patients scheduled for laparoscopic cholecystectomy: for whom it should be considered?

Purpose

We evaluated the impact of preoperative magnetic resonance cholangiopancreatography (MRCP) on patient outcomes, and found which patients should be considered for MRCP before cholecystectomy.

Methods

We performed retrospective analysis of 2,072 patients that underwent cholecystectomy for benign gallbladder disease from January 2014 to June 2017. Patients were grouped as CT only group (n = 737) and MRCP group (n = 1,335), including both CT and MRCP (n = 1,292) or MRCP only (n = 43). The main outcome measure was associated with complications after cholecystectomy, and the secondary outcomes were hospital stay, readmission, and events that could impact patient management due to addition of MRCP.

Results

There were no statistical differences in occurrence of intraoperative or postoperative complications or readmission rate between the 2 groups. Hospital stay was about 0.6 days longer in the MRCP group. However, MRCP group was more susceptible to complications due to underlying patient demographics (older age, higher frequency of diabetes, and higher level of the inflammatory markers). MRCP diagnosed common bile duct (CBD) stones in 6.5% of patients (84/1,292) without CBD stones in CT, and bile duct anomalies were identified in 41 patients (3.2%). Elevated γ-GT was the only independent factor for additional detection of CBD stones (adjusted odds ratio [OR], 2.89; P = 0.029) and subsequent biliary procedures (adjusted OR, 3.34; P = 0.018) when additional MRCP was performed.

Conclusion

MRCP is valuable for identification of bile duct variation and CBD stones. Preoperative MRCP can be considered, particularly in patients with elevated γ-GT, for proper preoperative management and avoidance of complications.

Preoperative magnetic resonance cholangiopancreatography before planned laparoscopic cholecystectomy: is it necessary?

Background:

The most feared complication of laparoscopic cholecystectomy (LC) is biliary tract injuries (BTI). We conducted a prospective study to evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in describing the biliary tract anatomy and to investigate its potential benefit to prevent BTI.

Materials and Methods:

From January 2012 to December 2016, 402 patients who underwent LC with preoperative MRCP were prospectively included. Routine intraoperative cholangiography was not performed. Patients' characteristics, preoperative diagnosis, biliary anatomy, conversion to laparotomy, and the incidence of BTI were analyzed.

Results:

Preoperative MRCP was performed prospectively in 402 patients. LC was indicated for cholecystitis and pancreatitis, respectively, in 119 (29.6%) and 53 (13.2%) patients. One hundred and five (26%) patients had anatomical variations of biliary tract. Three BTI (0.75%) occurred with a major BTI (Strasberg E) and two bile leakage from the cystic stump (Strasberg A). For these 3 patients, biliary anatomy was modal on MRCP. No BTI occurred in patients presenting “dangerous” biliary anatomical variations.

Conclusion:

MRCP could be a valuable tool to study preoperatively the biliary anatomy and to recognize “dangerous” anatomical variations. Subsequent BTI might be avoided. Further randomized trials should be designed to assess its real value as a routine investigation before LC.

Prospective Evaluation of Precision Multimodal Gallbladder Surgery Navigation: Virtual Reality, Near-infrared Fluorescence, and X-ray-based Intraoperative Cholangiography

OBJECTIVE

We aimed to prospectively evaluate NIR-C, VR-AR, and x-ray intraoperative cholangiography (IOC) during robotic cholecystectomy.

BACKGROUND

Near-infrared cholangiography (NIR-C) provides real-time, radiation-free biliary anatomy enhancement. Three-dimensional virtual reality (VR) biliary anatomy models can be obtained via software manipulation of magnetic resonance cholangiopancreatography, enabling preoperative VR exploration, and intraoperative augmented reality (AR) navigation.

METHODS

Fifty-eight patients were scheduled for cholecystectomy for gallbladder lithiasis. VR surgical planning was performed on virtual models. At anesthesia induction, indocyanine green was injected intravenously. AR navigation was obtained by overlaying the virtual model onto real-time images. Before and after Calot triangle dissection, NIR-C was obtained by turning the camera to NIR mode. Finally, an IOC was performed. The 3 modality performances were evaluated and image quality was assessed with a Likert-scale questionnaire.

RESULTS

The three-dimensional VR planning enabled the identification of 12 anatomical variants in 8 patients, of which only 7 were correctly reported by the radiologists (P = 0.037). A dangerous variant identified at VR induced a "fundus first" approach. The cystic-common bile duct junction was visualized before Calot triangle dissection at VR in 100% of cases, at NIR-C in 98.15%, and in 96.15% at IOC.Mean time to obtain relevant images was shorter with NIR-C versus AR (P = 0.008) and versus IOC (P = 0.00000003). Image quality scores were lower with NIR-C versus AR (P = 0.018) and versus IOC (P < 0.0001).

CONCLUSIONS

This high-tech protocol illustrates the multimodal imaging of biliary anatomy towards precision cholecystectomy. Those visualization techniques could complement to reduce the likelihood of biliary injuries (NCT01881399).

Anatomical Variations of Cystic Ducts in Magnetic Resonance Cholangiopancreatography and Clinical Implications

Background. Anatomical variations of cystic duct (CD) are frequently unrecognized. It is important to be aware of these variations prior to any surgical, percutaneous, or endoscopic intervention procedures. Objectives. The purpose of our study was to demonstrate the imaging features of CD and its variants using magnetic resonance cholangiopancreatography (MRCP) and document their prevalence in our population. Materials and Methods. This study included 198 patients who underwent MRCP due to different indications. Images were evaluated in picture archiving communication system (PACS) and variations of CD were documented. Results. Normal lateral insertion of CD at middle third of common hepatic duct was seen in 51% of cases. Medial insertion was seen in 16% of cases, of which 4% were low medial insertions. Low insertion of CD was noted in 9% of cases. Parallel course of CD was present in 7.5% of cases. High insertion was noted in 6% and short CD in 1% of cases. In 1 case, CD was draining into right hepatic duct. Congenital cystic dilation of CD was noted in one case with evidence of type IV choledochal cyst. Conclusion. Cystic duct variations are common and MRCP is an optimal imaging modality for demonstration of cystic duct anatomy.