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• W2119798477 abstract "Iatrogenic injury of the biliary tract after either an open or a laparoscopic cholecystectomy may occur since either normal or variant biliary ducts may be misinterpreted and thus incorrectly treated.1 The appropriate management of such patients depends on the injury type as well as the time of identification. Therefore, it is fundamental to identify the anatomic site of the injury and to evaluate the anatomy of the proximal biliary tract to establish an appropriate reconstruction strategy. In this setting, it has been shown that a conventional magnetic resonance (MR) cholangiography is able to assess iatrogenic bile duct injuries after cholecystectomy.2 In this report, we presented a patient with an iatrogenic biliary tract injury (Bismuth type III) following laparoscopic cholecystectomy in which a mangafodipir trisodium (MT) (Teslascan, Amersham, UK) MR cholangiography better described and characterized a biliary lesion than a conventional MR cholangiography. A 41-year-old woman had a laparoscopic cholecystectomy for lithiasis, but 1 week later a standard laboratory work-up showed an abnormal bilirubin plasma level (total bilirubin 5.27 mg/dL; direct bilirubin 3.63 mg/dL; normal value 0.1–1.1 mg/dL). An ultrasound (US) evaluation was therefore performed, but no clear abnormality of the biliary tree was found. However a thin fluid collection was observed in the subhepatic space. Subsequently, a conventional MR cholangiography was performed after oral administration of ferumoxil (Lumirem, Guerbet, Cedex, France) using a 1.5 Tesla field (Gyroscan Intera, Philips, Best, The Netherlands) with morphologic and dedicated T2-weighted sequences. The MR cholangiograms (Fig. 1) showed a regional stricture of the common hepatic duct with a fluid collection in the subhepatic region. To clarify the nature of this finding, particularly in differentiating between free fluid and bile collection, an MR cholangiography with MT was performed 1–2 h after the i.v. administration using a contrast dose of 10 mL (0.05 mmol/mL) over 3–5 min by hand injection; no side effects were observed in our patient after the MT infusion. MT MR images clearly demonstrated that the fluid collection was represented by bile extravasation for a biliary injury of the common hepatic duct (Fig. 2). On the basis of these results, the diagnosis of an iatrogenic lesion of the common hepatic duct (Bismuth type III) was made; hence, the patient underwent surgical treatment with a hepaticojejunostomy. During the surgerical intervention an intraoperative cholangiography confirmed the pre-operative MT MR imaging findings. Conventional magnetic resonance cholangiography T2-weighted in coronal view shows a focal stricture at the level of the common hepatic duct; a fluid collection in subhepatic space is also detected. Mangafodipir trisodium magnetic resonance T1-weighted cholangiography in coronal view clearly demonstrates that the fluid collection in the subhepatic space is a bile collection. Iatrogenic injury of the biliary tract after a cholecystectomy may occur, particularly when using a laparoscopic approach, and hence it is fundamental after surgical intervention to evaluate the biliary tree integrity.1,2 In such patients, it has been shown that an MR cholangiography is able to identify iatrogenic bile duct injuries after a cholecystectomy.2 Other imaging techniques traditionally used for this purpose are represented by Doppler US, contrast-enhanced computed tomography (CT), hepatobiliary scintigraphy, percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography.3 A particular advantage of an MR cholangiography is the noninvasive and rapid visualization of a normal as well as a variant biliary tree without the need of i.v. contrast material and thus without known side effects. However, MR cholangiography, similarly to CT or US, shows only the indirect signs of bile duct leaks as fluid collections. Since MR cholangiography demonstrates the anatomy of biliary ducts on the basis of their fluid content without the need of contrast, it cannot directly identify the site of bile extravasation. MR cholangiograms are obtained using a hydrographic T2-weighted turbo spin-echo sequence with fat suppression. In this technique the signal of static fluids such as bile, pancreatic secretion, urine, and the fluid of cystic lesions as well as free fluid is high; therefore, these fluid components cannot be differentiated from each other on conventional MR images. This feature explains why MR cholangiography is usually performed after the oral administration of a negative super-paramagnetic contrast material that reduces the high signal intensity of fluid present into the duodenum, thus allowing an easy evaluation of the biliary tree. To resolve the diagnostic limitations of conventional MR cholangiography, i.v. contrast-enhanced MR cholangiography using MT has recently been proposed for detecting and localizing bile duct leaks in patients who are undergoing laparoscopic or open cholecystectomy.4 MT is a paramagnetic MR imaging hepatobiliary contrast agent that consists of manganese bound to dipyridoxyl diphosphate, a vitamin B6 analog. This compound provides clear functional and anatomic evaluation of the biliary tree, increasing signal intensity on T1-weighted images and offering diagnostic information similarly to hepatobiliary scintigraphy as well as the conventional contrast-enhanced cholangiography. After an i.v. administration of MT, the contrast accumulates in the liver cells and is mainly excreted via bile, accurately designing intrahepatic and extrahepatic biliary ducts. In cases of biliary injury, it is reasonable to assume that the contrast is extravasated and accumulates as free fluid collections. When using this MR contrast agent side effects may occur; consisting of headaches, vomiting, nausea, a feeling of warmth and flushing in less than 2% of patients for each side effect. Another MR contrast agent with similar characteristics might be used for the same purpose; consisting of a gadolinium chelate, gadobenate dimeglumine, shows blood pool distribution in the extra-cellular space with hepatobiliary excretion.5,6 The mechanism of action of gadobenate dimeglumine is similar to that of gadolinium chelates such as gadopentetate dimeglumine, but with two key differences: transient and weak binding with serum albumin in the intravascular space, when the agent accumulates into hepatocytes and is excreted with the bile (up to 5% of the original dose). In the patient presented in this report, an iatrogenic biliary injury classified as Bismuth type III occurred after laparoscopic cholecystectomy for lithiasis. Conventional MR cholangiography showed a regional stricture of the common hepatic duct with a fluid collection in the subhepatic region but there were no definite imaging criteria to differentiate between free fluid or bile collection. For this purpose, an MR cholangiography after i.v. administration of MT was performed and the MT images clearly demonstrated that the fluid collection was represented by bile extravasation secondary to the biliary injury of the common hepatic duct. Therefore, for patients with iatrogenic injury of biliary tree, MR cholangiography with MT is recommended, since the use of this specific contrast agent with bile excretion specifically increases the signal throughout the biliary ducts or in bile collections when biliary injury and extravasation occur. This observation is concordant with the results observed by other investigators.4,7,8 In conclusion, since MT MR cholangiography better describes and characterizes biliary anatomy compared to conventional MR cholangiography, it is particularly recommended in patients with iatrogenic biliary injury after laparoscopic or open cholecystectomy." @default.
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• W2119798477 date "2011-05-26" @default.
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• W2119798477 title "Magnetic resonance cholangiography to evaluate biliary tree integrity after cholecystectomy: A case report" @default.
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• W2119798477 doi "https://doi.org/10.1111/j.1751-2980.2011.00500.x" @default.
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