Biliary Leaks: Multidisciplinary Approach to Diagnosis and Treatment.

Bile leaks arise from various causes such as trauma, complications after hepatobiliary surgery, and intrahepatic malignancies or their associated liver-directed treatments. Bile leaks can result in significant morbidity and mortality. Delayed diagnosis is not uncommon due to nonspecific manifestations; therefore, a high clinical suspicion is needed. A multidisciplinary approach for treatment of biliary leaks with prompt referral to tertiary care centers with experienced hepatobiliary surgeons, advanced endoscopists, and interventional radiologists is needed to address these challenging complications. Management of biliary leaks can range from conservative management to open surgical repair. Minimally invasive procedures play a crucial role in biliary leak treatment, and the interventional radiologist can help guide appropriate management on the basis of a clear understanding of the pathophysiology of biliary leaks and a current knowledge of the armamentarium of treatment options. In most cases, a simple diversion of bile to decompress the biliary system may prove effective. However, persistent and high-output biliary leaks require delineation of the source with tailored treatment options to control the leak. This may be done by additional diversions, occluding the source, reestablishing connections, or using a combination of therapies to bridge to more definitive surgical interventions. The authors describe the different treatment options and emphasize the role of interventional radiology. ©RSNA, 2024.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Aetiological Spectrum of Pancreaticobiliary Diseases in Adult Nigerians on Magnetic Resonance Cholangiopancreatography.

BACKGROUND: Imaging is vital for assessing pancreaticobiliary diseases. AIM: The aim of the study was to investigate the spectrum and pattern of pancreaticobiliary diseases in adult Nigerians using magnetic resonance cholangiopancreatography (MRCP). METHODS: This was a retrospective, descriptive cross-sectional study. The electronic radiological records of 110 adult Nigerians who had undergone MRCP were reviewed. The MRCP images were evaluated for bile duct dilatation, intraluminal filling defects, strictures, calculi, and other abnormalities. RESULTS: There were 45 males (40.9%) and 65 females (59.1%) aged 18-83 years, with a mean age of 51.93 ± 15.22 years. Jaundice (59.1%) and right hypochondrial pain (31.8%) were the most common presenting complaints. Gallstones (32.7%), common bile duct strictures (15.5%), choledocholithiasis (11.8%), pancreatic head carcinoma (10.9%), and gallbladder carcinoma (2.7%) were the most frequent abnormalities. There was biliary obstruction in 56.4% of participants, mostly at the distal and proximal common bile duct. Other findings include hepatomegaly (23.6%), hepatic cysts (6.4%), hepatic steatosis (0.9%), duodenal wall thickening (1.8%), and ascites (5.5%). MRCP was normal in 25 (22.7%) participants. CONCLUSION: Gallstones were the predominant pathology of the various pancreaticobiliary diseases, while Pancreatic head and gallbladder carcinoma were the most common malignant diseases.

The Diagnostic Yield of Magnetic Resonance Cholangiopancreatography in the Setting of Acute Pancreaticobiliary Disease - A Single Center Experience.

PURPOSE: To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. METHODS: A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. RESULTS: A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. CONCLUSION: An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations.

The real incidence of biliary tract complications after adult liver transplantation: the role of the prospective routine use of cholangiography during post-transplant follow-up.

Biliary tract complications (BTCs) still burden liver transplantation (LT). The wide reporting variability highlights the absence of systematic screening. From 2000 to 2009, simultaneous liver biopsy and direct biliary visualization were prospectively performed in 242 recipients at 3 and 6 months (n = 212, 87.6%) or earlier when indicated (n = 30, 12.4%). Median follow-up was 148 (107-182) months. Seven patients (2.9%) experienced postprocedural morbidity. BTCs were initially diagnosed in 76 (31.4%) patients; 32 (42.1%) had neither clinical nor biological abnormalities. Acute cellular rejection (ACR) was present in 27 (11.2%) patients and in 6 (22.2%) BTC patients. Nine (3.7%) patients with normal initial cholangiography developed BTCs after 60 (30-135) months post-LT. BTCs directly lead to 7 (2.9%) re-transplantations and 14 (5.8%) deaths resulting in 18 (7.4%) allograft losses. Bile duct proliferation at 12-month biopsy proved an independent risk factor for graft loss (P = 0.005). Systematic biliary tract and allograft evaluation allows the incidence and extent of biliary lesions to be documented more precisely and to avoid erroneous treatment of ACR. The combination 'abnormal biliary tract-canalicular proliferation' is an indicator of worse graft outcome. BTCs are responsible for important delayed allograft and patient losses. These results underline the importance of life-long follow-up and appropriate timing for re-transplantation.

Biliary cast syndrome after liver transplantation: A cholangiographic evolution study.

BACKGROUND AND AIM: The aim of this study is to describe the cholangiographic features and endoscopic management of biliary cast syndrome (BCS), a rare specific ischemic cholangiopathy following liver transplantation. METHODS: Patients with biliary complications were identified from prospectively collected database records of patients who underwent liver transplantation at the Erasme Hospital from January 2005 to December 2014. After excluding patients with hepatico-jejunostomy or no suspicion of stricture, cholangiograms obtained during endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging were systematically reviewed. Biliary complications were categorized as anastomotic (AS) and non-AS strictures, and patients with BCS were identified. Clinical, radiological, and endoscopic data were reviewed. RESULTS: Out of 311 liver transplantations, 14 cases were identified with BCS (4.5%) and treated with ERCP. Intraductal hyperintense signal on T1-weighted magnetic resonance and a "duct-in-a-duct" image were the most frequent features of BCS on magnetic resonance imaging. On initial ERCP, 57% of patients had no stricture. Complete cast extraction was achieved in 12/14, and one of these had cast recurrence. On follow-up, 85% of the patients developed biliary strictures that were treated with multiple plastic stents reaching 60% complete stricture resolution, but 40% of them had recurrence. After a median follow-up of 58 months, BCS patients had lower overall and graft survival (42.9% and 42.9%) compared with non-AS (68.8% and 56.3%) and AS (83.3% and 80.6%), respectively. CONCLUSIONS: Particular magnetic resonance-cholangiographic and ERCP-cholangiographic features of BCS have been identified. Outcomes for BCS are characterized by high complete cast extraction rates, high incidence of secondary strictures, and poorer prognosis.

Prospective randomized trial of a new multibending versus conventional ultra-slim endoscope for peroral cholangioscopy without device or endoscope assistance (with video).

BACKGROUND AND AIMS: Currently available peroral cholangioscopy (POC) is a duodenoscopy-assisted procedure that does not involve directly inserting an endoscope into the biliary tree. A prototype multibending (MB) ultra-slim endoscope has been developed as a dedicated cholangioscope to overcome the technical difficulties of direct POC. In this study, we evaluated the efficacy of the new MB ultra-slim endoscope compared with a conventional ultra-slim endoscope for free-hand insertion of an endoscope into the bile duct for direct POC without the assistance of accessories. METHODS: Ninety-two patients with biliary disease requiring diagnostic and/or therapeutic direct POC were assigned randomly to groups examined using an MB ultra-slim endoscope (MB group, n=46) versus a conventional ultra-slim endoscope (conventional group, n=46). The primary outcome was the technical success of free-hand insertion of the endoscope during direct POC, defined as successful insertion of the endoscope through the ampulla of Vater and advancement of the endoscope up to the bifurcation or to the obstructed segment of the biliary tree without any accessories within 15 minutes. RESULTS: Free-hand biliary insertion of the endoscope for direct POC was technically successful in 41 patients (89.1%) in the MB group, which was significantly higher than the rate (14 patients, 30.4%) in the conventional group (P < .001). The procedure time (mean ± standard deviation) of direct POC using free-hand biliary insertion of the endoscope was significantly shorter in the MB group than in the conventional group (3.2 ± 1.8 vs 6.0 ± 3.0 minutes, P = .004). Adverse events were observed in 3 patients (6.5%) in the MB group and 2 patients (4.3%) in the conventional group (P = .500), all of whom were treated conservatively. The technical success rates of the diagnostic or therapeutic intervention were not significantly different between the 2 groups in patients undergoing successful direct POC. CONCLUSIONS: Free-hand biliary insertion of the MB ultra-slim endoscope showed a high technical success rate without severe adverse events and effectively decreased procedure time compared with a conventional ultra-slim endoscope. Direct POC using the MB ultra-slim endoscope can be used for novel diagnostic and therapeutic procedures of the biliary tree without the assistance of another endoscope or accessory. (Clinical trial registration number: NCT02189421.).

Radiological findings in ischaemic cholangiopathy.

Ischaemic cholangiopathy occurs as a consequence of deficient arterial blood flow to the bile duct wall. Bile duct ischaemia can lead to full-thickness necrosis, bile leakage, biloma formation, and sepsis. It is an important cause of graft failure post-orthotopic liver transplantation. In the native liver, the causes of biliary ischaemia are diverse and include vasculitis or a complication of endovascular procedures. The present review describes the pathology and radiological findings of ischaemic cholangiopathy and outlines the role of interventional radiology in its management.

Intracavitary contrast-enhanced ultrasonography in children: review with procedural recommendations and clinical applications from the European Society of Paediatric Radiology abdominal imaging task force.

Contrast-enhanced ultrasonography (US) has become an important supplementary tool in many clinical applications in children. Contrast-enhanced voiding urosonography and intravenous US contrast agents have proved useful in routine clinical practice. Other applications of intracavitary contrast-enhanced US, particularly in children, have not been widely investigated but could serve as a practical and radiation-free problem-solver in several clinical settings. Intracavitary contrast-enhanced US is a real-time imaging modality similar to fluoroscopy with iodinated contrast agent. The US contrast agent solution is administered into physiological or non-physiological body cavities. There is no definitive list of established indications for intracavitary US contrast agent application. However, intracavitary contrast-enhanced US can be used for many clinical applications. It offers excellent real-time spatial resolution and allows for a more accurate delineation of the cavity anatomy, including the internal architecture of complex collections and possible communications within the cavity or with the surrounding structures through fistulous tracts. It can provide valuable information related to the insertion of catheters and tubes, and identify related complications such as confirming the position and patency of a catheter and identifying causes for drainage dysfunction or leakage. Patency of the ureter and biliary ducts can be evaluated, too. US contrast agent solution can be administered orally or a via nasogastric tube, or as an enema to evaluate the gastrointestinal tract. In this review we present potential clinical applications and procedural and dose recommendations regarding intracavitary contrast-enhanced ultrasonography.

Recent innovations in therapeutic endoscopy for pancreatobiliary diseases.

The development of endoscopic treatment for pancreatobiliary diseases in recent years is remarkable. In addition to conventional transpapillary treatments under endoscopic retrograde cholangiopancreatography (ERCP), new endoscopic ultrasound-guided therapy is being developed and implemented. On the other hand, due to the development/improvement of various devices such as new metal stents, a new therapeutic strategy under ERCP is also advocated. The present review focuses on recent advances in the endoscopic treatment of pancreatic pseudocysts, walled-off necrosis, malignant biliary strictures, and benign biliary/pancreatic duct strictures.

Surgeon attitudes toward point of care ultrasound for biliary disease: a nationwide Canadian survey

Summary: Multiple studies confirm that point of care ultrasound (PoCUS) has a high sensitivity and specificity for cholelithiasis and cholecystitis. However, there is poor perceived reliability of biliary PoCUS by surgeons. This survey was performed to assess surgeons' opinions on using PoCUS in gallstone disease and barriers that exist for its institution. The majority (60.3%) of respondents reported a total lack of confidence in PoCUS for the diagnosis of biliary disease. Most felt the sensitivity of PoCUS was poor and had concerns about the user-dependent nature of the test and the lack of imaging details provided. If offered ideal clinical/laboratory findings with PoCUS results, only 4.7% of surgeons would definitely operate for unremitting biliary colic and 5.4% for cholecystitis. The ability to replicate findings independently increased confidence in clinical decision-making. Our findings suggest there is substantial distrust in biliary PoCUS but that specific ultrasound training for the surgical workforce may prove tremendously beneficial for its utilization.

Recommendations for the Management of Incidental Hepatobiliary Findings in Adults: Endorsement and Adaptation of the 2017 and 2013 ACR Incidental Findings Committee White Papers by the Canadian Association of Radiologists Incidental Findings Working Group.

The Canadian Association of Radiologists Incidental Findings Working Group consists of both academic subspecialty and general radiologists and is tasked with adapting and expanding upon the American College of Radiology incidental findings white papers to more closely apply to Canadian practice patterns, particularly more comprehensively dealing with the role of ultrasound and pursuing more cost-effective approaches to the workup of incidental findings without compromising patient care. Presented here are the 2020 Canadian guidelines for the management of hepatobiliary incidental findings. Topics covered include initial assessment of hepatic steatosis and cirrhosis, the workup of incidental liver masses identified on ultrasound and computed tomography (with algorithms presented), incidental gallbladder findings (wall thickening, calcification, and polyps), and management of incidental biliary dilatation.

Endoscopic treatment of biliary complications after liver transplantation.

BACKGROUND: biliary complications are an important cause of morbidity and mortality after liver transplantation. Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic option, which is less invasive than surgical management. MATERIALS AND METHODS: the endoscopic management with ERCP of patients with biliary complications after liver transplantation in the Complexo Hospitalario Universitario de A Coruña between 2012 and 2018 was reviewed. RESULTS: there were 232 liver transplant recipients and biliary complications occurred in 70 (30.1 %) patients. Anastomotic strictures, most of them choledocho-choledochal, constituted the most frequent complication in 43 (61.4 %) patients. Biliary leak occurred in 16 (22.9 %) patients, non-anastomotic strictures in six (8.6 %) and choledocholithiasis in five (7.1 %). ERCP was performed in 39/43 patients with anastomotic strictures, achieving clinical success in 36 (92.3 %). All patients with a biliary leak were treated with CPRE, with a clinical resolution in 10/16 (62.5 %). ERCP was successful in 3/5 patients (60 %) with bile duct stones. In non-anastomotic strictures, ERCP was not effective in any case. Regarding complications, five (7.7 %) patients presented mild-moderate bleeding after biliary sphincterotomy. CONCLUSION: in our study, ERCP is useful in most biliary anastomotic strictures, early biliary leaks and choledocholithiasis after liver transplantation. The rate of ERCP complications in these patients was low and none were lethal.

Gadoxetate Disodium-Enhanced MR Cholangiography for Evaluation of Biliary-Enteric Anastomoses: Added Value Beyond Conventional T2-Weighted Images.

OBJECTIVE. The objective of our study was to evaluate image quality and reader confidence in MR cholangiography of bile ducts using conventional T2-weighted MR cholangiography alone in comparison with T2-weighted MR cholangiography and gadoxetate disodium-enhanced MR cholangiography in a series of patients with biliary-enteric anastomosis (BEA). SUBJECTS AND METHODS. Fifty patients with BEA and clinically and sonographically suspected complications underwent 1.5-T MRI. After acquisition of T1- and T2-weighted images, conventional MR cholangiography was performed using 3D fast relaxation fast spin-echo (FRFSE) and single-shot fast spin-echo (SSFSE) T2-weighted sequences (image set 1). In each patient, a 3D fat-suppressed Liver Acquisition with Volume Acceleration (LAVA) sequence was performed before and 15, 20, 25, 30, and 40 minutes after IV administration of 0.1 mL/kg of gadoxetate disodium (Primovist) (image set 2). Two radiologists in consensus evaluated image quality in the anatomic segments of the biliary tract and recorded diagnostic confidence scores for image set 1 alone and image sets 1 and 2 together. MRI findings were compared with postsurgical specimen if surgery was performed, conventional cholangiography, or 12 months of imaging follow-up. RESULTS. A significant improvement in image quality for visualization of all biliary segments was found using gadoxetate disodium-enhanced MR cholangiography in comparison with T2-weighted MR cholangiography alone. Readers judged diagnostic confidence of image set 1 alone and image sets 1 and 2 together as very confident in three and 37 cases, confident in 30 and 11, not confident in 14 and one, and not confident at all in three and 1, respectively. Concordance between image set 1 alone and image sets 1 and 2 together and the reference standard results was present in 23 of 50 cases (46%) and 47 of 50 cases (94%), respectively (p < 0.0001). CONCLUSION. Gadoxetate disodium-enhanced MR cholangiography can improve image quality for visualization of the biliary tract and further enhanced the diagnostic performance of conventional T2-weighted MR cholangiography in the evaluation of patients with BEA.

The clinical value of ERCP-guided cholangiopancreatoscopy using a single-operator system.

BACKGROUND: Single-operator, per-oral cholangiopancreatoscopy (SOPCP) enables direct biliopancreatic ductal visualization, targeted tissue sampling, and therapeutic intervention. At Karolinska University Hospital, SOPCP was introduced early and has since been extensively utilized according to a standardized protocol. We analysed the clinical value of SOPCP in the diagnosis and treatment of biliopancreatic diseases in a single high volume center. METHODS: All SOPCP procedures performed between March 2007 and December 2014 were retrospectively reviewed. Each procedure's diagnostic yield and therapeutic value was evaluated using a predefined 4 grade scale; 1 - no diagnostic or therapeutic value, 2 - information gained did not impact clinical decision-making and in case of a therapeutic intervention, did not alter the clinical course of the patient, 3 - information gained had an impact on clinical decision-making and in the case of a therapeutic intervention, assisted subsequent disease management, and finally, 4 - information gained was essential and critical for clinical decision-making and in case of a therapeutic intervention, solved the clinical problem requiring no further therapeutic actions. Descriptive statistics were used to analyse results, with uni- and multivariate analyses completed to assess risk of adverse events. RESULTS: During the study period, 365 SOPCP procedures were performed. We found SOPCP of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases. CONCLUSION: SOPCP offers direct access to the biliopancreatic ducts for both diagnostic and therapeutic purposes, adding significant clinical value in 64% of cases. TRIAL REGISTRATION: As this is a purely observational and retrospectively registered study in which the assignment of the medical intervention was not at the discretion of the investigator, it has not been registered in a registry.

Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak.

BACKGROUND: Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak. AIMS: This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak. METHODS: Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed. RESULTS: All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5 weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5 years, with no bile leak reported. CONCLUSIONS: Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.

[Differential diagnoses of biliary tract diseases : Computed tomography and magnetic resonance imaging]. / Differenzialdiagnosen von Gallenwegerkrankungen : Computertomographie und Magnetresonanztomographie.

CLINICAL/METHODICAL ISSUE: Bile duct diseases can be found in all age groups and show an increased prevalence in northern Europe. Pathologies range from benign diseases to malignant tumors with very poor survival. STANDARD RADIOLOGICAL METHODS: Magnetic resonance imaging (MRI) and computed tomography (CT) are the radiological methods of choice for a detailed evaluation of the bile duct system in addition to sonography. By assessing the lumen and the wall of the bile ducts as well as the surrounding structures, both obstructive and nonobstructive pathologies can be diagnosed and differentiated with high sensitivity and specificity. METHODICAL INNOVATIONS: Technical developments with postprocessing modalities as well as the use of biliary-excreted liver-specific MR contrast agents improve the diagnosis of bile duct diseases and enable morphological and functional assessment. PERFORMANCE: Due to high patient tolerance, minimal procedural risk in contrast to invasive endoscopic methods and the possibility of three-dimensional post-processing, beside CT, MRI with magnetic resonance cholangiography (MRC) represents the method of choice in patients with sonographically or clinically suspected bile duct disease and has significantly reduced the indications of diagnostic endoscopic retrograde cholangiopancreatography (ERCP). A complementary multimodality and multiparametric imaging approach is particularly helpful for preoperative assessment. PRACTICAL RECOMMENDATIONS: Rapidly evolving technology for both MRI and CT represent opportunities and challenges. By understanding the advantages and limitations of modern MR and CT techniques and by knowing the spectrum of bile duct pathologies, improved diagnosis and narrowing of possible differential diagnosis can be achieved.

Prenatal sonographic diagnosis of biliary tract malformations.

Congenital anomalies of the biliary tract include a variety of pathologic conditions, such as biliary atresia, choledochal cysts, gallbladder agenesis, congenital cholelithiasis, and gallbladder duplication. Although most of these malformations are rare and benign conditions, they may occasionally represent a major threat to extrauterine life. Visualization of a normal-sized gallbladder should be a mandatory component of the second-trimester anomaly ultrasound scan. Advances in prenatal sonography enable the detection of biliary tract congenital malformations. In this review, we discuss the detection rates, sonographic features, and prognosis of the most frequently prenatally diagnosed biliary tract malformations.

Modified breath-hold compressed-sensing 3D MR cholangiopancreatography with a small field-of-view and high resolution acquisition: Clinical feasibility in biliary and pancreatic disorders.

BACKGROUND: Compressed-sensing (CS) accelerated 3D MR cholangiopancreatography (MRCP) could be acquired in both navigator-triggered (NT) and breath-hold (BH) mode, but the latter has been considered inferior in depicting pancreatic duct and diagnosing pancreatic duct-related diseases. PURPOSE: To prospectively evaluate the clinical feasibility of a modified 3D BH-CS-MRCP prototype protocol with small field-of-view (FOV) and higher spatial resolution, and to compare its performance to the original BH-CS-MRCP and NT-CS-MRCP. STUDY TYPE: Prospective cohort study. POPULATION: Eighty-two patients with suspected pancreaticobiliary diseases (46 male, median age, 55 years, range, 16-79 years), including seven noncooperative patients. FIELD STRENGTH/SEQUENCE: 3T, CS-MRCP. ASSESSMENT: Three protocols were performed in random order in each patient. Acquisition time of each protocol was recorded. Image quality, background suppression, duct visibility, and diagnostic confidence with duct anatomic variations and duct-related pathologies were rated on a 5-point scale by two blinded radiologists independently. STATISTICAL TESTS: The Wilcoxon signed-rank test was used to compare the intraindividual difference. Interobserver agreement was determined using kappa coefficients. The diagnostic performance was calculated using receiver operating characteristic curves. RESULTS: Acquisition time was 17 seconds for both BH-CS-MRCP protocols, and 127.5 ± 36.9 seconds for NT-CS-MRCP. In 75 cooperative patients, the incidence of major artifacts was low for all protocols (5.3-8.0%). Background suppression was similar with the two BH-CS-MRCP protocols (3.67 ± 0.77 for original BH-CS-MRCP and 3.70 ± 0. 57 for modified BH-CS-MRCP, respectively), both inferior to the NT-CS-MRCP protocol (4.41 ± 0.68, P < 0.001 for both). Modified BH-CS-MRCP and NT-CS-MRCP depicted pancreatic duct and second-level branches of biliary duct better than original BH-CS-MRCP (all P < 0.01). The diagnostic performance for detecting bile duct abnormalities was similar for all protocols (P = 0.53-0.87), whereas for detecting pancreatic duct abnormalities, modified BH-CS-MRCP and NT-CS-MRCP had significantly better performance compared to original BH-CS-MRCP (both P < 0.01). In seven noncooperative patients, NT-CS-MRCP had superior image quality than both BH protocols (both P < 0.01). DATA CONCLUSION: Modified BH-CS-MRCP is feasible for pancreatic and biliary disorders. NT-CS-MRCP might be more useful in noncooperative patients. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1389-1399.

EUS-guided hepaticoenterostomy as a portal to allow definitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy.

BACKGROUND AND AIMS: EUS-guided hepaticoenterostomy (EUS-HE) usually is reserved for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiography (ERC) or inaccessible biliary tree in surgically altered anatomy (SAA). We describe the outcome of EUS-HE and antegrade therapy for benign biliary disease in patients with SAA. METHODS: Retrospective review of 20 consecutive patients with surgically altered anatomy and benign biliary obstruction who underwent EUS-HE performed by 1 endoscopist at a tertiary-care center over a 3-year period. RESULTS: During the study period, 37 patients underwent EUS-HE; 24 for benign disease. Of these, 20 patients had SAA and were analyzed (15 women, mean age, 62 years). SAA consisted of 9 Roux-en-Y gastric bypasses, 6 Roux-en-Y hepaticojejunostomy, 2 Billroth II procedures, and 3 Whipple procedures. Indications for ERC were common bile duct stones (n = 8), benign postoperative strictures (n = 7), chronic pancreatitis (n = 3), inflammatory stricture (n = 1), and treatment of a bile leak (n = 1). Five patients had previously failed balloon enteroscopy-assisted ERCs. The approach was transgastric in 15 and transjejunal in 5. In all cases, a branch of the left hepatic duct with a mean diameter of 7.8 mm was accessed. Median stent length was 80 mm, with diameters of 8 or 10 mm. Antegrade, definitive endoscopic therapy via the HE was performed in 18 patients, with an average of 2.7 procedures performed for resolution of stones and/or downstream strictures. HE stents were removed in 17 patients after a mean of 91 days without adverse events. Three patients experienced mild adverse events (1 with postprocedural pancreatitis after placement of a 10F transpapillary stent, 1 with postprocedural abdominal pain, and 1 with postprocedural cholangitis) requiring hospitalization for fewer than 3 nights; no severe adverse events occurred. The average postprocedural hospital stay was 1.3 days. No deaths occurred during follow-up. CONCLUSIONS: EUS-HE is safe and effective in the management of benign biliary obstruction in patients with surgically altered anatomy. It creates a portal to allow definitive, antegrade therapy and is a viable alternative to other endoscopic methods in this patient population.