Percutaneous Ultrasound Cholangiography With Microbubbles in Children With Biliary Diseases.

ABSTRACT: The application of intracavity contrast-enhanced ultrasound in the evaluation of biliary disease has been confirmed valuable among pediatric population. This pictorial essay aims to demonstrate the role of percutaneous ultrasound cholangiography (PUSC) with microbubbles in the diagnosis of different pediatric biliary diseases in our center. The biliary system's morphologic characteristics in PUSC mode of neonatal hepatitis, biliary atresia, choledochal cysts, and biliary complications of hepatobiliary surgery are presented.

Intra-operative ultrasound assessment of the biliary tree during robotic cholecystectomy.

Image-guided assessment of bile ducts and associated anatomy during laparoscopic cholecystectomy can be achieved with intra-operative cholangiography (IOC) or laparoscopic ultrasound (LUS). Rates of robotically assisted cholecystectomy (RC) are increasing and herein we describe the technique of intra-corporeal biliary ultrasound during RC using the Da Vinci system. For intraoperative evaluation of the biliary tree during RC, in cases of suspected choledocholithiasis, the L51K Ultrasound Probe (Hitachi, Tokyo, Japan) is used. The extrahepatic biliary tree is scanned along its length, capitalising on the benefits of the full range of motion offered by the articulated robotic instruments and integrated ultrasonic image display using TileProTM software. Additionally, this technique avoids the additional time and efforts required to undock and re-dock the robot that would otherwise be required for selective IOC or LUS. The average time taken to perform a comprehensive evaluation of the biliary tree, from the hepatic ducts to the ampulla of Vater, is 164.1 s. This assessment is supplemented by Doppler ultrasound, which is used to fully delineate anatomy of the porta hepatis, and accurate measurements of the biliary tree and any ductal stones can be taken, allowing for contemporaneous decision making and management of ductal pathologies. Biliary tract ultrasound has been shown to be equal to IOC in its ability to diagnose choledocholithiasis, but with the additional benefits of being quicker and having higher completion rates. We have described our practice of using biliary ultrasound during robotically assisted cholecystectomy, which is ergonomically superior to LUS, accurate and reproducible.

Real-time continuous image guidance for endoscopic retrograde cholangiopancreatography based on 3D/2D registration and respiratory compensation.

BACKGROUND: It has been confirmed that three-dimensional (3D) imaging allows easier identification of bile duct anatomy and intraoperative guidance of endoscopic retrograde cholangiopancreatography (ERCP), which reduces the radiation dose and procedure time with improved safety. However, current 3D biliary imaging does not have good real-time fusion with intraoperative imaging, a process meant to overcome the influence of intraoperative respiratory motion and guide navigation. The present study explored the feasibility of real-time continuous image-guided ERCP. AIM: To explore the feasibility of real-time continuous image-guided ERCP. METHODS: We selected 2 3D-printed abdominal biliary tract models with different structures to simulate different patients. The ERCP environment was simulated for the biliary phantom experiment to create a navigation system, which was further tested in patients. In addition, based on the estimation of the patient's respiratory motion, preoperative 3D biliary imaging from computed tomography of 18 patients with cholelithiasis was registered and fused in real-time with 2D fluoroscopic sequence generated by the C-arm unit during ERCP. RESULTS: Continuous image-guided ERCP was applied in the biliary phantom with a registration error of 0.46 mm ± 0.13 mm and a tracking error of 0.64 mm ± 0.24 mm. After estimating the respiratory motion, 3D/2D registration accurately transformed preoperative 3D biliary images to each image in the X-ray image sequence in real-time in 18 patients, with an average fusion rate of 88%. CONCLUSION: Continuous image-guided ERCP may be an effective approach to assist the operator and reduce the use of X-ray and contrast agents.

BiTNet: Hybrid deep convolutional model for ultrasound image analysis of human biliary tract and its applications.

Certain life-threatening abnormalities, such as cholangiocarcinoma, in the human biliary tract are curable if detected at an early stage, and ultrasonography has been proven to be an effective tool for identifying them. However, the diagnosis often requires a second opinion from experienced radiologists, who are usually overwhelmed by many cases. Therefore, we propose a deep convolutional neural network model, named biliary tract network (BiTNet), developed to solve problems in the current screening system and to avoid overconfidence issues of traditional deep convolutional neural networks. Additionally, we present an ultrasound image dataset for the human biliary tract and demonstrate two artificial intelligence (AI) applications: auto-prescreening and assisting tools. The proposed model is the first AI model to automatically screen and diagnose upper-abdominal abnormalities from ultrasound images in real-world healthcare scenarios. Our experiments suggest that prediction probability has an impact on both applications, and our modifications to EfficientNet solve the overconfidence problem, thereby improving the performance of both applications and of healthcare professionals. The proposed BiTNet can reduce the workload of radiologists by 35% while keeping the false negatives to as low as 1 out of every 455 images. Our experiments involving 11 healthcare professionals with four different levels of experience reveal that BiTNet improves the diagnostic performance of participants of all levels. The mean accuracy and precision of the participants with BiTNet as an assisting tool (0.74 and 0.61, respectively) are statistically higher than those of participants without the assisting tool (0.50 and 0.46, respectively (p<0.001)). These experimental results demonstrate the high potential of BiTNet for use in clinical settings.

Transmission of oral microbiota to the biliary tract during endoscopic retrograde cholangiography.

BACKGROUND: Endoscopic retrograde cholangiography (ERC) possesses a translocation risk of microbes to the biliary system. We studied bile contamination during ERC and its impact on patients' outcome in a real-life-situation. METHODS: Ninety-nine ERCs were analyzed and microbial samples were taken from the throat before and from bile during ERC and from irrigation fluid of the duodenoscope before and after ERC. RESULTS: 91.2% of cholangitis patients had detectable microbes in the bile (sensitivity 91%), but the same was true for 86.2% in the non-cholangitis group. Bacteroides fragilis (p=0.015) was significantly associated with cholangitis. In 41.7% of ERCs with contaminated endoscopes these microbes were found in the bile after the procedure. Analysis of duodenoscopes' irrigation liquid after ERC matched the microbial bile analysis of these patients in 78.8%. Identical microbial species were in throat and in bile samples of the same ERC in 33% of all cases and in 45% in the non-cholangitis group. Transmission of microbes to the biliary tract did not result in more frequent cholangitis, longer hospital stays, or worse outcome. CONCLUSIONS: During ERC bile samples are regularly contaminated with microbes of the oral cavity but it did not affect clinical outcome.

Low vs Standard-Dose Indocyanine Green in the Identification of Biliary Anatomy Using Near-Infrared Fluorescence Imaging: A Multicenter Randomized Controlled Trial.

BACKGROUND: Near-infrared fluorescence imaging using intravenous indocyanine green (ICG) facilitates intraoperative identification of biliary anatomy. We hypothesize that a much lower dose of ICG than the standard decreases hepatic and background fluorescence and improves bile duct visualization. STUDY DESIGN: In this multicenter randomized controlled trial, 55 adult patients undergoing laparoscopic cholecystectomy were randomized to low-dose (0.05 mg) or standard-dose (2.5 mg) ICG preoperatively on the day of surgery. A quantitative assessment was performed on recorded videos from the operation using ImageJ software to quantify the fluorescence intensity of the bile duct, liver, and surrounding/background fat. Operating surgeons blinded to ICG dose provided a qualitative assessment of various aspects of the visualization of the extrahepatic biliary tree comparing near-infrared fluorescence to standard visible light imaging using a scale of 1 to 5 (1, unsatisfactory; 5, excellent). Quantitative and qualitative scores were compared between the groups to determine any significant differences between the doses. RESULTS: The bile duct-to-liver and bile duct-to-background fat fluorescence intensity ratios were significantly higher for the low-dose group compared with the standard-dose group (3.6 vs 0.68, p < 0.0001; and 7.5 vs 3.3, p < 0.0001, respectively). Low-dose ICG had a slightly higher (ie better) mean score on the qualitative assessment compared to the standard dose, although the differences were not statistically significant. CONCLUSIONS: Low-dose ICG leads to quantitative improvement of biliary visualization using near-infrared fluorescence imaging by minimizing liver fluorescence; this further facilitates routine use during hepatobiliary operations.

Radiologic findings of biliary complications post liver transplantation.

Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.

Efficacy and Safety of Near-Infrared Florescence Cholangiography Using Indocyanine Green in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis.

Background: Achieving critical view of safety is a key for a successful laparoscopic cholecystectomy (LC) procedure. Near-infrared fluorescence cholangiography using indocyanine green (NIF-ICG) in LC has been extensively used and accepted as beneficial auxiliary tool to visualize extrahepatic biliary structures intraoperatively. This study aimed to analyze its safety and efficacy. Materials and Methods: Searching for potential articles up to March 25, 2022 were conducted on PubMed, Europe PMC, and ClinicalTrials.gov databases. Articles on the near infrared fluorescence during laparoscopy cholecystectomy were collected. Review Manager 5.4 software was utilized to perform the statistical analysis. Results: Twenty-two studies with a total of 3457 patients undergo LC for the analysis. Our meta-analysis revealed that NIF-ICG technique during LC was associated with shorter operative time (Std. Mean Difference -0.86 [95% confidence interval (CI) -1.49 to -0.23], P = .007, I2 = 97%), lower conversion rate (risk ratio [RR] 0.28 [95% CI 0.16-0.50], P < .0001, I2 = 0%), higher success in identification of cystic duct (CD) (RR 1.24 [95% CI 1.07-1.43], P = .003, I2 = 94%), higher success in identification of common bile duct (CBD) (RR 1.31 [95% CI 1.07-1.60], P = .009, I2 = 90%), and shorter time to identify biliary structures (Std. Mean Difference -0.52 [95% CI -0.78 to -0.26], P < .0001, I2 = 0%) compared with not using NIF-ICG. Conclusions: NIF-ICG technique beneficial for early real-time visualization of biliary structure, shorter operative time, and lower risk of conversion during LC. Larger randomized clinical trials are still needed to confirm the results of our study.

A Single Gallbladder Fold Creates a Unique Visual and Temporal Pattern of Radiotracer Accumulation on Hepatobiliary Scintigraphy.

ABSTRACT: Duplication of the gallbladder represents a variant of anomalous biliary anatomy that is rarely encountered on hepatobiliary scintigraphy. We describe the case of 76-year-old man with a gallbladder fold mimicking duplication of the gallbladder or an associated choledochal cyst on scintigraphy. Correlative imaging with CT and ultrasound helped elucidate the true anatomy. This case demonstrates the type of difficult scintigraphic patterns that can arise with variant anatomy and the necessary role of cross-sectional, anatomic imaging in unraveling such situations.

Percutaneous Cholangioscopy for the Diagnosis and Management of Biliary Pathology in Pediatric Patients: A Single-Center Experience.

Transhepatic percutaneous cholangioscopy (PC) can be used for the diagnosis and treatment of biliary pathology. It allows for direct visualization of the biliary system to identify pathologic changes, perform biopsies, and treat biliary obstruction. The effectiveness and safety of PC in adults have been established. However, the data on the use of PC in pediatric patients are limited. In this case series, the outcomes in 4 pediatric patients (3 girls; mean age, 4 [range, 1-8] years) who underwent 6 PC procedures were examined. Three out of the 6 (50%) PC procedures were performed for diagnostic visualization of the biliary tree and/or small intestine, whereas the remaining 3 (50%) were performed for the treatment of biliary obstruction causing chronic cholestasis. The technical and procedural success rate was 100%, and no complications were encountered during or 30 days after the procedure. This study supports the feasibility and safety of PC in pediatric patients for the management of biliary pathology.

Biliary Endoscopy in Altered Anatomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment of biliary disease with high success rates of greater than 90% in patients with standard anatomy. However, alterations in upper gastrointestinal anatomy can significantly complicate endoscopic biliary intervention. The past decade has seen significant advances in the endoscopic management of patients with altered anatomy. This review article will provide tips and tricks for successful biliary access in the most common surgical alterations with a focus on the management of biliary diseases following Roux-en-Y (RY) reconstructions.

Situations That Preclude Routine Intraoperative Cholangiography.

Intraoperative cholangiogram (IOC) is a useful tool for surgeons to assess anatomy of the biliary tree and diagnose biliary pathology. Many surgeons utilize cholangiography in most cases in hopes of preventing ductal injuries and are deemed routine cholangiographers. There is little data on the success rate and reasons why IOC is not performed. The purpose of this study was to evaluate the use of routine cholangiography and to determine reasons why cholangiography was not performed. 693 cholecystectomies were analyzed. Intraoperative cholangiogram was attempted in 553 (79.8%) of these cases. The success rate of performing cholangiograms in those attempted was 93.3%. Intraoperative cholangiogram was not attempted in 140 patients (20.2%) for various reasons. Although many surgeons consider themselves routine cholangiographers, there are times when IOC is not feasible. Knowledge of these reasons may help clarify indications for IOC. For most cases, routine cholangiography appears to be feasible.

Advanced Imaging of the Biliary System and Pancreas.

Despite advances in noninvasive techniques for imaging the pancreaticobiliary system, several disease processes including indeterminate biliary strictures as well as neuroendocrine tumors, inflammatory pseudotumors, and complex cysts of the pancreas remain difficult to characterize. New endoscopic imaging technologies have emerged to address these challenges. Cholangioscopy and intraductal ultrasound (IDUS) are powerful tools to characterize subtle biliary concretions and strictures. Confocal Laser Endomicroscopy (CLE) and Optical Coherence Tomography (OCT) are emerging approaches for the most difficult biliary lesions. Contrast harmonic endoscopic ultrasound (CH-EUS), elastography, and 3D-EUS are improving the approach to subtle pancreatic lesions, particularly in the context of indeterminate tissue sampling. Pancreatoscopy, pancreatic IDUS, and intracystic CLE hold promise to further improve the assessment of pancreatic cysts. We aim to comprehensively review the emerging clinical evidence for these innovative endoscopic imaging techniques.

Biliary Tree Diagnostics: Advances in Endoscopic Imaging and Tissue Sampling.

The diagnostic approach to the biliary tree disorders can be challenging, especially for biliary strictures. Albeit the great diagnostic impact of endoscopic retrograde cholangiopancreatography (ERCP) which allows one to obtain fluoroscopic imaging and tissue sampling through brush cytology and/or forceps biopsy, a considerable proportion of cases remain indeterminate, leading to the risk of under/over treated patients. In the last two decades, several endoscopic techniques have been introduced in clinical practice, shrinking cases of uncertainties and improving diagnostic accuracy. The aim of this review is to discuss recent advances and emerging technologies applied to the management of biliary tree disorders through peroral endoscopy procedures.

Artificial Intelligence Algorithm-Based CTA Imaging for Diagnosing Ischemic Type Biliary Lesions after Orthotopic Liver Transplantation.

The study focused on the clinical application value of artificial intelligence-based computed tomography angiography (CTA) in the diagnosis of orthotopic liver transplantation (OLT) after ischemic type biliary lesions (ITBL). A total of 66 patients receiving OLT in hospital were selected. Convolutional neural network (CNN) algorithm was used to denoise and detect the edges of CTA images of patients. At the same time, the quality of the processed image was subjectively evaluated and quantified by Hmax, Ur, Cr, and other indicators. Then, the digital subtraction angiography (DSA) diagnosis and CTA diagnosis based on CNN were compared for the sensitivity, specificity, positive predictive value, negative predictive value, and patient classification results. It was found that CTA can clearly reflect the information of hepatic aorta lesions and thrombosis in patients with ischemic single-duct injury after liver transplantation. After neural network algorithm processing, the image quality is obviously improved, the lesions are more prominent, and the details of lesion parts are also well displayed. ITBL occurred in 40 (71%) of 56 patients with abnormal CTA at early stage. ITBL occurred in only 8 (12.3%) of 65 patients with normal CTA at early stage. Early CTA manifestations had high sensitivity (72.22%), specificity (87.44%), positive predictive value (60.94%), and negative predictive value (92.06%) for the diagnosis of ITBL. It was concluded that artificial intelligence-based CTA had high clinical application value in the diagnosis of ITBL after OLT.

New Pharmacokinetic Parameters of Imaging Substrates Quantified from Rat Liver Compartments.

Hepatobiliary imaging is increasingly used by pharmacologists to quantify liver concentrations of transporter-dependent drugs. However, liver imaging does not quantify concentrations in extracellular space, hepatocytes, and bile canaliculi. Our study compared the compartmental distribution of two hepatobiliary substrates gadobenate dimeglumine [BOPTA; 0.08 liver extraction ratio (ER)] and mebrofenin (MEB; 0.93 ER) in a model of perfused rat liver. A gamma counter placed over livers measured liver concentrations. Livers were preperfused with gadopentetate dimeglumine to measure extracellular concentrations. Concentrations coming from bile canaliculi and hepatocytes were calculated. Transporter activities were assessed by concentration ratios between compartments and pharmacokinetic parameters that describe the accumulation and decay profiles of hepatocyte concentrations. The high liver concentrations of MEB relied mainly on hepatocyte and bile canaliculi concentrations. In contrast, the three compartments contributed to the low liver concentrations obtained during BOPTA perfusion. Nonlinear regression analysis of substrate accumulation in hepatocytes revealed that cellular efflux is measurable ∼4 minutes after the start of perfusion. The hepatocyte-to-extracellular concentration ratio measured at this time point was much higher during MEB perfusion. BOPTA transport by multidrug resistance associated protein 2 induced an aquaporin-mediated water transport, whereas MEB transport did not. BOPTA clearance from hepatocytes to bile canaliculi was higher than MEB clearance. MEB did not efflux back to sinusoids, whereas BOPTA basolateral efflux contributed to the decrease in hepatocyte concentrations. In conclusion, our ex vivo model quantifies substrate compartmental distribution and transport across hepatocyte membranes and provides an additional understanding of substrate distribution in the liver. SIGNIFICANCE STATEMENT: When transporter-dependent drugs target hepatocytes, cellular concentrations are important to investigate. Low concentrations on cellular targets impair drug therapeutic effects, whereas excessive hepatocyte concentrations may induce cellular toxicity. With a gamma counter placed over rat perfused livers, we measured substrate concentrations in the extracellular space, hepatocytes, and bile canaliculi. Transport across hepatocyte membranes was calculated. The study provides an additional understanding of substrate distribution in the liver.

Compressed sensing for breath-hold high-resolution hepatobiliary phase imaging: image noise, artifact, biliary anatomy evaluation, and focal lesion detection in comparison with parallel imaging.

PURPOSE: To assess image quality, performance for biliary anatomy diagnosis, and focal lesion detection rate of breath-hold high-resolution 3D T1-weighted hepatobiliary phase imaging using compressed sensing (CS HBP) compared to standard HBP using conventional parallel imaging. METHODS: This retrospective study assessed consecutive 125 patients who underwent CS HBP and standard HBP between November 2019 and July 2020. Optimized resolution and scan time for CS HBP were 1 × 1.4 × 1 mm3 and 15 s, while those for standard HBP were 1.3 × 1.8 × 3 mm3 and 16 s. Two independent radiologists evaluated qualitative indices on the clarity of liver margin, visibility of the hepatic vessel and bile duct, image noise, and artifact on a 5-point scale. Biliary anatomy, confidence for biliary anatomy diagnosis, expected number of bile duct openings, and number of focal lesions were assessed. Wilcoxon signed-rank test, Pearson chi-square test, and sensitivity for focal lesion were used for statistical analysis. Intraclass correlation coefficient (ICC) and Cohen's kappa (κ) were used to determine inter-observer agreement. RESULTS: CS HBP showed significantly better liver edge sharpness and bile duct visualization, but greater subjective image noise and non-respiratory artifacts compared to standard HBP. CS HBP showed higher number of concordantly assigned biliary anatomy across readers (86 vs. 80), indicating greater inter-observer agreement for biliary anatomy (κ, 0.67 vs. 0.45) and the number of bile duct openings (ICC, 0.860 vs. 0.579) with significantly higher diagnostic confidence (4.70-4.74 vs. 3.96-4.55; p = 0.002). Both readers identified more focal lesions in CS HBP than in standard HBP (88.2% and 84.5% vs. 66.3% and 73.4%). CONCLUSION: Breath-hold high-resolution CS HBP was a feasible clinical sequence providing superior liver edge sharpness, bile duct visualization, and focal lesion detection rate compared to standard HBP despite higher noise and artifact. Due to improved spatial resolution, CS HBP yielded a higher inter-observer agreement and confidence for the biliary anatomy diagnosis.

Pictorial Summary of Congenital Gallbladder and Biliary Duct Anomalies Presentation on HIDA Imaging.

Hepatobiliary iminodiacetic acid (HIDA) scan is one of the principal imaging modalities for the evaluation of the gallbladder and biliary tree. Congenital biliary anomalies are rare and can be difficult to recognize on HIDA scan. They may also mimic other biliary pathology. The purpose of this article is to review the spectrum of congenital gallbladder and biliary anomalies and describe their imaging appearance on HIDA scan. In addition, the diagnostic utility of functional imaging with HIDA when evaluating biliary tract anomalies is described.