- Email: [email protected]
MRCP evaluation of biliary system following vagotomy and gastric surgery
Journal of Clinical Imaging 29 (2005) 42 – 45
MRCP evaluation of biliary system following vagotomy and gastric surgery Gu¨l Ayse Erden a, A. Tuba Karagu¨lle Kendi b,*, Ilhan Erden a a
Department of Radiology, Ankara University School of Medicine, 06100, Ankara, Turkey b Integra MR Imaging center, Tahran caddesi No. 40, Kavaklidere, Ankara, Turkey Received 30 November 2003
Abstract Objective: The aim of this study was to show the usefulness of MR cholangiopancreatography (MRCP) in demonstrating biliary system pathologies in patients with a history of vagotomy and Billroth II operations. Methods: The hepatobiliary system of eight patients with a history of vagotomy and Billroth II operations was evaluated with MRCP. Three-dimensional fast spin – echo technique was used at a 1.0-T scanner with following parameters: TR = 2857 – 4615 ms, TE = 850 – 1117 ms, BW = 31.2, FOV = 40, 21 – 28 slices, NEX = 0.5, scan time = 90 s. Results: Eight patients were evaluated with MRCP. Three patients had cholecystectomy. In one patient the gall bladder wall was thickened, accompanied with an irregular, unknown filling defect at the level of the fundus. Four of these patients had common bile duct stones. Two patients had gallstones and one patient had a stone in the common hepatic duct. A capping deformity of the distal common bile duct was observed in all of the patients. Conclusion: We conclude that MRCP can be used effectively for evaluation of biliary system of patients with previous history of biliary or gastric operations. D 2005 Elsevier Inc. All rights reserved. Keywords: MR imaging; Surgery; Cholangiopancreatography; Biliary tract; Stomach
1. Introduction Surgical treatment of peptic ulcers has been attained by elimination of the lesion and by procedures attempting to reduce acid secretion by either sectioning the vagus, removing the hormonal stimulation from the antrum, or decreasing the number of parietal cells. Four operations devised to produce these results are subtotal gastrectomy, vagotomy and drainage, vagotomy and antrectomy, and parietal cell vagotomy [1]. Direct cholinergic stimulus to acid – pepsin secretion can be eliminated with vagotomy. Three types of vagotomy are performed: truncal, selective, and highly selective. Truncal vagotomy was initially applied alone but due to development of post vagotomy gastric atony it is accompanied with emptying procedures like pyloroplasty and gastrojejunostomy. Selective and highly selective modifications of vagotomy are used to preserve the innervation * Corresponding author. CMRR, University of Minnesota, 2021 6th Street SE, Minneapolis, MN 55455, USA. Tel.: +1-612-626-2001; fax: +1612-626-2004. E-mail address: [email protected] (A.T.K. Kendi). 0899-7071/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2004.01.002
of the rest of the gut [2] Convergent development of vagotomy and gastric resections resulted in a more effective operation than either procedure alone. After truncal vagotomy and antrectomy, gastrointestinal continuity must be reconstructed with either Billroth I (gastroduedonostomy) or Billroth II (gastrojejunostomy) procedures [1,2]. Since the vagus nerve innervates gastrointestinal viscera other than the stomach, it is expected to have changes following vagotomy in addition to a reduction of gastric acidity. However, it is difficult to analyse these changes as vagotomy is combined with another procedure, such as removal of a portion of the stomach, or a drainage operation. Thus, alterations in the functions of the gastrointestinal system after an operation can be attributed to vagotomy, the accompanying procedure, or a combination of both [3]. The effects of vagotomy and accompanying procedures upon the gall bladder and common bile duct have been shown in animal experimental studies. These studies clarified some points but complicated others due to species variations and differences in techniques and interpretations [3]. Endoscopic retrograde cholangiography is an effective procedure for the diagnosis and management of pancreato-
G.A. Erden et al. / Journal of Clinical Imaging 29 (2005) 42–45
43
Table 1 MRCP evaluation of biliary system and indications for MCP CBD CBD Patient diameter diameter no. Operation (mm) (mm)
CHD diameter (mm)
RHD diameter (mm)
LHD diameter Cystic (mm) canal (mm)
1
Billroth 2 67/E
7
7
6
6
Low medial Filling defect insertion in fundus 5 mm and stones
2 3
Billroth 2 60/K Billroth 2 72/E
10 10
5 8
3 7
3 6
5 3
4
Billroth 2 56/E
CBD 8 Tas¸ +10 mm
5, aberrant 5 right hepatic canal
3
5
Billroth 2 62/K
11
18
4
3
6
Billroth 2 42/K
CBD Tas¸+18 mm
CHD 9 Tas¸+16 mm
8
Not visualized 3
7
Billroth 2 50/E
8
3
3
8
Billroth 2 38/E
CBD Tas¸+12 mm CBD Tas¸+12 mm
10
8
9
Not visualized 2
Gall bladder
Gall bladder wall thickness (mm)
12 mm in Dilatation in fundus, normal intrahepatic bile in other sites duct in USG (extrahepatic cholestasis) Operated – Choledocholithiasis Multiple small 1 mm Dilatation in stones intrahepatic bile duct in USG (extrahepatic cholestasis) Bile sludge 2 Dilatation in intrahepatic bile duct in USG (extrahepatic cholestasis) Operated – Choledocholithiasis Small stones
2
Operated
–
N
2
Dilatation in intrahepatic bile duct in USG (extrahepatic cholestasis) Choledocholithiasis Dilatation in intrahepatic bile duct in USG (extrahepatic cholestasis)
CBD, common bile duct; CHD, common hepatic duct; RHD, right hepatic canal; LHD, left hepatic canal.
biliary disorders [4]. This procedure is performed by using a duodenoscope with fluoroscopic guidance. Although it has a high success rate of greater than 90%, prior gastric surgery, biliary – enteric anastomosis, or pancreatic surgery leads to great difficulty and often complications during application of ERCP [5– 10]. MR cholangiopancreatography (MRCP) is a noninvasive, non-operator-dependent technique that can be used to understand morphological changes in the biliary system in patients who had vagotomy and accompanying procedures. Ultrasonography can be used for detection of gall bladder and bile duct stones effectively. However, in patients with a previous history of gastric or biliary – pancreatic surgery, evaluation of the bile duct (especially the intrapancreatic part) becomes even more difficult due to obscuring intestinal gas and a difficult anatomy [5– 10]. In this study we aimed to show the effectiveness of MRCP in evaluation of biliary system of patients with previous history of biliary and/or gastric surgery. We have also seen capping deformity of distal common bile duct that can be defined as a short and narrow, tail-like appearance in the distal end of dilated intrahepatic bile duct. MRCP appearance in these patients was similar to spasm appearance of the
common bile duct at ERCP. This finding could be secondary to passage of stones, stricture, or edema. As these patients could not be evaluated with ERCP, MRCP can be used as a noninvasive investigative method
Fig. 1. MR cholangiogram of a 42-year-old female patient shows dilated common bile duct—common hepatic duct and stones within them (arrows).
44
G.A. Erden et al. / Journal of Clinical Imaging 29 (2005) 42–45
for evaluation of the biliary system after vagotomy and accompanying procedures.
2. Patients and methods The MRCP images of 8 patients who had a previous history of vagotomy and accompanying procedures (Billroth II) were reviewed during a 10-month period. The patients were 5 men and 3 women with a mean age of 55.87 years (range 42– 72 years). All patients had a previous ultrasonographic evaluation that had revealed intrahepatic bile duct dilatation and/or choledocholithiasis (Table 1). In one patient (the patient numbered as Patient 8 in Table 1) ERCP has been reported as tried and failed. All patients underwent MR imaging with a superconducting magnet (Signa Horizon; General Electric Medical Systems, Milwaukee, WI) operating at 1.0 T. A phased array torso coil was used for signal detection. MR imaging was performed with heavily T2-weighted sequences by using single-shot fast spin – echo (TR = 2857 – 4615, TE = 850 – 1117, BW = 31.2, FOV = 40, 21 – 28 slices, NEX = 0.5, scan time = 90 s). Images were obtained as both a thick collimation (single section) and thin collimation multisection technique at a coronal plane. Thin collimation source images were reconstructed by using maximum intensity projection (MIP) algorithm.
3. Results MRCP was performed successfully in all patients. Three patients had cholecystectomy. The common bile ducts of these 3 patients were slightly dilated secondary to postcholecystectomy. Gall bladder dimensions of the remaining 5 patients were in normal limits. In one patient, the gall
Fig. 2. MR cholangiogram of a 62-year-old female patient demonstrates dilated common bile duct and slight dilatation of the intrahepatic biliary system. There is capping deformity of the distal end of the common bile duct (arrow).
bladder wall was thick and accompanied with an irregular, unknown filling defect. Intrahepatic bile ducts of 3 patients and the cystic canal of 1 patient were enlarged. Pancreatic ducts of 2 patients were slightly enlarged. Four of the patients had common bile duct stones (Fig. 1). Two patients had gallstones and 1 patient had a stone in the common hepatic duct (Fig. 1). All patients had a capping deformity appearance at the distal part of the common bile duct similar to spasm appearance of the common bile duct at endoscopic retrograde cholangiography (Fig. 2). Table 1 shows specific diameters of biliary ducts, evaluation of gall bladder, and indications for MRCP.
4. Discussion Effects of vagotomy on biliary system has been increasingly studied in recent years. Stimulation of the vagus results in contraction of the gall bladder and relaxation of the sphincter of Oddi so that bile can flow into the duodenum [3]. Pitt et al. [11] studied the role of altered extrahepatic biliary function in the pathogenesis of gallstones after vagotomy. They have found that increased resistance to flow through the sphincter of Oddi after truncal vagotomy may be the initial step leading to gallbladder dilatation, bile stasis, and gallstone formation. However, in another study evaluating the opening of the sphincter of Oddi, it was found that vagotomy leads to definite reduction in the resistance of Oddi’s sphincter [12]. Experimental studies have shown that intrinsic myogenic tonicity of the sphincter of Oddi is decreased and bile flow is increased with hepatic plexus vagotomy [13 – 15]. These conflicting results lead to confusion about the effect of vagotomy on the biliary system. This could be attributed to varying degrees of incomplete denervation in patients with vagotomy. Experimental animal studies have helped us to clarify some points but have complicated others due to species variations, differences in techniques, and interpretations [3]. It has been known that truncal vagus nerves modulate the gastroduodenal motility pattern. Truncal vagotomy seems to break down vagally mediated preduodenal mechanism, resulting in delayed onset and reduced rate of emptying of gall bladder. However, in gastrojejunostomy (Billroth II), due to bypass of the duodenum gall bladder emptying is significantly reduced resulting in increased risk of gallstone formation [16,17]. Kobayashi et al. [18] studied the effects of subtotal gastrectomy on the spontaneous motility of the sphincter of Oddi in a dog. They have found that gastrectomy induced dysfunction, an increase of the perfusion pressure and the frequent phasic contractions of the sphincter of Oddi. Thus, following vagotomy and gastrectomy, gall bladder dilatation and Oddi sphincter dysfunction can be accepted as expected findings. Hence, in patients with previous history of vagotomy and partial gastrectomy, one might expect impairment
G.A. Erden et al. / Journal of Clinical Imaging 29 (2005) 42–45
in the emptying of the gall bladder, gall bladder dilatation, and Oddi sphincter dysfunction with slight dilatation of the common bile duct by 3 to 4 mm [19]. ERCP is difficult to perform especially in patients with previous gastric, pancreatobiliary surgery and results in higher complication rate [5 – 10]. Ultrasonography is an important and most commonly used diagnostic tool in the evaluation of biliary system pathologies; however, it has limited diagnostic value in the biliary system pathologies of patients with biliary or gastric operations. Imaging of distal common bile duct with sonography has been reported to be impossible in up to 25% of cases [10]. This can be attributed to obscuring intestinal gas and difficult anatomy following surgery [5– 10]. Ultrasonography also has limited benefit in the evaluation of biloma and pancreatic leakage in biliary – enteric anastomosis, unlike MRCP [8]. Pavone et al. [5] used non-breath-hold MRCP in the evaluation of biliary – enteric anastomosis and found MRCP as an effective method in the evaluation of biliary tree in postoperative patients. With development of breath-hold MRCP, image quality further increased and pancreatobiliary system postsurgical anatomy complications more satisfactorily demonstrated [6,8]. MRCP, which is a noninvasive, nonionic diagnostic procedure characterised by heavily T2 weighted images can be effectively used in the evaluation of biliary system of patients following pancreatobiliary and gastric surgery [4– 8,10]. In our preliminary study, we found a capping appearance in the distal common bile duct in patients with previous vagotomy, antrectomy, and Billroth I or II procedures. This appearance could be attributed to Oddi sphincter dysfunction following vagotomy and gastrectomy, previous passage of stones, postoperative stricture, or edema. Three of the patients had previous cholecystectomy. In the remaining six patients, two had gallstones. In one patient the gall bladder wall was thickened, accompanied with an irregular, unknown filling defect at the level of the fundus. Four of these patients had common bile duct stones and one patient had a stone in the common hepatic duct. Intrahepatic biliary ductal dilatation is seen in all of our patients. This dilatation may be the result of prior cholecystectomy in three of the patients opposed to the vagotomy and gastric surgery. Effect of vagotomy and accompanying procedures on the biliary system still have conflicting results. Thus, morphological changes of the biliary system must be studied in these patients with larger multitrial studies. This preliminary study demonstrated no increase in the volume of gall bladder of patients following vagotomy and accompanying procedures unlike expected. However, the appearance of capping deformity secondary to spasm of the Oddi sphincter supports the results of previous experimental studies [18,19]. Biliary system pathologies including thickening of gallbladder wall and stones were well evaluated with MRCP. In conclusion, MRCP can be accepted as a valuable imaging method in the evaluation of biliary system pathol-
45
ogies in patients with previous history of biliary system and/ or gastric surgery.
References [1] Schwartz SI. Principles of surgery. 7th ed. New York: McGraw-Hill, 1998. pp. 1208 – 11. [2] Seymour NE. Operations for peptic ulcer and their complications. In: Feldman M, Sleisenger MH, Scharschmidt BF, editors. Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders, 1998. pp. 696 – 700. [3] Ballinger WF. The extragastric effects of vagotomy. Surg Clin North Am 1966;46:455 – 62. [4] Wall SD, Yee J. Diagnostic ERCP and PTC in Hepatobiliary and pancreatic radiology. In: Gazelle GS, Saini S, Mueller PR, editors. Hepatobiliary and Pancreatic Radiology Imaging and Intervention. New York: Thieme, 1998. pp. 154 – 5. [5] Pavone P, Laghi A, Catalano C, Broglia L, Panebianco V, Messina A, Salvatori FM, Passariello R. MR cholangiography in the evaluation of patients with biliary – enteric anastomoses. Am J Roentgenol 1997; 169:807 – 11. [6] Sugiyama M, Abe N, Tokuhara M, Masaki T, Mori T, Takahara T, Hachiya J, Atomi Y. Magnetic resonance cholangiopancreatography for postoperative follow-up of intraductal papillary – mucinous tumors of the pancreas. Am J Surg 2003;185:251 – 5. [7] Motohara T, Semelka RC, Bader TR. MR cholangiopancreatography. Radiol Clin North Am 2003;41:89 – 96. [8] Tang Y, Yamashita Y, Arakawa A, Namimoto T, Mitsuzaki K, Abe Y, Katahira K, Takahashi M. Pancreatobiliary ductal system: value of half-Fourier rapid acquisition with relaxation enhancement MR cholangiography for postoperative evaluation. Radiology 2000;215:81 – 8. [9] Costamagna G, Multignani M, Perri V, Gabrielli A, Locicero P, Crucitti F. Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy. Acta Gastroenterol Belg 1994;57:155. [10] Holzknecht N, Gauger J, Stehling MK, Weinzierl M, Reiser M. Choledocholithiasis after Billroth II surgery: MR cholangiographic diagnosis. Eur Radiol 1997;7:520 – 3. [11] Pitt HA, Doty JE, Roslyn JJ, DenBesten L. The role of altered extrahepatic biliary function in the pathogenesis of gallstones after vagotomy. Surgery 1981;90:418 – 25. [12] Labeyrie E. Evaluation of the opening of the sphincter of Oddi. J Chir (Paris) 1976;112:281 – 7. [13] Gu¨ler O, Aydın M, Ugras S, Demirtas I, Berktas M, Go¨nenci R. The influence of sphincterotomy and hepatic plexus vagotomy on ascending infections of the biliary tract: an experimental study in dogs. Hepatogastroenterology 1998;45:662 – 4. [14] Sener M, Cilingiroglu K. The influence of hepatic plexus vagotomy as an adjunt to cholecystectomy on the sphincter of Odd. Turk J Surg 1986;3:31 – 8. [15] Schein CJ, Beneventano TC, Rosen RG, Dardik HM, Gliedman ML. Hepatic plexus vagectomy as an adjunt to cholecystectomy. Surg Gynecol Obstet 1969;128:241 – 51. [16] Pechlivanides G, Xynos E, Chrysos E, Tzovaras G, Fountos A, Vassilakis JS. Gallbladder emptying after antiulcer gastric surgery. Am J Surg 1994;168:335 – 9. [17] Richter HM. Physiologic consequences of vagotomy and gastric resection. Gastroenterol Clin North Am 1994;23:193 – 213. [18] Kobayashi T, Hosoba T, Mori M, Mimura H, Miyake J, Hamaz H, Tsuge H, Orita K, Yamasato T, Neya T, Mizutani M, Nakayama, S. Effects of gastrectomy on motility, perfusion pressure, and caeruleininduced relaxation of sphincter of Oddi. J Smooth Muscle Res 1994;30:85 – 96. [19] Rudick J, Hutchinson JSF. Evaluation of vagotomy and biliary function by combined oral cholecystography and intravenous cholangiography. Ann Surg 1965;162:234 – 40.
MRCP evaluation of biliary system following vagotomy and gastric surgery Gu¨l Ayse Erden a, A. Tuba Karagu¨lle Kendi b,*, Ilhan Erden a a
Department of Radiology, Ankara University School of Medicine, 06100, Ankara, Turkey b Integra MR Imaging center, Tahran caddesi No. 40, Kavaklidere, Ankara, Turkey Received 30 November 2003
Abstract Objective: The aim of this study was to show the usefulness of MR cholangiopancreatography (MRCP) in demonstrating biliary system pathologies in patients with a history of vagotomy and Billroth II operations. Methods: The hepatobiliary system of eight patients with a history of vagotomy and Billroth II operations was evaluated with MRCP. Three-dimensional fast spin – echo technique was used at a 1.0-T scanner with following parameters: TR = 2857 – 4615 ms, TE = 850 – 1117 ms, BW = 31.2, FOV = 40, 21 – 28 slices, NEX = 0.5, scan time = 90 s. Results: Eight patients were evaluated with MRCP. Three patients had cholecystectomy. In one patient the gall bladder wall was thickened, accompanied with an irregular, unknown filling defect at the level of the fundus. Four of these patients had common bile duct stones. Two patients had gallstones and one patient had a stone in the common hepatic duct. A capping deformity of the distal common bile duct was observed in all of the patients. Conclusion: We conclude that MRCP can be used effectively for evaluation of biliary system of patients with previous history of biliary or gastric operations. D 2005 Elsevier Inc. All rights reserved. Keywords: MR imaging; Surgery; Cholangiopancreatography; Biliary tract; Stomach
1. Introduction Surgical treatment of peptic ulcers has been attained by elimination of the lesion and by procedures attempting to reduce acid secretion by either sectioning the vagus, removing the hormonal stimulation from the antrum, or decreasing the number of parietal cells. Four operations devised to produce these results are subtotal gastrectomy, vagotomy and drainage, vagotomy and antrectomy, and parietal cell vagotomy [1]. Direct cholinergic stimulus to acid – pepsin secretion can be eliminated with vagotomy. Three types of vagotomy are performed: truncal, selective, and highly selective. Truncal vagotomy was initially applied alone but due to development of post vagotomy gastric atony it is accompanied with emptying procedures like pyloroplasty and gastrojejunostomy. Selective and highly selective modifications of vagotomy are used to preserve the innervation * Corresponding author. CMRR, University of Minnesota, 2021 6th Street SE, Minneapolis, MN 55455, USA. Tel.: +1-612-626-2001; fax: +1612-626-2004. E-mail address: [email protected] (A.T.K. Kendi). 0899-7071/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2004.01.002
of the rest of the gut [2] Convergent development of vagotomy and gastric resections resulted in a more effective operation than either procedure alone. After truncal vagotomy and antrectomy, gastrointestinal continuity must be reconstructed with either Billroth I (gastroduedonostomy) or Billroth II (gastrojejunostomy) procedures [1,2]. Since the vagus nerve innervates gastrointestinal viscera other than the stomach, it is expected to have changes following vagotomy in addition to a reduction of gastric acidity. However, it is difficult to analyse these changes as vagotomy is combined with another procedure, such as removal of a portion of the stomach, or a drainage operation. Thus, alterations in the functions of the gastrointestinal system after an operation can be attributed to vagotomy, the accompanying procedure, or a combination of both [3]. The effects of vagotomy and accompanying procedures upon the gall bladder and common bile duct have been shown in animal experimental studies. These studies clarified some points but complicated others due to species variations and differences in techniques and interpretations [3]. Endoscopic retrograde cholangiography is an effective procedure for the diagnosis and management of pancreato-
G.A. Erden et al. / Journal of Clinical Imaging 29 (2005) 42–45
43
Table 1 MRCP evaluation of biliary system and indications for MCP CBD CBD Patient diameter diameter no. Operation (mm) (mm)
CHD diameter (mm)
RHD diameter (mm)
LHD diameter Cystic (mm) canal (mm)
1
Billroth 2 67/E
7
7
6
6
Low medial Filling defect insertion in fundus 5 mm and stones
2 3
Billroth 2 60/K Billroth 2 72/E
10 10
5 8
3 7
3 6
5 3
4
Billroth 2 56/E
CBD 8 Tas¸ +10 mm
5, aberrant 5 right hepatic canal
3
5
Billroth 2 62/K
11
18
4
3
6
Billroth 2 42/K
CBD Tas¸+18 mm
CHD 9 Tas¸+16 mm
8
Not visualized 3
7
Billroth 2 50/E
8
3
3
8
Billroth 2 38/E
CBD Tas¸+12 mm CBD Tas¸+12 mm
10
8
9
Not visualized 2
Gall bladder
Gall bladder wall thickness (mm)
12 mm in Dilatation in fundus, normal intrahepatic bile in other sites duct in USG (extrahepatic cholestasis) Operated – Choledocholithiasis Multiple small 1 mm Dilatation in stones intrahepatic bile duct in USG (extrahepatic cholestasis) Bile sludge 2 Dilatation in intrahepatic bile duct in USG (extrahepatic cholestasis) Operated – Choledocholithiasis Small stones
2
Operated
–
N
2
Dilatation in intrahepatic bile duct in USG (extrahepatic cholestasis) Choledocholithiasis Dilatation in intrahepatic bile duct in USG (extrahepatic cholestasis)
CBD, common bile duct; CHD, common hepatic duct; RHD, right hepatic canal; LHD, left hepatic canal.
biliary disorders [4]. This procedure is performed by using a duodenoscope with fluoroscopic guidance. Although it has a high success rate of greater than 90%, prior gastric surgery, biliary – enteric anastomosis, or pancreatic surgery leads to great difficulty and often complications during application of ERCP [5– 10]. MR cholangiopancreatography (MRCP) is a noninvasive, non-operator-dependent technique that can be used to understand morphological changes in the biliary system in patients who had vagotomy and accompanying procedures. Ultrasonography can be used for detection of gall bladder and bile duct stones effectively. However, in patients with a previous history of gastric or biliary – pancreatic surgery, evaluation of the bile duct (especially the intrapancreatic part) becomes even more difficult due to obscuring intestinal gas and a difficult anatomy [5– 10]. In this study we aimed to show the effectiveness of MRCP in evaluation of biliary system of patients with previous history of biliary and/or gastric surgery. We have also seen capping deformity of distal common bile duct that can be defined as a short and narrow, tail-like appearance in the distal end of dilated intrahepatic bile duct. MRCP appearance in these patients was similar to spasm appearance of the
common bile duct at ERCP. This finding could be secondary to passage of stones, stricture, or edema. As these patients could not be evaluated with ERCP, MRCP can be used as a noninvasive investigative method
Fig. 1. MR cholangiogram of a 42-year-old female patient shows dilated common bile duct—common hepatic duct and stones within them (arrows).
44
G.A. Erden et al. / Journal of Clinical Imaging 29 (2005) 42–45
for evaluation of the biliary system after vagotomy and accompanying procedures.
2. Patients and methods The MRCP images of 8 patients who had a previous history of vagotomy and accompanying procedures (Billroth II) were reviewed during a 10-month period. The patients were 5 men and 3 women with a mean age of 55.87 years (range 42– 72 years). All patients had a previous ultrasonographic evaluation that had revealed intrahepatic bile duct dilatation and/or choledocholithiasis (Table 1). In one patient (the patient numbered as Patient 8 in Table 1) ERCP has been reported as tried and failed. All patients underwent MR imaging with a superconducting magnet (Signa Horizon; General Electric Medical Systems, Milwaukee, WI) operating at 1.0 T. A phased array torso coil was used for signal detection. MR imaging was performed with heavily T2-weighted sequences by using single-shot fast spin – echo (TR = 2857 – 4615, TE = 850 – 1117, BW = 31.2, FOV = 40, 21 – 28 slices, NEX = 0.5, scan time = 90 s). Images were obtained as both a thick collimation (single section) and thin collimation multisection technique at a coronal plane. Thin collimation source images were reconstructed by using maximum intensity projection (MIP) algorithm.
3. Results MRCP was performed successfully in all patients. Three patients had cholecystectomy. The common bile ducts of these 3 patients were slightly dilated secondary to postcholecystectomy. Gall bladder dimensions of the remaining 5 patients were in normal limits. In one patient, the gall
Fig. 2. MR cholangiogram of a 62-year-old female patient demonstrates dilated common bile duct and slight dilatation of the intrahepatic biliary system. There is capping deformity of the distal end of the common bile duct (arrow).
bladder wall was thick and accompanied with an irregular, unknown filling defect. Intrahepatic bile ducts of 3 patients and the cystic canal of 1 patient were enlarged. Pancreatic ducts of 2 patients were slightly enlarged. Four of the patients had common bile duct stones (Fig. 1). Two patients had gallstones and 1 patient had a stone in the common hepatic duct (Fig. 1). All patients had a capping deformity appearance at the distal part of the common bile duct similar to spasm appearance of the common bile duct at endoscopic retrograde cholangiography (Fig. 2). Table 1 shows specific diameters of biliary ducts, evaluation of gall bladder, and indications for MRCP.
4. Discussion Effects of vagotomy on biliary system has been increasingly studied in recent years. Stimulation of the vagus results in contraction of the gall bladder and relaxation of the sphincter of Oddi so that bile can flow into the duodenum [3]. Pitt et al. [11] studied the role of altered extrahepatic biliary function in the pathogenesis of gallstones after vagotomy. They have found that increased resistance to flow through the sphincter of Oddi after truncal vagotomy may be the initial step leading to gallbladder dilatation, bile stasis, and gallstone formation. However, in another study evaluating the opening of the sphincter of Oddi, it was found that vagotomy leads to definite reduction in the resistance of Oddi’s sphincter [12]. Experimental studies have shown that intrinsic myogenic tonicity of the sphincter of Oddi is decreased and bile flow is increased with hepatic plexus vagotomy [13 – 15]. These conflicting results lead to confusion about the effect of vagotomy on the biliary system. This could be attributed to varying degrees of incomplete denervation in patients with vagotomy. Experimental animal studies have helped us to clarify some points but have complicated others due to species variations, differences in techniques, and interpretations [3]. It has been known that truncal vagus nerves modulate the gastroduodenal motility pattern. Truncal vagotomy seems to break down vagally mediated preduodenal mechanism, resulting in delayed onset and reduced rate of emptying of gall bladder. However, in gastrojejunostomy (Billroth II), due to bypass of the duodenum gall bladder emptying is significantly reduced resulting in increased risk of gallstone formation [16,17]. Kobayashi et al. [18] studied the effects of subtotal gastrectomy on the spontaneous motility of the sphincter of Oddi in a dog. They have found that gastrectomy induced dysfunction, an increase of the perfusion pressure and the frequent phasic contractions of the sphincter of Oddi. Thus, following vagotomy and gastrectomy, gall bladder dilatation and Oddi sphincter dysfunction can be accepted as expected findings. Hence, in patients with previous history of vagotomy and partial gastrectomy, one might expect impairment
G.A. Erden et al. / Journal of Clinical Imaging 29 (2005) 42–45
in the emptying of the gall bladder, gall bladder dilatation, and Oddi sphincter dysfunction with slight dilatation of the common bile duct by 3 to 4 mm [19]. ERCP is difficult to perform especially in patients with previous gastric, pancreatobiliary surgery and results in higher complication rate [5 – 10]. Ultrasonography is an important and most commonly used diagnostic tool in the evaluation of biliary system pathologies; however, it has limited diagnostic value in the biliary system pathologies of patients with biliary or gastric operations. Imaging of distal common bile duct with sonography has been reported to be impossible in up to 25% of cases [10]. This can be attributed to obscuring intestinal gas and difficult anatomy following surgery [5– 10]. Ultrasonography also has limited benefit in the evaluation of biloma and pancreatic leakage in biliary – enteric anastomosis, unlike MRCP [8]. Pavone et al. [5] used non-breath-hold MRCP in the evaluation of biliary – enteric anastomosis and found MRCP as an effective method in the evaluation of biliary tree in postoperative patients. With development of breath-hold MRCP, image quality further increased and pancreatobiliary system postsurgical anatomy complications more satisfactorily demonstrated [6,8]. MRCP, which is a noninvasive, nonionic diagnostic procedure characterised by heavily T2 weighted images can be effectively used in the evaluation of biliary system of patients following pancreatobiliary and gastric surgery [4– 8,10]. In our preliminary study, we found a capping appearance in the distal common bile duct in patients with previous vagotomy, antrectomy, and Billroth I or II procedures. This appearance could be attributed to Oddi sphincter dysfunction following vagotomy and gastrectomy, previous passage of stones, postoperative stricture, or edema. Three of the patients had previous cholecystectomy. In the remaining six patients, two had gallstones. In one patient the gall bladder wall was thickened, accompanied with an irregular, unknown filling defect at the level of the fundus. Four of these patients had common bile duct stones and one patient had a stone in the common hepatic duct. Intrahepatic biliary ductal dilatation is seen in all of our patients. This dilatation may be the result of prior cholecystectomy in three of the patients opposed to the vagotomy and gastric surgery. Effect of vagotomy and accompanying procedures on the biliary system still have conflicting results. Thus, morphological changes of the biliary system must be studied in these patients with larger multitrial studies. This preliminary study demonstrated no increase in the volume of gall bladder of patients following vagotomy and accompanying procedures unlike expected. However, the appearance of capping deformity secondary to spasm of the Oddi sphincter supports the results of previous experimental studies [18,19]. Biliary system pathologies including thickening of gallbladder wall and stones were well evaluated with MRCP. In conclusion, MRCP can be accepted as a valuable imaging method in the evaluation of biliary system pathol-
45
ogies in patients with previous history of biliary system and/ or gastric surgery.
References [1] Schwartz SI. Principles of surgery. 7th ed. New York: McGraw-Hill, 1998. pp. 1208 – 11. [2] Seymour NE. Operations for peptic ulcer and their complications. In: Feldman M, Sleisenger MH, Scharschmidt BF, editors. Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders, 1998. pp. 696 – 700. [3] Ballinger WF. The extragastric effects of vagotomy. Surg Clin North Am 1966;46:455 – 62. [4] Wall SD, Yee J. Diagnostic ERCP and PTC in Hepatobiliary and pancreatic radiology. In: Gazelle GS, Saini S, Mueller PR, editors. Hepatobiliary and Pancreatic Radiology Imaging and Intervention. New York: Thieme, 1998. pp. 154 – 5. [5] Pavone P, Laghi A, Catalano C, Broglia L, Panebianco V, Messina A, Salvatori FM, Passariello R. MR cholangiography in the evaluation of patients with biliary – enteric anastomoses. Am J Roentgenol 1997; 169:807 – 11. [6] Sugiyama M, Abe N, Tokuhara M, Masaki T, Mori T, Takahara T, Hachiya J, Atomi Y. Magnetic resonance cholangiopancreatography for postoperative follow-up of intraductal papillary – mucinous tumors of the pancreas. Am J Surg 2003;185:251 – 5. [7] Motohara T, Semelka RC, Bader TR. MR cholangiopancreatography. Radiol Clin North Am 2003;41:89 – 96. [8] Tang Y, Yamashita Y, Arakawa A, Namimoto T, Mitsuzaki K, Abe Y, Katahira K, Takahashi M. Pancreatobiliary ductal system: value of half-Fourier rapid acquisition with relaxation enhancement MR cholangiography for postoperative evaluation. Radiology 2000;215:81 – 8. [9] Costamagna G, Multignani M, Perri V, Gabrielli A, Locicero P, Crucitti F. Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy. Acta Gastroenterol Belg 1994;57:155. [10] Holzknecht N, Gauger J, Stehling MK, Weinzierl M, Reiser M. Choledocholithiasis after Billroth II surgery: MR cholangiographic diagnosis. Eur Radiol 1997;7:520 – 3. [11] Pitt HA, Doty JE, Roslyn JJ, DenBesten L. The role of altered extrahepatic biliary function in the pathogenesis of gallstones after vagotomy. Surgery 1981;90:418 – 25. [12] Labeyrie E. Evaluation of the opening of the sphincter of Oddi. J Chir (Paris) 1976;112:281 – 7. [13] Gu¨ler O, Aydın M, Ugras S, Demirtas I, Berktas M, Go¨nenci R. The influence of sphincterotomy and hepatic plexus vagotomy on ascending infections of the biliary tract: an experimental study in dogs. Hepatogastroenterology 1998;45:662 – 4. [14] Sener M, Cilingiroglu K. The influence of hepatic plexus vagotomy as an adjunt to cholecystectomy on the sphincter of Odd. Turk J Surg 1986;3:31 – 8. [15] Schein CJ, Beneventano TC, Rosen RG, Dardik HM, Gliedman ML. Hepatic plexus vagectomy as an adjunt to cholecystectomy. Surg Gynecol Obstet 1969;128:241 – 51. [16] Pechlivanides G, Xynos E, Chrysos E, Tzovaras G, Fountos A, Vassilakis JS. Gallbladder emptying after antiulcer gastric surgery. Am J Surg 1994;168:335 – 9. [17] Richter HM. Physiologic consequences of vagotomy and gastric resection. Gastroenterol Clin North Am 1994;23:193 – 213. [18] Kobayashi T, Hosoba T, Mori M, Mimura H, Miyake J, Hamaz H, Tsuge H, Orita K, Yamasato T, Neya T, Mizutani M, Nakayama, S. Effects of gastrectomy on motility, perfusion pressure, and caeruleininduced relaxation of sphincter of Oddi. J Smooth Muscle Res 1994;30:85 – 96. [19] Rudick J, Hutchinson JSF. Evaluation of vagotomy and biliary function by combined oral cholecystography and intravenous cholangiography. Ann Surg 1965;162:234 – 40.