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The use of magnetic resonance cholangiopancreatography in surgical patients
AGAA201i
April 2000
underw ent 3D ultrasonographic exam ination for bilialy tract diseases (cancer of bile duct n = I ; cancer of papilla of Vater n= 3; papillitis of Vater n= I ; obstructive jaundice due to cancer of the pancreas n= I ) between June 1999 and October 1999. We used a real-time ultrasound system (SSD-2000, ALOKA , Tok yo, Japan) with a 3.5 MHz convex prove to attach a electromagnetic sensor and a commercial 3D ultrasonography reconstruction system (SAS-200, ALOKA, Tok yo, Japan) for this study. The transmitter to generate a multipli city of electromagnetic fields was located within 50cm of the subjects when we scanned bilialy tract after overnight fasting. We automatically produced VC images by surface rendering method and compared them with the resected specimen s or chol angioscopy or endoscopic retrograde cholangiography. Result We could produce VC images of the dilated bile duct s in all cases. In three case s, we could create VC images of the region s of stenosis. In a case of cancer of the bile duct , VC images showed dilated intrahepatic bile ducts. In a case of cancer of papilla of Vater , VC images clearly displayed that the tumor extended into the bile duct. In a case of obstruct ive jaundice due to cancer of the pancre as, VC showed dilated common bile duct was obstructed due to pancreatic cancer. Because the region s of stenosis were affected by gastrointe stinal gas, we could not produce VC in two cases of cancer of papill a of Vater and a case of papillitis of Vater . It took about fifteen minutes on the average to reconstruct VC images . Conclusion 3D ultrasonography by use of electromagnetic fields can visualize internal structures of bile duct. Although cholangioscopy is accurate for diagnosis of bilialy tract diseases, it is invasive, and lack of patient acceptance. VC using transabdominal three-dimensional ultrasonography is a noninvasive method. It may be useful to diagnose 3D extent and configurations of tumor s in bile duct if software and hardware are improved to provide faster rendering and to reveal tumor shape and extent accurately.
1272 THE USEFULNESS OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) FOR THE DIAGNOSIS OF BILIOPANCREATIC DISEASE. Masaru Izumi, Susumu Ohwada, Izumi Tak eyoshi, Tomohiro Inoue , Yoshiyuki Kawash ima, Naoki Tomizawa, Mure o Ksahara, Susumu Kawate , Yutaka Sunose, Tohru Koyama , Yasuo Mori shita, Kurosawa Hosp, Takasaki, Japan ; 2nd Dept of Surg Gunm a Univ Sch of Med , Maebashi , Japan. Magneti c resonance cholangiopancreatography(MRCP ) is a new nonin vasive imaging technique for the diagn osis of biliopancreatic disease . The aim of this study was to evaluate the feasibility of MRCP by comparing with drip infusion cholangiography(DIC) , three-dimensional-computed tomograph y (3D-CT) and invasive direct cholan giopan creato-graphy includ ing endoscopic retrograde cholangiopancreatography(ERCP ), percutaneous transhepatic cholangiography(PTC) and intraoperati ve cholangiography . Patients and Method : From Oct. 1995 to Oct. 1999, MRCP was performed in 350 patients (mean age ; 56:!: 10 years old, ranging 23 to 86) with biliopancre atic disease due to, ( I) preoperative assessment for laparoscop ic cholecystectomy (n= 237), (2) suspected choledochalstone (n=61), (3) bile duct disease (n= 30) and (4) pancreatic disease (n=23). The MRCP was performed with an 1.5T superconducting magne t (Gyroscan NT; Philips , the Netherl ands). Results: (1) In preoperative assessment for laparoscopic surgery , the cystic duct was comfirmed in 52% of DIC patients, in 93% of 3D-CT and in 95% of MRCP patients. The image quality was higher in 3D-CT than in MRCP and DIC, however 3D-CT was inferior in cases with severe cholecystitis , liver dysfunction and obstructive jaundice. (2) In choledocholith iasis, MRCP showed 94 % sensitivity, 100% specificity and 91.4 % overall diagno stic accuracy . (3) In bile duct disease, MRCP showed pancreatico-bil iary muljunction in two patients, and stenotic lesions in 28. Twenty five patients were correctly diagnosed as malignant and three as benign . Choledochal carcinoma with choled ocholithiasis was misdiagnosed as benign in two patients . (4) The dilated peripheral pancreatic duct due to obstruction was exactl y evaluated by MRCP than by ERCP and PTC in 20 patients with chron ic pancreatitis and pancreatic carcinoma. The normal pancreatic duct was shown in its entirel y in 249(71 %) of 350 patients. Conclu sion s: MRCP can be considered a techniqu e which completel y can replace traditional DIC and it may replace diagno stic ERCP . 3D-CT demonstrated clear image of the cystic duct than MRCP despite the limitation of its application for cases with DIC negative cholangiogram. MRCP can be used as a noninvasive first screening method for biliopancreatic disease compared with 3D-CT. 1273 THE USE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY IN SURGICAL PATIENTS. Jeroen Wa Ley tens, Marc P. Proosdij , George Zied ses des Plantes, Eric H. Eddes , Hugo Ja Hazenberg, Marinu s Eeftinck Schattenkerk, Deventer Ziekenhui s, Deventer, Netherlands. Magnetic Resonance Cholangiopancreatogr aphy (MRCP) is a new clinical tool which seems suitable for non-inv asive diagnostic imaging of the gallbladder, bile duct system and pancreas. In order to evaluate whther MRCP is a suitable technique, twenty-two MRCP's performed between 1997 and 1999, were retrospectively analysed. Fourteen MRCP's were performed before laparoscopic cholecystectomy, 8 for other reasons. Thirteen out of these 14 preoperative MRCP ' s showed no abnormalities. The indicati on for MRCP in this group was a medical history and liver functions suggestive for cholestasis due to chol odocholithiasis. In all 13 pa-
tients with normal MRCP, an uncomplicated laparoscopic cholecystectomy followed subsequently. One patient showed choledocholithiasis for which an ERCP was succesfully performed. After this procedure a laparoscopic cholecystectomy followed uncomplicated. In 3 patients, common bile duct stones were detected postoperatively by MRCP and thereafter removed by ERCP. In I patient, bile leakage was clinica1l1y suspected and detected by MRCP . By ERCP a stent was inserted in the common bile duct. Another patient with pancreatitis showed compression of the distal part of the common bile duct on MRCP, without any signs of bile stones and a normal diameter of the cornmon bile duct. It was decided not to perform an ERCP and the patient recovered with out any furhter intervention. In 3 other patients MRCP was perfomed for several other reasons. In conclu sion results obtained by MRCP were comparable to those of "gold standard" ERCP. Therefore we feel, the diagn ostic impact of MRCP in daily gastroenterology practice becomes of increasing importance, especially taking the ERCP related morbidity and mortality into account. For future diagnostics, MRCP will probably replace ERCP
1274 INTRADUCTAL ULTRASONOGRAPHY (mUS) FOR PREOPER· ATIVE DIAGNOSIS OF BILE DUCT STRICTURES. PROSPEC· TIVE STUDY COMPARING mus WITH CONVENTIONAL EN· DOSONOGRAPHY (EUS). Josef Menzel, Christopher Poremba, Karlheinz Dietl, Werner Boecker , Norbert Senninger, Wolfram Domschke, Dept of Medicine B, Muenster, Germany; Dept of Pathology, Muenster, Germany; Dept of Surg, Muenster, Germany. Background: Accuracy of intraductal ultrasonography (lDUS) and endoscopic ultrasonography (EUS) were compared in diagnosing biliary obstruction and in predicting surgical resectability. Patients and Methods: Fifty-six patients with biliary obstruction were investigated preoperatively with both conventional endo scopic ultras onography (EUS) and intraductal ultrasonography (IDUS ). The ultrasonographic miniprobe (ALO KA, 2.0 mm diameter, 20 MHz frequency) was inserted into the bile duct system through the working channel of the duodenoscope during ERCP. Con ventional endosonography was performed using the echoendoscopes (Olympus EU-M3 or EU-M20) in standard technique. Images of endoluminal ultrasonography were prospectively reviewed and compared with intraoperative findings and resection specimen analyses. Results : Intraductal ultrasonography exceeded endo scopic ultrasonography in terms of accuracy (IDU S: 89.1%; EUS : 75.6 %; p
1275 TRANSPAPILLARY BILIARY SONOGRAPHY BEFORE BILIARY DRAINAGE (TPBS-BD) IN ASSESSMENT OF THE LONGITUDI· NAL EXTENT OF BILE DUCT CANCER -COMPARED WITH CHOLEDOCHOSCOPY AND BIOPSY-, Yutak a Noda , Naotaka Fujita, Go Kobayashi, Katsumi Kimura, Atsuo Matsunaga, Toyohiko Yuki , Mikiko Nomura, Tadasu Sato , Kazuhiko Ishida, Sendai City Med Ctr, Sendai , Japan. Objectives: We previously reported that " transpapillary biliary sonography (TPBS) before biliary drainage" (TPBS-BD) is much more useful than 10 US after biliary drainage in assessment of the longitudinal extent of bile duct cancer. We evaluated the diagno stic efficacy of TPBS-BD for the longitudinal extent of bile duct cancer compared with that of choledochoscopy and mapping biop sy. Patients and Methods: We performed TPBS-BD preoperatively in 16 patient s with carcinoma of the uppe r (2 patient ), middle (8 patients ) and lower (6 patients ) bile duct , and evalu ated the longitudinal extent of the carcinoma. When "irregularity of the muco sal surface andlor uneven or localized thickening of the internal hypoechoic layer of the bile duct adjacent to the main tumor " were observed and almost completely corresponded to the mucosal andlor intramural spread of the bile duct cancer histologically in the surgical material, the preoperative diagnosi s for extent of cancer by TPBS-BD was considered to be correct. Eight of the 16 patients were also examined by choled ochoscop y and mapping biopsy (7 by the percutane ous transhepatic approach and one by the peroral approach). The microscanners used for this study were 20 MHz radial-scan probes manu factured by Olympus, and Aloka . TPBS-BD was performed by a ropeway method using a microscanner with a guidew ire channel. Results: The diagnostic accuracy of the longitudinal extent of the bile duct cancer on the hepatic and duodenal sides by TPBS-BD was 14/16(87.5%) and 12/16(75%), respectively. That by choledochoscopy and biopsy was 7/8(87.5%) and 3/8(37.5%), respectively. That by combination of TPBS-BD and choledochoscopylbiopsy was 8/8(100%) and 6/8(75 %), respectively. Conclusion: TPBS-BD is as useful as choledochoscopy and mapping biopsy for evaluation of the longitudinal extent of bile duct cancer.
April 2000
underw ent 3D ultrasonographic exam ination for bilialy tract diseases (cancer of bile duct n = I ; cancer of papilla of Vater n= 3; papillitis of Vater n= I ; obstructive jaundice due to cancer of the pancreas n= I ) between June 1999 and October 1999. We used a real-time ultrasound system (SSD-2000, ALOKA , Tok yo, Japan) with a 3.5 MHz convex prove to attach a electromagnetic sensor and a commercial 3D ultrasonography reconstruction system (SAS-200, ALOKA, Tok yo, Japan) for this study. The transmitter to generate a multipli city of electromagnetic fields was located within 50cm of the subjects when we scanned bilialy tract after overnight fasting. We automatically produced VC images by surface rendering method and compared them with the resected specimen s or chol angioscopy or endoscopic retrograde cholangiography. Result We could produce VC images of the dilated bile duct s in all cases. In three case s, we could create VC images of the region s of stenosis. In a case of cancer of the bile duct , VC images showed dilated intrahepatic bile ducts. In a case of cancer of papilla of Vater , VC images clearly displayed that the tumor extended into the bile duct. In a case of obstruct ive jaundice due to cancer of the pancre as, VC showed dilated common bile duct was obstructed due to pancreatic cancer. Because the region s of stenosis were affected by gastrointe stinal gas, we could not produce VC in two cases of cancer of papill a of Vater and a case of papillitis of Vater . It took about fifteen minutes on the average to reconstruct VC images . Conclusion 3D ultrasonography by use of electromagnetic fields can visualize internal structures of bile duct. Although cholangioscopy is accurate for diagnosis of bilialy tract diseases, it is invasive, and lack of patient acceptance. VC using transabdominal three-dimensional ultrasonography is a noninvasive method. It may be useful to diagnose 3D extent and configurations of tumor s in bile duct if software and hardware are improved to provide faster rendering and to reveal tumor shape and extent accurately.
1272 THE USEFULNESS OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) FOR THE DIAGNOSIS OF BILIOPANCREATIC DISEASE. Masaru Izumi, Susumu Ohwada, Izumi Tak eyoshi, Tomohiro Inoue , Yoshiyuki Kawash ima, Naoki Tomizawa, Mure o Ksahara, Susumu Kawate , Yutaka Sunose, Tohru Koyama , Yasuo Mori shita, Kurosawa Hosp, Takasaki, Japan ; 2nd Dept of Surg Gunm a Univ Sch of Med , Maebashi , Japan. Magneti c resonance cholangiopancreatography(MRCP ) is a new nonin vasive imaging technique for the diagn osis of biliopancreatic disease . The aim of this study was to evaluate the feasibility of MRCP by comparing with drip infusion cholangiography(DIC) , three-dimensional-computed tomograph y (3D-CT) and invasive direct cholan giopan creato-graphy includ ing endoscopic retrograde cholangiopancreatography(ERCP ), percutaneous transhepatic cholangiography(PTC) and intraoperati ve cholangiography . Patients and Method : From Oct. 1995 to Oct. 1999, MRCP was performed in 350 patients (mean age ; 56:!: 10 years old, ranging 23 to 86) with biliopancre atic disease due to, ( I) preoperative assessment for laparoscop ic cholecystectomy (n= 237), (2) suspected choledochalstone (n=61), (3) bile duct disease (n= 30) and (4) pancreatic disease (n=23). The MRCP was performed with an 1.5T superconducting magne t (Gyroscan NT; Philips , the Netherl ands). Results: (1) In preoperative assessment for laparoscopic surgery , the cystic duct was comfirmed in 52% of DIC patients, in 93% of 3D-CT and in 95% of MRCP patients. The image quality was higher in 3D-CT than in MRCP and DIC, however 3D-CT was inferior in cases with severe cholecystitis , liver dysfunction and obstructive jaundice. (2) In choledocholith iasis, MRCP showed 94 % sensitivity, 100% specificity and 91.4 % overall diagno stic accuracy . (3) In bile duct disease, MRCP showed pancreatico-bil iary muljunction in two patients, and stenotic lesions in 28. Twenty five patients were correctly diagnosed as malignant and three as benign . Choledochal carcinoma with choled ocholithiasis was misdiagnosed as benign in two patients . (4) The dilated peripheral pancreatic duct due to obstruction was exactl y evaluated by MRCP than by ERCP and PTC in 20 patients with chron ic pancreatitis and pancreatic carcinoma. The normal pancreatic duct was shown in its entirel y in 249(71 %) of 350 patients. Conclu sion s: MRCP can be considered a techniqu e which completel y can replace traditional DIC and it may replace diagno stic ERCP . 3D-CT demonstrated clear image of the cystic duct than MRCP despite the limitation of its application for cases with DIC negative cholangiogram. MRCP can be used as a noninvasive first screening method for biliopancreatic disease compared with 3D-CT. 1273 THE USE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY IN SURGICAL PATIENTS. Jeroen Wa Ley tens, Marc P. Proosdij , George Zied ses des Plantes, Eric H. Eddes , Hugo Ja Hazenberg, Marinu s Eeftinck Schattenkerk, Deventer Ziekenhui s, Deventer, Netherlands. Magnetic Resonance Cholangiopancreatogr aphy (MRCP) is a new clinical tool which seems suitable for non-inv asive diagnostic imaging of the gallbladder, bile duct system and pancreas. In order to evaluate whther MRCP is a suitable technique, twenty-two MRCP's performed between 1997 and 1999, were retrospectively analysed. Fourteen MRCP's were performed before laparoscopic cholecystectomy, 8 for other reasons. Thirteen out of these 14 preoperative MRCP ' s showed no abnormalities. The indicati on for MRCP in this group was a medical history and liver functions suggestive for cholestasis due to chol odocholithiasis. In all 13 pa-
tients with normal MRCP, an uncomplicated laparoscopic cholecystectomy followed subsequently. One patient showed choledocholithiasis for which an ERCP was succesfully performed. After this procedure a laparoscopic cholecystectomy followed uncomplicated. In 3 patients, common bile duct stones were detected postoperatively by MRCP and thereafter removed by ERCP. In I patient, bile leakage was clinica1l1y suspected and detected by MRCP . By ERCP a stent was inserted in the common bile duct. Another patient with pancreatitis showed compression of the distal part of the common bile duct on MRCP, without any signs of bile stones and a normal diameter of the cornmon bile duct. It was decided not to perform an ERCP and the patient recovered with out any furhter intervention. In 3 other patients MRCP was perfomed for several other reasons. In conclu sion results obtained by MRCP were comparable to those of "gold standard" ERCP. Therefore we feel, the diagn ostic impact of MRCP in daily gastroenterology practice becomes of increasing importance, especially taking the ERCP related morbidity and mortality into account. For future diagnostics, MRCP will probably replace ERCP
1274 INTRADUCTAL ULTRASONOGRAPHY (mUS) FOR PREOPER· ATIVE DIAGNOSIS OF BILE DUCT STRICTURES. PROSPEC· TIVE STUDY COMPARING mus WITH CONVENTIONAL EN· DOSONOGRAPHY (EUS). Josef Menzel, Christopher Poremba, Karlheinz Dietl, Werner Boecker , Norbert Senninger, Wolfram Domschke, Dept of Medicine B, Muenster, Germany; Dept of Pathology, Muenster, Germany; Dept of Surg, Muenster, Germany. Background: Accuracy of intraductal ultrasonography (lDUS) and endoscopic ultrasonography (EUS) were compared in diagnosing biliary obstruction and in predicting surgical resectability. Patients and Methods: Fifty-six patients with biliary obstruction were investigated preoperatively with both conventional endo scopic ultras onography (EUS) and intraductal ultrasonography (IDUS ). The ultrasonographic miniprobe (ALO KA, 2.0 mm diameter, 20 MHz frequency) was inserted into the bile duct system through the working channel of the duodenoscope during ERCP. Con ventional endosonography was performed using the echoendoscopes (Olympus EU-M3 or EU-M20) in standard technique. Images of endoluminal ultrasonography were prospectively reviewed and compared with intraoperative findings and resection specimen analyses. Results : Intraductal ultrasonography exceeded endo scopic ultrasonography in terms of accuracy (IDU S: 89.1%; EUS : 75.6 %; p
1275 TRANSPAPILLARY BILIARY SONOGRAPHY BEFORE BILIARY DRAINAGE (TPBS-BD) IN ASSESSMENT OF THE LONGITUDI· NAL EXTENT OF BILE DUCT CANCER -COMPARED WITH CHOLEDOCHOSCOPY AND BIOPSY-, Yutak a Noda , Naotaka Fujita, Go Kobayashi, Katsumi Kimura, Atsuo Matsunaga, Toyohiko Yuki , Mikiko Nomura, Tadasu Sato , Kazuhiko Ishida, Sendai City Med Ctr, Sendai , Japan. Objectives: We previously reported that " transpapillary biliary sonography (TPBS) before biliary drainage" (TPBS-BD) is much more useful than 10 US after biliary drainage in assessment of the longitudinal extent of bile duct cancer. We evaluated the diagno stic efficacy of TPBS-BD for the longitudinal extent of bile duct cancer compared with that of choledochoscopy and mapping biop sy. Patients and Methods: We performed TPBS-BD preoperatively in 16 patient s with carcinoma of the uppe r (2 patient ), middle (8 patients ) and lower (6 patients ) bile duct , and evalu ated the longitudinal extent of the carcinoma. When "irregularity of the muco sal surface andlor uneven or localized thickening of the internal hypoechoic layer of the bile duct adjacent to the main tumor " were observed and almost completely corresponded to the mucosal andlor intramural spread of the bile duct cancer histologically in the surgical material, the preoperative diagnosi s for extent of cancer by TPBS-BD was considered to be correct. Eight of the 16 patients were also examined by choled ochoscop y and mapping biopsy (7 by the percutane ous transhepatic approach and one by the peroral approach). The microscanners used for this study were 20 MHz radial-scan probes manu factured by Olympus, and Aloka . TPBS-BD was performed by a ropeway method using a microscanner with a guidew ire channel. Results: The diagnostic accuracy of the longitudinal extent of the bile duct cancer on the hepatic and duodenal sides by TPBS-BD was 14/16(87.5%) and 12/16(75%), respectively. That by choledochoscopy and biopsy was 7/8(87.5%) and 3/8(37.5%), respectively. That by combination of TPBS-BD and choledochoscopylbiopsy was 8/8(100%) and 6/8(75 %), respectively. Conclusion: TPBS-BD is as useful as choledochoscopy and mapping biopsy for evaluation of the longitudinal extent of bile duct cancer.