99mTc-mebrofenin Hepatobiliary Scintigraphy Research Articles

BN SO15 - Post Cholecystectomy Syndrome: Definition, Aetiology, Investigation & Management – A Systematic Review

Abstract Background Post-cholecystectomy syndrome (PCS) is a term commonly used to refer to the persistence of abdominal symptoms following cholecystectomy, or de-novo symptoms that develop post operatively. Despite the common use of the term, there is no widely agreed upon consensus definition. PCS is reported to affect between 5-40% of patients that undergo cholecystectomy representing a large populational burden. Despite this, there are no guidelines or protocols in place for the routine investigation and management of this large heterogenous patient group. In this study we systematically review the literature describing definition, aetiology, investigation and up-to-date management of PCS. Method An updated systematic search of the Medline, EMBASE and Cochrane databases was undertaken to identify studies where patients underwent cholecystectomy and subsequently were diagnosed with PCS. Included papers were published between 2016-2024, had a minimum of 10 cases of PCS following laparoscopic or open cholecystectomy. Excluded studies were case reports, narrative and systematic reviews, paediatric patient population or papers unavailable in the English language. Paper characteristics were extracted and where present, the definition of PCS, aetiology, investigations and management of these patients was both extracted and analysed. Results 145 papers were identified of which 13 were included after title, abstract and full text screening. Definition of PCS, where present, was highly heterogenous between papers. Aetiology was often divided into biliary and non-biliary causes, with some papers claiming early-PCS and late-PCS as distinct clinical phenomena. In such papers, early-PCS was most commonly attributed to gastro-oesophageal pathologies and late-PCS to biliary pathologies. Investigation strategy is sparingly reported and without guideline or protocol. Most frequently used tests include LFTs, USS, MRCP, CT, ERCP and OGD. Some studies also used 99m Tc-Mebrofenin Hepatobiliary Scintigraphy, sphincter manometry and colonoscopy. Conclusion PCS has a widely reported prevalence in the published literature. This is potentially due to the heterogeneity of definitions used to cover the syndrome. The effective management of such patients depends on both the accurate diagnosis of the underlying cause, as well as exclusion of procedure related complications. There are currently no guidelines or protocols available for the investigation and management of patients presenting with symptoms post cholecystectomy despite the large populational burden. Further studies should aim to provide a consensus definition of PCS, and work towards guidelines for the investigation and management of this patient group.

Decreased mebrofenin uptake in patients with non-colorectal liver tumors requiring liver volume augmentation—a single-center analysis

BackgroundPosthepatectomy liver failure (PHLF) remains a life-threatening complication after hepatectomy. To reduce PHLF, a preoperative assessment of liver function is indispensable. For this purpose, 99mTc-mebrofenin hepatobiliary scintigraphy with SPECT (MSPECT) can be used. The aim of the current study was to evaluate the predictive value of MSPECT for PHLF in patients with non-colorectal liver tumors (NCRLT) compared to patients with colorectal liver metastasis (CRLM) undergoing extended liver resection.MethodsWe included all patients undergoing extended liver resections via two-stage procedures between January 2019 and December 2021 at the University Medical Center Hamburg-Eppendorf, Germany. All patients received a preoperative MSPECT.ResultsTwenty patients were included. In every fourth patient, PHLF was observed. Four patients had PHLF grade C. There were no differences between patients with CRLM and NCRLT regarding PHLF rate and future liver remnant (FLR) volume. Patients with CRLM had higher mebrofenin uptake in the FLR compared to those with NCRLT (2.49%/min/m2 vs. 1.51%/min/m2; p = 0.004).ConclusionMebrofenin uptake in patients with NCRLT was lower compared to those patients with CRLM. However, there was no difference in the PHLF rate and FLR volume. Cut-off values for the mebrofenin uptake might need adjustments for different surgical indications, surgical procedures, and underlying diseases.

Assessing regional hepatic function changes after hypertrophy induction by radioembolisation: comparison of gadoxetic acid-enhanced MRI and 99mTc-mebrofenin hepatobiliary scintigraphy

BackgroundTo compare Gd-ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and 99mTc-labelled mebrofenin hepatobiliary scintigraphy (HBS) as imaging-based liver function tests after unilateral radioembolisation (RE) in patients with primary or secondary liver malignancies.MethodsTwenty-three patients with primary or secondary liver malignancies who underwent Gd-EOB-DTPA-enhanced MRI within a prospective study (REVoluTion) were evaluated. REVoluTion was a prospective open-label, non-randomised, therapy-optimising study of patients undergoing right-sided or sequential RE for contralateral liver hypertrophy at a single centre in Germany. MRI and hepatobiliary scintigraphy were performed before RE (baseline) and 6 weeks after (follow-up). This exploratory subanalysis compared liver enhancement on hepatobiliary phase MRI normalised to the spleen (liver-to-spleen ratio (LSR)) and the muscle (liver-to-muscle ratio (LMR)) with mebrofenin uptake on HBS for the total liver (TL) and separately for the right (RLL) and left liver lobe (LLL).ResultsMebrofenin uptake at baseline and follow-up each correlated significantly with LSR and LMR on MRI for TL (≤ 0.013) and RLL (≤ 0.049). Regarding the LLL, mebrofenin uptake correlated significantly with LMR (baseline, p = 0.013; follow-up, p = 0.004), whereas with LSR, a borderline significant correlation was only seen at follow-up (p = 0.051; p = 0.046).ConclusionLSRs and LMR correlate with mebrofenin uptake in HBS. This study indicates that Gd-EOB-DTPA-enhanced MRI and 99mTc-labelled mebrofenin HBS may equally be used to assess an increase in contralateral liver lobe function after right-sided RE.Relevance statementMRI may be a convenient and reliable method for assessing the future liver remnant facilitating treatment planning and monitoring of patients after RE-induced hypertrophy induction.Key points• Both MRI and HBS can assess liver function after RE.• Liver enhancement on MRI correlates with mebrofenin uptake on HBS.• MRI might be a convenient alternative for estimating future liver remnants after hypertrophy induction.Graphical

Comparing Liver Venous Deprivation and Portal Vein Embolization for Perihilar Cholangiocarcinoma: Is It Time to Shift the Focus to Hepatic Functional Reserve Rather than Hypertrophy?

Purpose: Among liver hypertrophy technics, liver venous deprivation (LVD) has been recently introduced as an effective procedure to combine simultaneous portal inflow and hepatic outflow abrogation, raising growing clinical interest. The aim of this study is to investigate the role of LVD for preoperative optimization of future liver remnant (FLR) in perihilar cholangiocarcinoma (PHC), especially when compared with portal vein embolization (PVE). Methods: Between January 2013 and July 2022, all patients diagnosed with PHC and scheduled for preoperative optimization of FTR, through radiological hypertrophy techniques, prior to liver resection, were included. FTR volumetric assessment was evaluated at two distinct timepoints to track the progression of both early (T1, 10 days post-procedural) and late (T2, 21 days post-procedural) efficacy indicators. Post-procedural outcomes, including functional and volumetric analyses, were compared between the LVD and the PVE cohorts. Results: A total of 12 patients underwent LVD while 19 underwent PVE. No significant differences in either post-procedural or post-operative complications were found. Post-procedural FLR function, calculated with (99m) Tc-Mebrofenin hepatobiliary scintigraphy, and kinetic growth rate, at both timepoints, were greater in the LVD cohort (3.12 ± 0.55%/min/m2 vs. 2.46 ± 0.64%/min/m2, p = 0.041; 27.32 ± 16.86%/week (T1) vs. 15.71 ± 9.82%/week (T1) p < 0.001; 17.19 ± 9.88%/week (T2) vs. 9.89 ± 14.62%/week (T2) p = 0.034) when compared with the PVE cohort. Post-procedural FTR volumes were similar for both hypertrophy techniques. Conclusions: LVD is an effective procedure to effectively optimize FLR before liver resection for PHC. The faster growth rate combined with the improved FLR function, when compared to PVE alone, could maximize surgical outcomes by lowering post-hepatectomy liver failure rates.

Determination of the segmental hepatic clearance rate of 99mTc-mebrofenin and its application in the functional assessment of future liver remnant after liver resection

99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT (HBS-M) has become an important quantitative method to evaluate global liver function and future liver remnant (FLR) function in patients who are candidates for resective liver surgery. The purpose of this work was to describe the method in the prediction of post-surgical liver failure.The overall liver function and that of the FLR are obtained by analysis of the initial dynamic phase of the scan. Liver volume to be preserved is expressed as a percentage of the total liver volume measured in both CT sections.HBS-M is able to accurately gauge regional liver function abnormalities that could be represented as normal liver tissue parenchyma in the CT study. This technique can provide very valuable prognostic information for the estimation of the postoperative risk of liver failure in all patients who are candidates for resective liver surgery.

Determinación de la tasa de aclaramiento hepático segmentario de 99mTc-mebrofenina y su aplicación en la evaluación funcional del remanente hepático futuro tras resección hepática

99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT (HBS-M) has become an important quantitative method to evaluate global liver function and future liver remnant function (FLR) in patients candidate for resective liver surgery. The purpose of this work is to describe the method, in the prediction of post-surgical liver failure.The overall liver function and that of the future liver remmant (FLR) are obtained from the analysis of the initial dynamic phase of the scan. Liver volume to be preserved is expressed as a percentage of the total liver volume measured both from the CT sections.HBS-M is able to accurately gauge regional liver function abnormalities that could be represented as normal liver tissue parenchyma in the CT study. This technique can provide very valuable prognostic information for the estimation of the postoperative risk of liver failure in all patients candidates for resective liver surgery.

Search threshold values of future liver remnant function and volume for extensive resections in children

Aim. To evaluate the relationship between the future liver remnant volume and function and determine the possible threshold values of these parameters for predicting posthepatectomy liver failure in children.Methods. Data of 57 patients who underwent major hepatectomy from July 2017 to February 2021 were retrospectively analyzed. Before surgery all children underwent the CT-volumetry and 99mTc-Mebrofenin hepatobiliary scintigraphy. The threshold values for the future liver volume and function were considered 25%, and 2.7%/min/m2 , respectively. After surgery the ISGLS and 50–50 criteria for posthepatectomy liver failure were assessed. The principal components method was used to identify risk factors for its development. The correlation analysis included the maximum value of total bilirubin after hepatectomy, as well as the values of total bilirubin, albumin, urea, prothrombin index, international normalized ratio and platelets on the postoperative day 5.Results. The posthepatectomy liver failure was observed in 2 patients: grade B developed in a patient with FLR-V 43%, FLR-F 1.8%/min/m2 , grade A in a patient with FLR-V 16.5% and FLR-F 4.78%/min/m2 . A significant statistical relationship of average strength was revealed between the indicators of FLR-F and FLR-V (Pearson η = 0.409; p &lt; 0.01). However, direct pairwise comparison did not reveal the relationship between future liver remnant volume, function and the laboratory parameters. The principal components analysis showed that during the postoperative period, the prothrombin index and international normalized ratio value were the most sensitive to the large volume of the liver parenchyma loss. The threshold value of FLR-F (3%/min/m2 ) was calculated. The decrease below this value can lead to posthepatectomy liver failure, which will manifest as a hemostasis disorder.Conclusion. Planning a one-staged hepatectomy not only the future liver remnant volume should be taken into account, but also its function. The threshold for future liver remnant volume in children is below the generally accepted level 25%. To perform one-stage hepatectomies in such patients, the FLR-F must be at least 2.7%/min/m2 . The future investigations in this field is waranteed.

99mTc-mebrofenin hepatobiliary scintigraphy and volume metrics before liver preparation: correlations and discrepancies in non-cirrhotic patients.

BackgroundAccurate identification of insufficient future liver remnant (FLR) is required to select patients for liver preparation and limit the risk of post-hepatectomy liver failure (PHLF). The objective of this study was to investigate the correlations and discrepancies between the most-commonly used FLR volume metrics and 99mTc-mebrofenin hepatobiliary scintigraphy (HBS).MethodsIn 101 non-cirrhotic patients who underwent HBS before major hepatectomy, we retrospectively analyzed the correlations and discrepancies between FLR function and FLR volume metrics: actual percentage (FLRV%), standardized to body surface area (FLRV%BSA) and weight (FLRV%weight), and FLR to body weight ratio (FLRV-BWR).ResultsAmong 67 patients with FLR function ≥2.69%/min/m2, PHLF was observed in none and 13 patients according to respectively 50-50 and ISGLS criteria. FLRV%, FLRV%BSA, FLRV%weight and FLRV-BWR significantly correlated with FLR function (P<0.001), with Spearman’s correlation coefficients of 0.680, 0.704, 0.698, and 0.711, respectively. No difference was observed between the areas under the curve of FLRV%, FLRV%BSA, FLRV%weight and FLR-BWR (all P=ns). Overall, the percentages of patients misclassified by FLRV%, FLRV%BSA, FLRV%weight (thresholds: 30%) and FLR-BWR (threshold: 0.5) versus FLR function (threshold: 2.69%/min/m2) were 23.8% (95% CI: 15.9–33.3%), 18.8% (95% CI: 11.7–27.8%), 17.8% (95% CI: 11–26.7%), and 31.7% (95% CI: 22.8–41.7%), respectively. FLR volume metrics wrongly classified 1–13.9% of patients with sufficient FLR function (i.e., ≥2.69%/min/m2), and 9.9–30.7% of patients with insufficient FLR function. FLRV-BWR was the most and the least reliable measure to identify patients with sufficient and insufficient FLR function, respectively.ConclusionsDespite significant correlations, the discrepancy rates between FLR volume and function metrics speaks in favor of implementing 99mTc-mebrofenin HBS in the work-up before liver preparation.

Major Hepatectomy in a Child with Extremely Low Future Liver Remnant Without Posthepatectomy Liver Failure

Introduction: The threshold value of future liver remnant volume (FLR-V)-25% for healthy liver is a standard in adults liver surgery. This method was translated in pediatric population without correlation to age, weight and liver function in children. Assessment of future liver remnant function (FLR-F) by means of hepatobiliary scintigraphy (HBS) is supposed to be more precise tool in children undergoing extended liver resection. An experience of major hepatectomy (MH), accomplished despite the extremely low FLR-V in a 27mo boy with advanced hepatoblastoma (HB) is discussed below. Method: Since June 2017 in our Center investigation of both: FLR-V (CT-volumetry) and FLR-F by means of 99mTc-Mebrofenin HBS before liver resections became a standard practice. The cut-off value of FLR-F is 2.7%/min/m2. The decision about MH was made on the basis of received values. Results: According to preoperative CT-volumetry, in patient with HB involving segments 4,7,8,1 (POSTTEXT III) the FLR-V in S2,3 came to 16.5%. 99mTc-Mebrofenin HBS showed the FLR-F 3.95%/min/m2. Taking into consideration the sufficient FLR-F, the extended right hepatectomy and caudate lobectomy was implemented instead of two-staged hepatectomy (TSH). The postoperative course was uneventful with no signs of posthepatectomy liver failure (PHLF). Patient was discharged on POD 12 and started adjuvant chemotherapy on time. The repeat FLR-F investigation on POD 30 came to 15.8%/min/m2. Conclusion: The presented case depicts that FLR-F is more precise than FLR-V in prediction of PHLF. 99mTc-Mebrofenin HBS is a sensitive method in selection of pediatric patients for safe MH instead of TSH or liver transplantation.

External Validation of the Use of Tc-99m Mebrofenin Hepatobiliary Scintigraphy to Assess Future Liver Remnant Function before Major Liver Surgery

Purpose: Accurate assessment of future remnant liver function (FRL-F) is paramount before major liver resection to avoid post-hepatectomy liver failure (PHLF), which remain the main perioperative cause of mortality. This study aims to analyse FRL-F using 99mTc-mebrofenin hepatobiliary scintigraphy before major liver surgery. Methods: All consecutive patients who underwent major liver resection between February 2018 and December 2020 and who had a preoperative 99mTc-mebrofenin hepatobiliary scintigraphy to assess FRL-F were included. FRL-V was expressed as percentage of total liver volume and assessed using preoperative computed tomography (CT). Receiver operating characteristic (ROC) curve analysis was performed to evaluate both methods in predicting PHLF. Results: A total of 29 patients were included, with a mean age of 61 years, a mean of BMI 26 kg/m2 and 62% (n=18) were men. PHLF occurred in 6 patients (21%). Scintigraphy showed significant ability to predict PHLF (AUC = 0.7, CI: 0.4-0.9), with cut-off value of 2.62 %/min/m2 showing a true positive (sensitivity) of 0.18, a specificity of 1.00 (false positive rate of 0), and a positive predictive value of 1.00. CT and FRL-V had no capacity to predict the occurrence of PHLF (AUC=0.5, CI: 0.2-0.8). Conclusion: Preoperative 99mTc-mebrofenin hepatobiliary scintigraphy and FRL-F demonstrated better sensitivity, specificity, positive and negative predictive value compared to CT and FRL-V for PHLF prediction. Therefore, where available, scintigraphy should be used systematically preoperatively before major liver surgery to assess FRL-F.

Deportalization, Venous Congestion, Venous Deprivation: Serial Measurements of Volumes and Functions on Morphofunctional 99mTc-Mebrofenin SPECT-CT.

The objective was to assess the changes in regional volumes and functions under venous-impaired vascular conditions following liver preparation. Twelve patients underwent right portal vein embolization (PVE) (n = 5) or extended liver venous deprivation (eLVD, i.e., portal and right and middle hepatic veins embolization) (n = 7). Volume and function measurements of deportalized liver, venous-deprived liver and congestive liver were performed before and after PVE/eLVD at days 7, 14 and 21 using 99mTc-mebrofenin hepatobiliary scintigraphy with single-photon emission computed tomography and computed tomography (99mTc-mebrofenin SPECT-CT). Volume and function progressed independently in the deportalized liver (p = 0.47) with an early decrease in function (median −18.2% (IQR, −19.4–−14.5) at day 7) followed by a decrease in volume (−19.3% (−22.6–−14.4) at day 21). Volume and function progressed independently in the venous deprived liver (p = 0.80) with a marked and early decrease in function (−41.1% (−52.0–−12.9) at day 7) but minimal changes in volume (−4.7% (−10.4–+3.9) at day 21). Volume and function progressed independently in the congestive liver (p = 0.21) with a gradual increase in volume (+43.2% (+38.3–+51.2) at day 21) that preceded a late and moderate increase in function at day 21 (+34.8% (−8.3–+46.6)), concomitantly to the disappearance of hypoattenuated congestive areas in segment IV (S4) on CT, initially observed in 6/7 patients after eLVD and represented 35.3% (22.2–46.4) of whole S4 volume. Liver volume and function progress independently whatever the vascular condition. Hepatic congestion from outflow obstruction drives volume increase but results in early impaired function.

The utility of 99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT for selective internal radiation therapy in hepatocellular carcinoma.

Studies assessing the impact of selective internal radiation therapy (SIRT) on the regional liver function in patients with hepatocellular carcinoma (HCC) are sparse. This study assessed the changes in total and regional liver function using hepatobiliary scintigraphy (HBS) and investigated the utility of HBS to predict post-SIRT liver dysfunction. Patients treated with SIRT for HCC between 2011 and 2019, underwent Tc-mebrofenin HBS with single-photon emission computed tomography/computed tomography (SPECT/CT) before and 6 weeks after SIRT. The corrected mebrofenin uptake rate (cMUR) and corresponding volume was measured in the total liver, and in treated and nontreated liver regions. Patients with and without post-SIRT liver dysfunction were compared. A total of 29 patients, all Child-Pugh-A and mostly intermediate (72%) stage HCC were included in this study. Due to SIRT, the cMURtotal declined from 5.8 to 4.5%/min/m (P < 0.001). Twenty-two patients underwent a lobar SIRT, which induced a decline in cMUR (2.9-1.7%/min/m, P < 0.001) and volume (1228-1101, P = 0.002) of the treated liver region, without a change in cMUR (2.4-2.0%/min/m, P = 0.808) or volume (632-644 mL, P = 0.661) of the contralateral nontreated lobe. There were no significant pre-SIRT differences in total or regional cMUR or volume between patients with and without post-SIRT liver dysfunction. In patients treated with SIRT for HCC, HBS accurately identified changes in total and regional liver function and may have a complementary role to personalize lobar or selective SIRT. In this pilot study, there were no pre-SIRT differences in cMUR or volume to aid in predicting post-SIRT liver dysfunction.

Comparison of functional and volumetric increase of the future remnant liver and postoperative outcomes after portal vein embolization and complete or partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)

BackgroundPortal vein embolization (PVE) is performed to induce hypertrophy of an insufficient future remnant liver (FRL) before major liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) aims to offer a more rapid and increased hypertrophy response. The first stage can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. This study aimed to investigate the increase in FRL volume and function, as well as postoperative outcomes after PVE or complete- or partial-ALPPS1.MethodsPatients with insufficient FRL undergoing either PVE or ALPPS underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy (HBS). Severe complications and 90-day mortality were evaluated after liver resection.ResultsSeventy-two patients were included; 51 underwent PVE, 12 complete-ALPPS1 and 9 partial-ALPPS1 of which 7 laparoscopic. The median increase in FRL function was 1.5-, 1.7- and 1.3-fold higher, respectively, than the increase in volume; (P<0.01, P<0.01 and P=0.44). The target hypertrophy response did not differ between the groups, but was reached earlier in both ALPPS1 groups (8 and 10 days) compared to the PVE group (23 days). Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively.ConclusionsIncrease of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. A (laparoscopic) partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.

Hypertrophy responses after portal vein embolization, complete and partial ALPPS in patients undergoing major liver resection

Background: Portal vein embolization (PVE) is the standard technique to induce hypertrophy of a small future remnant liver (FRL). ALPPS offers a more rapid hypertrophy response. The first stage (ALPPS1) can be performed with complete or partial (laparoscopic) transection of the liver parenchyma. The aim of this study was to investigate the increases in volume, function and postoperative outcomes among these procedures. Material & Methods: 72 patients with insufficient FRL were included in this retrospective analysis and were divided into three groups: 51 underwent PVE, 12 complete-ALPPS1 (open) and 9 partial-ALLPS1. All patients underwent CT-volumetry and functional assessment using 99mTc-mebrofenin hepatobiliary scintigraphy before and after VPE or ALPPS1. The increase in FRL function and volume were compared between the groups. Severe complications (Clavien-Dindo=3A) and 90-day mortality were evaluated after final liver resection. Results: The median increase in FRL function in the PVE, complete-ALPPS1 and partial-ALPPS1 group was 1.5, 1.7 and 1.3 fold higher, respectively, than the increase in volume; this was however not significant in the partial-ALPPS1 group (P<0.01, P<0.01 and P=0.44). The volumetric hypertrophy response did not differ between the three groups, but was reached earlier in both ALPPS1 groups (8 and 10 days, respectively) compared to the PVE group (23 days). Of all groups, 37 (73%), 10 (83%) and 6 (67%), respectively, proceeded with liver resection. All resected patients after partial-ALPPS1 had laparoscopic stage 1 in combination with percutaneous PVE. Of the resected patients, 18%, 30% and 17% had severe postoperative complications and the 90-day mortality was 2%, 25% and 0%, respectively. Conclusion: Increase of FRL function exceeded increase of volume after both PVE and ALPPS1. The target hypertrophy response was reached earlier in ALPPS. Complete and partial-ALPPS1 showed comparable functional and volumetric hypertrophy responses. Laparoscopic partial-ALPPS1 is preferred considering lower morbidity and mortality rates after resection.

TC-99m mebrofenin hepatobiliary scintigraphy combined with SPECT/CT to predict severity of post-hepatectomy liver failure according to the international study group of liver surgery criteria: a pilot study

TC-99m mebrofenin hepatobiliary scintigraphy combined with SPECT/CT to predict severity of post-hepatectomy liver failure according to the international study group of liver surgery criteria: a pilot study

Liver Functional Evaluation Using Gadoxetic Acid Versus the Gold Standard Hepatobiliary Scintigraphy in Patients with Bile Duct Diseases

Objective. To compare liver function assessments using Gd-EOB-DTPA-enhanced MRI and the gold standard hepatobiliary scintigraphy (HBS) in patients with bile duct diseases.Material and methods. The investigation enrolled 18 patients (male/female = 11/7; age, 29–70 years, Klatskin tumor (n=16), bile duct epithelial dysplasia (n=1), intrahepatic cholangiolithiasis (n=1)) after biliary decompression, who underwent 21 paired MRIs and 99mTc-mebrofenin HBS at a study interval of no more than 3 days. In the same regions of interest with a size of 30–50 pixels located in liver segments II–III, IV, V–VIII, and VI–VII, a MRI signal was measured before MR contrast agent (MRCA) injection into the standard vascular phases and at 10, 20, 30 and 40 minutes, then the signal was expressed as a percentage of intensity compared to the precontrast series. After MR volumetry, the functional volumes of the left and right liver lobes were also defined as the area under the MRCA accumulation curve, which was multiplied by the lobe volume and expressed as a percentage of the similarly calculated function of the entire liver. Similar intensity parameters and functional volumes were estimated for a HBS study.Results. The lobe functional volumes measured by the two methods were highly correlated (R=0.8; p&lt;0.001) and did not show a significant difference at all when comparing with the Mann–Whitney test (p&gt;0.3). The excretion rate of 99mTc-mebrofenin was also highly correlated with MRI findings (R=0.5–0.9; p&lt;0.05). Conclusion. Gd-EOB-DTPA-enhanced MRI revealed a high correlation with the gold standard; however, additional studies are needed to clarify the possibilities and limitations of replacing one method with another one.&gt;&lt;0.05).Conclusion. Gd-EOB-DTPA-enhanced MRI revealed a high correlation with the gold standard; however, additional studies are needed to clarify the possibilities and limitations of replacing one method with another one.

Comparison between dynamic gadoxetate-enhanced MRI and 99mTc-mebrofenin hepatobiliary scintigraphy with SPECT for quantitative assessment of liver function

ObjectivesTo compare Gd-EOB-DTPA dynamic hepatocyte-specific contrast-enhanced MRI (DHCE-MRI) with 99mTc-mebrofenin hepatobiliary scintigraphy (HBS) as quantitative liver function tests for the preoperative assessment of patients undergoing liver resection.MethodsPatients undergoing liver surgery and preoperative assessment of future remnant liver (FRL) function using 99mTc-mebrofenin HBS were included. Patients underwent DHCE-MRI. Total liver uptake function was calculated for both modalities: mebrofenin uptake rate (MUR) and Ki respectively. The FRL was delineated with both SPECT-CT and MRI to calculate the functional share. Blood samples were taken to assess biochemical liver parameters.ResultsA total of 20 patients were included. The HBS-derived MUR and the DHCE-MRI-derived mean Ki correlated strongly for both total and FRL function (Pearson r = 0.70, p = 0.001 and r = 0.89, p < 0.001 respectively). There was a strong agreement between the functional share determined with both modalities (ICC = 0.944, 95% CI 0.863–0.978, n = 20). There was a significant negative correlation between liver aminotransferases and bilirubin for both MUR and Ki.ConclusionsAssessment of liver function with DHCE-MRI is comparable with that of 99mTc-mebrofenin HBS and has the potential to be combined with diagnostic MRI imaging. This can therefore provide a one-stop-shop modality for the preoperative assessment of patients undergoing liver surgery.Key Points• Quantitative assessment of liver function using hepatobiliary scintigraphy is performed in the preoperative assessment of patients undergoing liver surgery in order to prevent posthepatectomy liver failure.• Gd-EOB-DTPA dynamic hepatocyte-specific contrast-enhanced MRI (DHCE-MRI) is an emerging method to quantify liver function and can serve as a potential alternative to hepatobiliary scintigraphy.• Assessment of liver function with dynamic gadoxetate-enhanced MRI is comparable with that of hepatobiliary scintigraphy and has the potential to be combined with diagnostic MRI imaging.

Estimated remnant liver function prior to hepatectomy for CR metastasis is a better predictor of post-hepatectomy liver failure than APRI score.

Background: Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy with a high mortality rate. The future remnant liver volume (FLRV%) and the total liver function both influence the occurrence of PHLF. Total liver function can be reduced in chemotherapy associated liver injury (CALI). Different tools predicting PHLF have been described in hepatectomy for colorectal liver metastasis after chemotherapy. Aspartate aminotransferase to platelet ratio index (APRI) has been shown to predict CALI and PHLF related to severe CALI. Estimation of the future liver remnant function (eFLRF) in a formula combining 99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBS) and FLRV% liver volumetry has been shown to predict PHLF. No direct comparison between eFLRF and APRI has been performed up to now. Methods: Estimation of the future liver remnant function (eFLRF) was performed in 140 patients prior to liver resection for colorectal liver metastasis after preoperative systemic therapy. When the cut-off for eFLRF was under 2.3%/min/m2, portal vein embolization or ligation was performed. APRI scores was calculated in all patients. Results: In ROC analysis, FLRV% and eFLRF had a better predictive value for PHLF than HBS alone and APRI. In multivariate analysis, eFLRF seems to be the only predicting factor for PHLF. Conclusion: PHLF is best predicted by combining volumetry with liver function in one formula than by separate volumetric or functional evaluation of the liver.

Hepatobiliary scintigraphy allows the evaluation of short-term functional toxicity of liver stereotactic body radiotherapy: Results of a pilot study.

PurposeTo study the potential of (99m)Tc-Mebrofenin hepatobiliary scintigraphy (HBS) in identifying the short-term variations of liver function after stereotactic body radiotherapy (SBRT) for liver cancers.Material and methodsWe treated with SBRT 3 patients (pts) affected by a cholangiocarcinoma and 3 patient presenting liver metastases (3x15 Gy, 4 pts; 5x8 Gy, 1 pt; 6x5 Gy, 1 pt). All patients received HBS before and 3 months after SBRT, which were co-registered with the simulation CT-scan. Structures corresponding to isodoses from 10–90 Gy were created, with intervals of 10 Gy. Finally, the variations of the mean activity (MBq) in each isodose structure have been calculated. Then, a linear regression analysis was performed.ResultsWe showed a linear reduction of the activity, significantly related to the delivered dose (p<0.01), and a reduction of the perfusion of 0.78% for each delivered Gy. The linear equation has predictive value of the loss of the function of 96% (R2 = 0.9605).ConclusionsHBS could improve treatment plans for liver SBRT, by allowing the identification of the liver function variations after SBRT and, potentially, the prediction of remnant liver function after SBRT. These preliminary results should be confirmed on long-term prospective data and larger population.

To Evaluate Whether the Presence of Duodenogastric Reflux Seen on Hepatobiliary Scintigraphy Correlatates With the Presence of Clinical Gastroesophageal Reflux Disease

Introduction: To evaluate whether the presence of duodenogastric reflux seen on hepatobiliary scintigraphy, and the correlation with the presence of clinical gastroesophageal reflux disease. Methods: We reviewed 612 Tc-99m mebrofenin hepatobiliary scintigraphy (HIDA) obtained from January 2011 until December 2014. HIDA scans were performed following fasting for at least 4 hours before the radiotracer administration. No patient in the study fasted longer than 24 hours. The study included outpatients, emergency patients, and inpatients. The patient was injected with 5.0-6.8 mCi Tc-99m mebrofenin intravenously. All patients received 1 hour of immediate dynamic images over the anterior abdomen. Delayed images and images following the administration of sincalide for gallbladder ejection fraction were reviewed to obtain additional clinical information. Images were obtained using a dualheaded, large field of view gamma with a low energy, high resolution, parallel hole collimator. Two physicians interpreted each initial one hour of dynamic images and concurrently came with a consensus of no duodenogastric reflux (DGR), mild DGR, medium DGR, or severe DGR. Medical records were reviewed to identify the clinical presence of gastroesophageal reflux disease. Results: There were 83 patients who demonstrated DGR on hepatobiliary scintigraphy with 45 females and 38 males and mean age 47.9 ranging from 13-93 years old. Of these patients 31.3% of the patients were diagnosed with cholecystitis and 7.2% of the patients were diagnosed with biliary colic without mention of cholecystitis. Of the 83 patients, 25.3% had only a clinical history of GERD and no other significant medical history. Of these patients with GERD, there were 42.9% with clinical evidence of severe DGR, 38.1% with moderate DGR, and 19% with mild DGR. Of the patients that had GERD and severe DGR, 4.7% had histopathologic evidence of Barrett's esophagus. Conclusion: HIDA can assess the degree of DGR which correlates strongly with the presence of GERD, which are both risk factors for Barrett's esophagus. Correlation of Duodenogastric Reflux Detected on Tc-99m Mebrofenin Hepatobiliary Scintigraphy with Gastroesophageal Reflux Disease has a strong association. HIDA is a potential non-invasive method to evaluate DGR in patients with symptomatic GERD, it could possibly be used as a screening tool to better select patients that should be under surveillance for Barrett's and esophageal cancer