Chapter 109: Preoperative Evaluation

(A–B) Magnetic resonance cholangiopancreatography (MRCP) examples of variant duct anatomy relevant in planning living donor transplantation. Part A shows a common variant known as crossover anomaly consisting of the right posterior duct (RPD) joining the left hepatic duct (LHD). Part B shows an aberrant right hepatic duct (RHD) joining the common hepatic duct (CHD). Awareness of the presence of such anatomic variants is of paramount importance in order to prevent complications associated with the surgical reconstruction of bile flow.

(A–B) Primary sclerosing cholangitis (PSC). (A) MRCP shows multiple strictures alternating with mild dilatation adopting the so-called “pruned tree” appearance. (B) Axial T1-weighted magnetic resonance imaging (MRI) demonstrates diffuse abnormally enhanced thickening of the bile duct wall (arrows). Notice that the hepatic contour and morphology are preserved despite biopsy-proven advanced fibrosis in this 28-year-old female patient with PSC.

A 24-year-old female patient with cirrhosis due to autoimmune hepatitis. Computed tomography (CT) protocol include a triple-phase study including arterial phase (A), portal venous phase (B), and delayed phase (not shown). During the arterial phase, the enhancing of the liver parenchyma is mild, making hepatocellular carcinomas more conspicuous, given the hypervascular nature of this tumor. In this example the liver is decreased in size and exhibits the nodular contour typical of cirrhosis. There is both ascites (A) and splenomegaly.

(A–D) MRI of the same patient. On T2-weighted image (A) multiple low-signal regenerating nodules are noted on a background of surrounding moderate hyperintense fibrous septa. T1-weighted fat-suppressed arterial (B), portal (C), and delayed phase (D) images confirm the typical findings of cirrhosis but show no evidence of hepatocellular carcinoma. Delayed enhancement of the fibrous septa is evident (arrows). MRI, with its excellent contrast resolution, is more sensitive to depict the pathologic alterations of the cirrhotic liver, as well as to detect and characterize focal lesions.

(A–B) Axial T2 and T2*-weighted MRI images reveal the presence of countless small low-signal intensity nodules consistent with regenerative iron-containing nodules (siderotic nodules).

(A–D) Tortuous tubular enhancing structures correspond to esophageal varices (V). Filling defects consistent with bland thrombi are noted in the superior mesenteric vein (SMV) and right portal vein (yellow arrows). Incipient cavernoma formation is noticed (red arrows).