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Frequency of Anatomical Variations and Congenital Anomalies in Pancreatobiliary Tract Through Magnetic Resonance Cholangiopancreatography

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Frequency of Anatomical Variations and Congenital Anomalies in Pancreatobiliary Tract Through Magnetic Resonance Cholangiopancreatography Original Article Frequency of Anatomical Variations and Congenital Anomalies in Pancreatobiliary Tract through Magnetic Resonance Cholangiopancreatography Imran Ishaque 1 , Naveed Ali Siddqui 2 , Mahveen 3 , Jay Kreshan 4 , Sara 5 , Amber Ilyas 6 Abstract Objective: To determine the frequency of anatomical variations and congenital anomalies of pancreatobiliary tract in adults through the Magnetic Resonance Cholangiopancreatography (MRCP). Methods: This cross-sectional observational study was done on patients suspected to have pancreatobiliary disease referred to MRI unit. MRCP was performed on a 1.5 Tesla in MR unit, using phased-array coil for signal detection. Heavily T2 weighted images were obtained with SSF-SE tech- nique. Axial and coronal source images and reformatted images were evaluated together for the pos- sibility of any anomaly and variation in pancreatobiliary tract. Analysis was done by SPSS version 20. Results: Total no of 377 patients included in this study. The patients presented with epigastric pain, obstructive jaundice, pancreatitis and post-cholecystectomy epigastric pain and jaundice. MRCP was performed on these patients to examine the pancreatobiliary tract. In this study, 52% were females and 48% were males. The variations and anomalies were found in 24.93 and 75.07% had normal anatomy of pancreatobiliary tract. The most observed frequency was low insertion of cystic duct and least observed frequency was duct of Santorini. High insertion of cystic duct, absent gallbladder and aberrant hepatic ducts were not found in this study. Conclusion: Majority of the patients in this study were found to be free from pancreatobiliary disease. It is important to clarify the anatomy of the pancreatobiliary tract by preoperative evaluation. Congenital anomalies and anatomical variation in pancreatobiliary tract present a complex spectrum, which are worthy of alteration in both the clinical and surgical setting and are readily identified by MRCP. Keywords: Pancreas, biliary tract, magnetic resonance imaging. IRB: Approved by Institutional Review Board of Dow University of Health Sciences. Dated 29th May 2012. Ref No. IRB-330/DUHS-12 Citation: Ishaq I, Siddiqui NA, Mahveen, Kreshan J, Sara, ILyas A, Frequency of Anatomical Variations and Congenital Anomalies in Pancreatobiliary Tract Through Magnetic Resonance Cholangiopancreatography [Online]. Annals ASH & KMDC 2020;25. (ASH & KMDC 25(4):204;2020) Introduction Surgeon's expertise is vital in detecting anatomical variation or congenital anomaly during surgery. It Deleterious consequences during peri-operative has been reported that among general population, pancreaticobiliary surgery include bile duct injuries 57.7% show normal pancreaticobiliary tract and their risk increases with the presence of ana- anatomy while from the remainder 42.3%, 41% tomical variations. Therefore, pre-operative evalua- show variation and 1.3% show anomaly in tion and identifying the anatomic variation or pancreaticobiliary tract 1-3 . Studies show female pre- anomaly is useful for avoiding injury during surgery. dominance in variation and anomaly in comparison 1 Department of Anatomy, to male, probably as a consequence of different 2 Department of Biochemistry, 2 3 Department of Pathology, embryological development . The reported variation 4 Department of Community of Health Medicine, is seen higher among Asians in comparison to USA United Medical and Dental College 4 5 Department of Anatomy, Dow University of Health Sciences and Europe . For reductions in post-operative com- 6 Department of Anatomy, Sindh Medical College plication, as strong background knowledge of Correspondence: Dr. Imran Ishaque pancreaticobiliary tract anatomy is pivotal, similarly Department of Anatomy, United Medical & Dental College a strong knowledge of anatomical variation and Email: [email protected] 3-4 Date of Submission: 21 st July 2020 anomaly is also vital . The variations in anatomy Date of Acceptance: 13 th March 2021 204 Annals Abbasi Shaheed Hospital & Karachi Medical & Dental College Imran Ishaque, Naveed Ali Siddqui, Mahveen, Jay Kreshan, Sara, Amber Ilyas and anomalies of pancreticobiliary tract are usually aids surgeons throughout the surgical procedure, to asymptomatic in childhood and either diagnosed as diagnose and treat the conditions accordingly. More an incidental finding or in adulthood. The sign and importantly, MRCP is non-invasive. Assessing pa- symptoms seen are pain in the abdomen, nausea tency of pancreaticobiliary tract is of prime impor- and vomiting which might be because of recurrent tance as patients undergoing pancreacticobiliary pancreatitis or obstructed gastric outlet due to pan- tract surgery commonly tend to have post-operative creatic variant (congenital) or pancreatic duct sys- complications. Therefore, using the non-invasive- tem 5 . ness methodology of MRCP, it has widely gained popularity for identifying ductal system in Surgeon's knowledge of normal pancrea- pancreaticobiliary tract. Through MRCP, clear plus ticobiliary anatomy with its abnormalities is useful accurate information regarding anatomical variations for identifying and differentiating them between in bile ducts and anomalies within pancreaticobiliary structures involved during surgery. Lack of proper tract helps to diagnose various types of disorders knowledge may lead to trauma, biliary leak, division present in pancreaticobiliary system 10 . Examination or ligation of the major bile duct 6 . through magnetic resonance (MR) is done on a 1.5 During pancreaticobiliary surgery, bile duct TESLA system (Siemens, Avanto, Erlangen and Si- trauma is common in both laparoscopy or in open gna). MRCP is an advanced method of testing com- (laparotomy) technique. Present data is inconclu- pared to other techniques. Software mostly use is sive regarding incidence of injury to bile duct; how- single shot fast spin echo (SSFSE) and T2 weighed ever, a rough estimation shows 1 in a 1,000 images or single-section and multi-section by torso cases 7 . Injuries to bile duct can have life threaten- array coil. Pancreaticobiliary tract visibility is seen ing complications, and are usually seen during in coronal section whereas pancreatic duct andbile cholecystectomies, especially laparoscopic in com- duct is seen in axial section. All sequences are ac- parison to open technique, probably because of dis- quired in a single breath-hold after 4-6 hours of fast- tortion in anatomy, variations in anatomy or ing, for promoting filling of gallbladder. Whole pancreaticobiliary tract anomalies. In cholecystec- procedure takes about 20 minutes 11 . The rationale tomy, injury to bile duct is seen in 0.3 % to 0.62 % of the study will prove to be a useful addition to the of patients and this figure is observed in patients research data of our country benefiting for clinical having anatomic variations or anomalies 8 . In order to health professionals and decreasing the incidence prevent peri-operative damage to biliary tract, it is of surgical complications during the procedure and vital to have pre-operative investigations for ana- the aim of the study to evaluate the existing con- tomic variation and / or anomalies in the patients genital anomalies and anatomical variations in pa- undergoing surgery. Multiple radiological procedures tients with pancreatobiliary tract disease using can be carried out to detect pancreatico-biliary tract MRCP in adults. abnormalities. These include the conventional cho- langiography, ultrasonography (U/S), biliary scintig- Patients and Method raphy, endoscopic retrograde C This cross-sectional multi-center study using cholangio-pancreatogram (ERCP) and percutaneous non-probability convenient sampling technique was trans-hepatic cholangiogram (PTC) 9 . done at radiology department DUHS at Ojha and In order to examine the anatomy of AKUH. After ethical approval and written informed pancreaticobiliary and hepatobiliary tract, magnetic consent was taken, 377 pancreaticobiliary tract dis- resonance imaging (MRI) of a special type is used, ease patients were included in the study from radi- known as MRCP. This MRI provides information ology department in eight months. Inclusion criteria about the physiology as well as pathology of consisted of patients of either gender diagnosed as pancreaticobiliary and hepatobiliary system which a case of pancreaticobiliary disease on ultrasonog- Volume No. 25 (4), December 2020 205 Frequency of Anatomical Variations and Congenital Anomalies in Pancreatobiliary Tract through Magnetic Resonance raphy and patients having epigastric pain, obstruc- 377. The data analysis was conducted by using tive jaundice, pancreatitis and post cholecystec- SPSS versions 20. Since it was a qualitative data, tomy epigastric pain and jaundice, post pubertal the prevalence was measured in percentages. patients and MRCP images having clear anatomic Prevalence of variations and anomalies in views. Patients undergoing MRCP but images not pancreaticobiliary tract were calculated at 95% con- being optimal on technical grounds, dementia pa- fidence interval. The frequencies of parameters were tients, claustrophobic patients, patients unable to statistically analysed by using binomial test. P < hold breath for 30 seconds or more, non MRI com- 0.001 was considered statistically significant. Fre- patible pacemaker patients or patients with im- quencies or percentages were shown through bar plants and mechanical prosthesis were excluded graphs and tables. from the study. Results Booking of patients
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