The Past, Present, and Future of Hepatobiliary and Pancreatic by mirit35


									Claire E. Bender, MD I Andreas Adam, MB I Peter R. Mueller, MD                                                                          I Eric vanSonnenberg,                   MD
Johannes Lammer, MD I Steven K. Teplick, MD I Robert   Braden

International                      Society           of Hepato-Biliary              and        Pancreatic                Radiology

The Past,                                             Present,                 and Future                                                             of
Hepatobiliary                                                              and Pancreatic                                                              Radiology1
For the past 2 decades,                   radiologists          have       tant      to share            with       our        readers.        On      future       (5). Linking           this technology                with
been the contributors                  to as well as recipi-               December           3, 1986,        the initial          meeting       of    detailed       resolution          will be achieved              in the
ents     of noteworthy                diagnostic          imaging          the “Biliary           Radicles”          was held            in Chi-       future.
and interventional                techniques         in hepatic,           cago,      Ill. Focused         topics       of percutaneous
biliary,       and      pancreatic           diseases.        Since        cholecystostomy,                  gallstone            lithotripsy,         Hepatic          Intervention
then,      we have         not only        experienced            the      and gallstone           dissolution           agents        were dis-       Transjugular               Intrahepatic
development             and numerous              dramatic        im-      cussed        in an informal             setting.         The colle-        Portosystemic               Shunts
provements              i n ultrasonography                    (US),       gial, scientific,         yet informal            format        of this
computed            tomography             (CT),       and    mag-         initial      small     group        has expanded                to the          The percutaneous             creation        of a shunt
netic     resonance            (MR) imaging,             but have          current         annual       gathering           of nearly          150     between      the portal       and systemic            venous
also contributed               to the vast array of non-                   members,            which        includes          international            systems     is now        recognized            as a major
surgical        interventional             procedures            cur-      radiologists         with subspecialty                expertise       in    advance     in the management                 of advanced
rently      available         in liver, biliary         tree, and          diagnostic          imaging          of and         intervention            portal   hypertension.           The initial        enthusi-
pancreatic         disorders.                                              in     hepatic,        biliary,         and     pancreatic         dis-     asm for the procedure              has been tempered
    The history           of the Interventional                Soci-       eases.   In 1993, the first European           meeting                      by the realization          that     in many        patients
ety of Hepato-Biliary                and Pancreatic           Radi-        of the ISHBPR         was held      in Vienna,       Aus-                   the stent      will become            narrowed         or oc-
ology      (ISHBPR)         is unique      and thus impor-                 tria,  in conjunction         with     the European                         cluded    by epithelial            hyperplasia.          How-
                                                                           Congress      of Radiology.        The goal of the                          ever, the development               of defense        mecha-
                                                                           ISHBPR     is to provide     an open      atmosphere                        nisms   against      this complication             promises
                                                                           for the sharing        of knowledge         and exper-                      to expand       the applications             of this tech-
                                                                           tise   with       a can-do        attitude.                                 nique.
    Index       terms:
                                                                               The foundations         of percutaneous,             hepa-
    Gastrointestinal             tract
    Radiology        and radiologists,   research                          tobiliary,       and    pancreatic          intervention                    Tumor          Ablation
    Subspecialty        society messages                                   were built on the descriptions                  of percuta-
                                                                                                                                                           Tumor        embolization        has made       a major
                                                                           neous      transhepatic         cholangiography               by
    Radiology            1998;     209:317-319
                                                                                                                                                       contribution            to the management          of hepa-
                                                                           Huard      and Do in 1937 (1), the invention
                                                                                                                                                       tocellular        carcinoma       but its success      with
                                                                           of the “skinny”          needle      at Chiba        Univer-
                                                                                                                                                       metastases          has been     limited.    Clearly,     im-
    1   From the Department                   of Radiology,      Mayo      sity in 1969           (2), and         the development               of
                                                                                                                                                       provement             in local     drug   delivery       and
    Clinic,   200    First           St  SW, Rochester,         MN         percutaneous             biliary        drainage   in 1974           by
    (C.E.B.); Department               of Radiology,     the Guy’s
                                                                                                                                                       embolization             techniques            to decrease            tu-
                                                                           Molnar       and      Stockum            (3).
    Hospital,    London,             England     (A.A.);   Depart-                                                                                     mor growth            and increase              growth         of nor-
    ment        of Radiology,             Massachusetts       General                                                                                  ma! liver parenchyma                     need to be further
    Hospital,       Boston          (P.R.M.);       Department        of                                                                               researched.          In recent          years,       a variety          of
    Radiology,   University   of Texas Medical                             Hepatic           Imaging
                                                                                                                                                       percutaneous             methods          of ablation            of he-
    Branch, Galveston (E.V.); the Universitatsklin-
    iken-AKH, Vienna, Austria (J.L.); Department                                Evaluation           of focal         and    diffuse        liver      patic      metastases           have        been       developed,
    of Radiology,           University          of South   Alabama,        disease        continues            to evolve          with        our      and there         is very active              research         in this
    Mobile (S.K.T.); and the international    Soci-                        spectrum          of imaging           modalities         (US, CT,          field. Alcohol          injection,         like chemoembo-
    ety of Hepato-Biliary and Pancreatic Radiol-
                                                                           MR, and nuclear                 medicine).        While       detec-        lization,      is effective        in ablating          hepatocel-
    ogy, Reston, Va (R.B.). Received April 17;
    accepted   April 22. Address      reprint   re-                        tion       of disease           has     improved,           disease         lular carcinoma.             However,           the poor vascu-
    quests       to C.E.B.                                                 specificity         still     remains         at the      level      of     larity     and relatively            firm consistency                   of
    e RSNA, 1998                                                           the      needle         or knife.           Everyone’s           goal       metastases          result      in uneven            distribution
    See also the articles by vanSonnenberg et al                           should        be to diagnose                the type,        grade,         of the ethanol             within        the tumor,             which
    (pp 314-316) and Ferrucci (pp 320-322) in                              and extent          of tumor         on the initial        evalua-          results      in only patchy              destruction            of the
    this issue.                                                            tion      (4). Use of radiolabeled                   antibodies             malignant         cells. Thermal             methods          of abla-
                                                                           may       provide         that     accuracy        in the near              tion      of metastases              are more              effective;

cryotherapy          has produced            good        results,              tumor.         Preliminary               results       suggest          that       surgical        techniques            for removal             of ne-
but this is generally           used at open            surgery                this is unlikely               to improve              substantially               crotic      pancreatic           debris     need       to be im-
because        of the large        size of the probes.                         the     performance                 of metallic            stents         be-      proved        in order         to decrease         the surgical
Percutaneous           laser therapy        is effective           in          cause      the reduction                  in occlusion              by tu-         rate. In patients            with mature          pseudocysts,
producing         tumor      necrosis,       but until            re-          mor ingrowth               is offset by an increase                      rate      percutaneous                 catheter         insertion            fre-
cently      it has been         limited       by the rela-                     of stent blockage                 due to bile incrustation.                        quently         results      in cure when             pancreatic
tively     short     range     of heat        distribution.                    A more           promising              approach           is to coat              ductal      drainage         into the gut occurs.
The      development           of “beam             splitters,”                stents      with       pharmaceuticals                  that      inhibit              In chronic             pancreatitis,         pain        due      to
which      allow laser energy           to be distributed                      tumor        growth.          One         example         is the em-               obstruction             of the pancreatic               duct     may
down      four or eight       fibers simultaneously,                           ployment            of paclitaxel,               which         prevents            respond          to endoscopic             pancreatic           stent
has greatly       extended       the practical       applica-                  angiogenesis.               Three-dimensional                        imag-         insertion.         Percutaneous           intervention             has
tions of laser.                                                                ing-guided            (MR or CT) biliary                      drainage             a limited         role     in selected           cases,      often      to
    Radio     frequency        is also being          applied                  may be helpful                for treating            Klatskin         type        those       patients          in whom             conversion             of
to tumor        ablation     and seems         capable         of              of tumors.                                                                         pancreatic          fluid collections             to ductal        stent
producing         lesions    of comparable             size to                     Many        benign          strictures         continue           to be        placement             can       be achieved.             As in the
that of laser with a single             electrode.         This                repaired         surgically           with excellent              results.         biliary      tree,      stent       placement            should         be
is achieved          by extending          the     range       of              However,           biliary         dilation         has an impor-                  used       conservatively                in benign            disease,
heat distribution          by using     saline      infusion                   tant role in this area especially                         in patients              but if the problem                  of epithelial         hyperpla-
or small            projections           from         the   tip of the        who are not good candidates                              for surgery.              sia is solved,             stent      placement            could        be
electrode      (6). Another        method         of increas-                  Metallic        stents       are used conservatively                        in     more widely             applied.
ing the size of the coagulated                  area during                    benign        biliary      stricture          disease      because          of          Percutaneous              ablation        of tumors         in the
laser     and radio-frequency               hyperthermia                       the risk of occlusion                     by epithelial            hyper-          pancreas         is currently             being      investigated.
is to limit       portal    venous        perfusion;        cur-               plasia.     This menacing                   problem        is likely to            Although            it is unlikely             to lead to cure,
rently     an experimental           method,         this may                  be overcome               within          the next         few years,              laser therapy            promises           to offer improved
soon find a practical           application.                                   opening           up an important                     new        field      to     palliation         of this distressing              condition.
    During       the next       5-10      years,      thermal                  interventional              radiologists.                                               CT-guided            celiac       ganglion          block        can
methods         of ablation         are certain           to be                    Percutaneous              cholecystostomy                   can play           provide         considerable               relief     of deep          ab-
refined      and      combined          with       improved                    an important               role in acute              cholecystitis,               dominal         pain in the patient                  with pancre-
techniques         of imaging       guidance.          In addi-                especially          in acalculous                 cholecystitis.              It   atic cancer          and pancreatitis.
tion,         microwave             and    ultrasound           focused        may be curative                or temporizing.
on the tumors    without                     the need for needle
                                                                                                                                                                  Hepatobiliary              and        Pancreatic
placement     promise                      to become      practi-
                                                                                                                                                                  Radiology             Viewed          in a Crystal             Ball
cable.                                                                         Pancreatic              Imaging
                                                                                   Contemporary             imaging        of the pancreas
                                                                                                                                                                      Creativity         in the further             development
Biliary            Imaging                                                     continues       to improve           with use of US, CT,
                                                                                                                                                                  of imaging            must       be encouraged              for the
                                                                               MR, nuclear         medicine,         and positron         emis-
    Direct     cholangiography,             the reference                                                                                                         ongoing          challenges            to improve           patient
                                                                               sion tomography                (PET).     Although        infor-
standard        of bile duct        imaging,        is being                                                                                                      care.     Imaging          for early        detection         of tu-
                                                                               mation      display       has improved,            timing        of
challenged        by CT (8,9) and MR cholangi-                                                                                                                    mors      may have            to take precedence                 over
                                                                               detection       of malignant              disease     has not
ography       (10,1 1). While         the degree       of im-                                                                                                     development              of other        modalities.         We are
                                                                               improved.        Screening         of high-risk       patients
age resolution           is improving,           the detec-                                                                                                       going       to have        to provide          algorithms           for
                                                                               will need to be studied               as imaging      modali-
tion of minimal          ductal    abnormalities          with                                                                                                    imaging         along       with     the team          work      with
                                                                               ties continue         to improve          in their abilities
CT and MR methods                  does      not compare                                                                                                          our clinical           colleagues           in the        develop-
                                                                               to enable      detection.
with     that    of direct      cholangiography.              As                                                                                                  ment       of clinical         guidelines         and manage-
                                                                                   In acute      pancreatitis,          MR imaging           can
with     all imaging         improvements,            resolu-                                                                                                     ment      of care. Three-dimensional                      imaging
                                                                               provide       the      same    information           as that
tion capabilities         will continue         to improve                                                                                                        with MR cholangiopancreatography                                  per-
                                                                               obtained        with a combination             of contrast
with         CT and MR of the bile ducts.                                                                                                                         haps       by using           holographic             techniques
                                                                               material-enhanced             CT and diagnostic            en-
                                                                                                                                                                  may supersede              diagnostic         ERCP. Fusion            of
                                                                               doscopic       retrograde     cholangiopancreatog-
                                                                                                                                                                  ductal       and vascular             imaging        with     organ
Biliary            Intervention                                                raphy       (ERCP).       MR imaging          offers    high
                                                                                                                                                                  or lesion       imaging          should      be on the draw-
                                                                               contrast       between      normal        pancreatic       tis-
    Today,          most      patients          with     unresectable                                                                                             ing board.
                                                                               sue and low signal          intensity       of the tumor,
tumors     obstructing                    the     biliary     tree    are                                                                                             How soon      will we be using   functional
                                                                               making          early     tumor         detection          easier.
treated  with endoscopic                       techniques.         How-                                                                                           imaging     in the hepatobiliary   and pancre-
ever, interventional                      radiology        continues                                                                                              atic systems?
to play            a major       role,    particularly           in hilar
                                                                               Pancreatic              Intervention
strictures.     Metallic     stents     have   made      a
substantial     contribution        in this area and                                Percutaneous          drainage        plays an impor-
should      now be considered            the preferred                         tant role in the management                        of patients                         The      treatment         of hepatobiliary             and
method       of percutaneous         drainage     in pa-                       with acute pancreatitis.                Although         pancre-                   pancreatic           disease,     perhaps        more     than
tients     with    malignant         obstructive         jaun-                 atic abscesses        and phlegmons              can be cured                      any other          in medicine,          is dependent         on
dice (12). There           has been       a considerable                       with       this method          (13), radiologic           drain-                  multidisciplinary             collaboration          between
amount         of research       into plastic-covered,                         age may          also be used           as a temporizing                           internists,       surgeons,       and radiologists.          En-
self-expanding          metallic     stents     in an effort                   measure          to improve            the     condition          of               doscopic        techniques        continue        to improve
to minimize                occlusion        due to ingrowth               of   critically      ill patients       before     surgery.      Non-                   rapidly,       providing       better      images     and in-

318            Radiology
          #{149}                   November1998
                               #{149}                                                                                                                                                                                       Bender      et aI
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Volume      209        Number
                   #{149}          2                                                                 The Past,       Present,     and    Future       of Hepatoblllary        and Pancreatic            Radiology             319

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