First successful three-dimensional endoscopic retrograde cholangio-pancreaticography (ERCP) with computed tomography (CT-) and magnetic resonance (MR-) image-fusion

Three-dimensional (3D) visualization can add important complementary information compared to standard two-dimensional (2D) imaging for diagnostic purposes as well as for the navigation of complex interventional procedures such as in the biliary hilus or in complex pancreatic alterations.

We report on the first three-dimensional ERCP performed in a 30 kg female pig with subsequent CT and MRI image fusion using a new multi-axis vascular X-ray robot platform. A multi-axis X-ray robot system for vascular interventions was used (Siemens Healthcare, Erlangen, Germany; animal platform). At first an endoscopic retrograde filling of the pancreatic duct via the (separate) pancreatic pig papilla was performed using a 9.1 mm gastro scope under 2D X-ray control. Subsequently a 360 degree spin of the 40 × 30 cm high resolution flat detector was carried out by the robot creating a three-dimensional DynaCT sequence at 7.5 images per second during a 6 second spin around the “patient”. The same imaging was then performed for the biliary system after cannulation of the biliary papilla and contrast filling of the extra- and intra-hepatic bile duct system as well as the gallbladder (75 ml of non-ionic contrast medium; 270 mg iodine/ml). Radiologic parameters used were: 6 s 'Dyna CT' spin; 90 KV, 98 mA, 3.5 milliseconds at 60 images/seconds with a total dose of solely 4975µGym2.

Images were then successfully fused with data sets of a 128 slice CT scanner (0.75 mm slice with, 0.5 mm increments) and images gained by a 1.5 Tesla MRI (TIM4G + DOT, 48 channels, #D MRCP with echo PACE 3D FSE T2, 1 mm slices). An exact three-dimensional anatomical position of the pancreatic duct, the biliary system and endoscope position was achieved and could be rotated around various virtual axes. The video impressively illustrates the findings. Further potential indications for use include 3D contrast-imaging after transgastric and transduodenal echoendoscopic punctures and drainage of the biliary system and right kidney. Further systematic basic and clinical research will be necessary to evaluate the objective benefit of this impressive technique.