Revolutionizing hepatolithiasis management: Transformative role of DynaCT in imaging and intervention

Abstract

In this editorial, we comment on the article by Ye et al. We specifically focused on the novel use of DynaCT biliary soft tissue reconstruction technology in the diagnosis and treatment of hepatolithiasis with bile duct stenosis, which is an innovative approach for enhancing the preoperative evaluation and surgical outcomes in hepatolithiasis. This study also highlights the limitations of conventional imaging techniques such as computed tomography and magnetic resonance cholangiopancreatography, which have low sensitivity for small stones and complex biliary strictures. Given the intricate anatomy of the biliary system and the challenges posed by limited visualization using conventional methods, DynaCT addresses these issues by providing high-resolution, three-dimensional reconstruction of the bile ducts, stones, and vascular structures, thus improving anatomical clarity and enabling precise surgical planning. We also focused specifically on the limitations of DynaCT, such as the need for specialized equipment and patient selection criteria, as well as its advantages and disadvantages compared with conventional PTOBF approaches. Overall, DynaCT represents a significant advancement in hepatolithiasis management, with the potential to become a standard imaging modality for safer and more effective biliary procedures.

Key Words: Hepatolithiasis; Biliary stenosis; DynaCT; One-step percutaneous transhepatic cholangioscopic lithotripsy; Editorial

Core Tip: DynaCT has revolutionized hepatolithiasis management by offering superior imaging and procedural precisions. This cutting-edge technology enhances the visualization of complex biliary and vascular anatomy, enabling accurate lesion detection and targeted interventions, particularly in combination with therapies such as transarterial chemoembolization and microwave ablation. Compared with traditional imaging, DynaCT demonstrates greater sensitivity and safety while minimizing complications. Despite challenges, such as high costs and training demands, its potential to optimize outcomes in hepatobiliary and other interventional fields is undeniable. This editorial underscores DynaCT’s transformative impact and explores future directions to maximize its clinical utility.

INTRODUCTION

Renowned for its superior imaging capabilities and adaptability, DynaCT has emerged as a pivotal innovation in hepatobiliary imaging, transforming the way hepatolithiasis is diagnosed and managed[1,2]. Hepatolithiasis is a clinical condition characterized by the formation of pigmented calculi, principally composed of calcium bilirubinate, with a smaller amount of cholesterol in the biliary ducts within the liver[3]. DynaCT enhances procedural effectiveness by identifying additional lesions and feeding arteries, refining catheter placement, and navigating complex vascular anatomy[4]. This editorial explores the innovation that DynaCT brings to hepatolithiasis management, discusses its advantages and potential complications, and considers future directions for this technology.

DYNACT TECHNOLOGY: OVERVIEW AND GUIDANCE FOR TARGETED INTERVENTIONS

DynaCT, commonly referred to as modern C-arm computed tomography (CT) or cone-beam CT angiography, integrates advanced features of electronic imaging angiography platforms and has been successfully employed across various medical fields, including hepatobiliary and neurovascular imaging[5]. DynaCT-assisted procedures utilize multimodal image fusion to enhance the visualization of comprehensive anatomical structures, such as the skull base and critical pathways, enabling precise route planning and improving the accuracy of interventions[2], particularly in complex structures such as the biliary tree. DynaCT real-time functionality greatly minimizes procedural complications and enhances the success rate of the procedure[2]. During procedures such as DynaCT needle guidance for trigeminal nerve balloon compression from studies of Santiago et al[6], DynaCT enables procedural precision and safety by providing accurate needle guidance and minimizes the risk of damaging significant surrounding structures[6]. Between January 2018 and December 2023, Wang et al[7] conducted a study at Hebei General Hospital involving 19 patients undergoing percutaneous balloon compression guided by DynaCT. The procedures showed enhanced visualization, which effectively reduced the likelihood of harm to adjacent structures[7]. In the study by Hussain et al[4], all patients underwent intraprocedural DynaCT for the visualization of drug deposition and to look for other lesions or feeding arteries, especially in cases of non-homogeneous drug distribution[4].

COMBINATION WITH ADVANCED THERAPIES

DynaCT has been most useful in procedures in which transarterial chemoembolization (TACE) is combined with other modalities, most often microwave ablation. Such synergistic approaches serve to improve clinical outcomes by allowing precise targeting of lesions and increased efficiency in procedural workflows[4,8]. In the study by Hussain et al[4], a 57-year-old man with small hepatocellular carcinoma was treated with DynaCT-guided microwave ablation simultaneously with TACE. In this case, DynaCT was very useful in detecting other lesions in the liver and in overcoming the difficulties created by vascular overlap or tortuosity because it provided three-dimensional imaging, which helped in the precise identification and cannulation of the feeding arteries, thus proving to be important in complex vascular interventions[4].

COMPARATIVE ANALYSIS OF TRADITIONAL IMAGING TECHNIQUES AND DYNA CT

Conventional imaging modalities such as ultrasound and two-dimensional fluoroscopy often cannot provide adequate visualization of the biliary system. Inherent feature of two-dimensional imaging is its low resolution when using ultrasound. Furthermore, fluoroscopy, using ionizing radiation, has a limited ability to image soft tissues, thus making it less useful for detailed visualization[9]. In a study by Hussain et al[4], digital subtraction angiography was not able to detect lesions < 10 mm or deep in the liver segments. Similarly, through TACE for treating hepatocellular carcinoma, DynaCT facilitated the identification of additional or small lesions to ensure that the lesion was treated and prevented the recurrence of the disease[4]. Insufficient spatial detail in two-dimensional imaging from B-mode ultrasound, CT, or magnetic resonance imaging complicates stone localization, resulting in increased risks for surgery and reduced effectiveness[10].

In a study by Wang et al[5], DynaCT demonstrated greater sensitivity than digital subtraction angiography anterior-posterior imaging during transarterial uterine artery embolization of fibroids for identifying the origin of the bilateral uterine arteries, especially in patients with intricate vascular structures. In neurosurgical applications, such as trigeminal neuralgia treatment, DynaCT offers real-time adjustment, ensuring accurate needle placement and reducing surgery duration. While traditional methods remain valuable for routine imaging, DynaCT’s integration into procedural workflows enhances accuracy and safety and mitigates risks of surgical adverse events across various medical specialties[2]. Furthermore, radiation exposure in urological DynaCT in studies by Ritter et al[9] has been shown to be higher than fluoroscopy, but lower than the use of imaging in complex procedures such as standard multidetector CT[9]. For instance, in trigeminal neuralgia treatment, the adoption of DynaCT significantly lowered the average fluoroscopy dose compared to traditional methods, providing a safer alternative for both patients and total radiation exposure of operators[6].

CHALLENGES, LIMITATIONS AND FUTURE DIRECTIONS

Despite its advantages, the limitations of DynaCT adoption have been mentioned in the studies by Hussain et al[4] For example, a small study population due to the novelty of the procedure in the researcher’s region, the inability to evaluate radiation exposure levels, and the lack of assessment of time efficiency benefits anatomical visualization and feeding artery identification using DynaCT[4]. In addition, it involves high initial costs, as the necessary system can significantly increase the expense of setting up an endourologic operating room. Additionally, successful implementation relies on coordinated team training, including that of nurses and anesthesiologists. The technique also requires extensive training for operators to handle the system, use the guiding software, and perform procedures effectively[9]. Studies by Cheng et al[2] suggested that future research on DynaCT should focus on studies with larger sample sizes to improve the generalizability of the findings. The control group was also encouraged to allow for more robust comparisons[2].

CONCLUSION

DynaCT has been shown to enhance interventional procedures in hepatobiliary conditions, as evidenced by its application in TACE and other biliary interventions. Its integration into treatment protocols, including minimally invasive approaches such as TACE, underscores its potential to localize lesions and optimize therapeutic outcomes. DynaCT has been documented to identify additional lesions and vessels that would otherwise remain undetected, thereby improving treatment precision.