Downloaded from www.ajronline.org by University of Illinois at Chicago Library on 02/06/14 from IP address 128.248.155.225. Copyright ARRS. For personal use only; all rights reserved

785

Bile Duct Disruption and Biloma After Laparoscopic Cholecystectomy: Imaging Evaluation

Andrew T. Walker1 Avishai W. Shapiro1 David C. Brooks2 John M. Braver1 Sabah S. Tumeh1’3

Disruption of the biliary tree after laparoscopic cholecystectomy has been reported in 0-7% of cases, and likely represents the most significant postoperative complication. Documenting the presence and extent of a bile leak is often difficult. We reviewed the first 264 Iaparoscopic cholecystectomies performed at our institution and found seven cases of bile extravasation and/or biloma formation (prevalence, 2.7%). All patients were first seen in the early postoperative period with abdominal pain and low-grade fever. Sonography was performed in five of seven, CT in five of seven, hepatobiliary scintigraphy with diisopropyliminodiacetic acid in five of seven, and ERCP in four of seven cases. While sonography and CT were initially helpful in determining the presence of abdominal fluid collections, they were unable to differentiate between postoperative seroma, lymphocele, hematoma, and bile leak. Hepatobiliary scintigraphy was useful in demonstrating continuity of these fluid collections with the biliary tree and guiding further therapy. Four cases were managed with endoscopic biliary decompression, with the use of sphincterotorny or nasobiliary stent placement, with good clinical result. The other three cases were treated surgically with T-tube or external drainage. All patients did well clinically, without evidence of bile reaccumulation. Our experience suggests that sonography and CT are useful in detecting postoperative

fluid

collections,

but cannot

differentiate

raphy is valuable as a noninvasive guiding further therapy. AJR

Received August 29, 1991 sion November 14, 1991. 1 Department of Radiology,

;

accepted Harvard

after revi-

MA

and Women’s

Hospital,

Boston,

02115.

Present address: Department of Radiology, Eastern Virginia Medical School, Depaul Hospital, 1 50 Kingsley Lane, Norfolk, VA 23505. 3

0361 -803X/92/1 584-0785 0 American Roentgen Ray Society

bile

from

other

of investigating

fluids.

Hepatobiliary

possible

scintig-

bile leaks

and in

April 1992

Bilomas and bile duct disruptions have been described in association with abdominal trauma and right upper quadrant surgery. With the introduction of laparoscopic cholecystectomy, these relatively uncommon complications have increased in frequency [1 , 2]. Because this procedure is being performed with increasing frequency, radiologists must increase their awareness of this potential complication and consider the development of a biloma in patients who have clinical difficulties in the early postoperative period. Bile leaks often pose a difficult diagnostic challenge. We reviewed our experience with seven bile duct disruptions and/or biloma formations occurring in the first 264 patients in whom laparoscopic cholecystectomy was performed at our institution.

Medical

School, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 021 1 5. Address reprint requests to A. T. Walker, Department of Radiology. 2 Department of Surgery, Harvard Medical SChOOl, Brigham

158:785-789,

means

Materials

and

Methods

We reviewed the first 264 laparoscopic cholecystectomies performed at Brigham and Women’s Hospital between January 1 , 1 990, and March 1 5, 1 991 . Seven cases of clinically significant

bile

leak

and/or

biloma

formation

were

found

(Table

1). The

group

included

four

women and three men 26-72 years old (mean, 54 years). The most common presenting symptoms were abdominal pain, distension, and nausea. All patients had an elevated WBC count in the range of 1 4,000-1 6,000/mm3 and low-grade temperatures ranging from 37.2#{176}C to 37.8#{176}C.They were first seen 3-9 days after laparoscopic cholecystectomy. Two of the seven patients had not been discharged from the hospital after the original procedure.

WALKER

786

Downloaded from www.ajronline.org by University of Illinois at Chicago Library on 02/06/14 from IP address 128.248.155.225. Copyright ARRS. For personal use only; all rights reserved

TABLE

1: Summary

Case No.

of Imaging

and Therapy

1

2

of Bile Duct Disruption

Sonography

DaysSuice 5

Small

9

fossa Complex

collection

ET AL.

After

AJR:158,

Laparoscopic

CT

in gallbladder

perihepatic

collec-

Perihepatic

Cholecystectomy

DISIDA

ND

collection

April 1992

ERCP

Treatment

ND

Accessory

ND

extravasation ND

duct

Sphincterotomy

Surgery

tion

3

5

Free peritoneal

4 5

3 7

ND Complex

6

6

Normal

7

8

ND

fluid

ND

perihepatic

collec-

Extravasation

Peritoneal Perihepatic

fluid collection

Extravasation Extravasation

Collection fossa Peritoneal

in gallbladder

Extravasation

fluid

Extravasation

Cystic duct extravasation No extravasation ND

Nasobiliary

catheter

Sphincterotomy Surgery

tion

Note.-DIS

IDA

=

“Tc-di

isopropyllminodiacetic

acid scintigra

phy; ND

=

Biloma

fluid

was

and culture

collections;

the

fluid

obtained

at surgery

in three was

and

sent

of the four patients

culture-positive

in one

leak was documented by surgical exploration in three cases, and hepatobiliary scintigraphy

for

microbiological

with loculated case

(case

fluid 2). Bile

in three cases, in one case.

ERCP

Results was

performed

suggested

the diagnosis

technically

limited

because

in five of the seven

in four of the

cases; patient’s

the fifth extreme

cases,

and

study

was

discom-

fort. We found a spectrum of sonographic findings. Two patients had anechoic, well-circumscribed collections within the gallbladder fossa and adjacent perihepatic region. One patient had a large, complex fluid collection with multiple fine internal septa that compressed the left lobe of the liver (Fig. 1). In one patient, only free peritoneal fluid within the pelvis was seen. CT was performed in five cases. It showed discrete, fluidattenuation collections in three patients. The smallest loculated bile accumulation was a 2-cm collection within the gallbladder fossa that could have easily been mistaken for a normal gallbladder without knowledge of the patient’s previous

surgery.

The

largest

accumulation

was

a 1 5-cm

catheter

Surgery

uptake surrounding the liver and abnormal pooling of radiotracer within the paracolic gutters and pelvis on delayed images. ERCP was performed in four of the seven cases and showed a biliary system leak with extravasation of contrast material in three cases. In case 4, the DISIDA scan showed extrabiliary accumulation of radiopharmaceutical, consistent with

a bile leak.

corn-

plex collection that surrounded and compressed the left lobe of the liver and extended into the gallbladder fossa (Fig. 1). Two cases showed only free peritoneal fluid within the pelvis. Biliary scintigraphy was performed in five of the seven patients and showed extrabiliary accumulation of the radiopharmaceutical in each case (Fig. 2). Two scans showed discrete, well-defined regions of perihepatic or gallbladder fossa uptake, consistent with loculated bile collections or bilomas. The other three cases showed abnormal radiotracer

ERCP

the next

day failed

to demonstrate

bile

duct disruption, but was technically limited by problems in cannulating and maintaining position within the common bile duct, so that much of the injected contrast material escaped into the duodenum. Evaluation was also somewhat hampered by residual barium within the colon from previous CT exarnination (Fig. 3). Four patients were treated with endoscopic bile duct decompression by using sphincterotomy or nasobiliary stent placement.

Sonography

Nasobiliary

not done.

Sonography was performed with 3- to 5-MHz sector transducers. Hepatobiliary scintigraphy was performed with 3-5 mCi (111-185 MBq) of “Tc-diisopropyliminodiacetic acid (DISIDA) by using a gamma camera with a large field of view and an all-purpose collimator (Starcam, General Electric, Milwaukee, WI). Images were obtained with 450,000-500,000 counts at 5, 1 5, 30, 45, and 60 mm. Delayed images at 90 mm were obtained in all cases. CT was performed with a high-resolution Somatom 3 or Somatom Plus scanner (Siemens, Iselin, NJ). Scans were obtained with 1 0-mm contiguous imaging with oral but no IV contrast material. analysis

Cystic duct extravasation ND

Three

patients

had

surgery

again

in hopes

of

definitively repairing the bile duct. In two of these cases, bile collections were found, but the specific site of bile leakage could not be identified, and external drains were placed under direct visualization. In the third case, a leak in the right hepatic duct was found at its junction with the left hepatic duct, and a T-tube was placed across the duct disruption. All patients did well clinically, with resolution of their symptoms, and none showed evidence of bile reaccumulation.

Discussion

Laparoscopic cholecystectomy has rapidly emerged as an alternative treatment of symptomatic gallstone disease. Bile duct injury and bile leaks are likely the most significant postoperative complications, and have been recently reported to occur in 0-7% of patients [1 , 2]. Bile extravasation is predominantly attributed to an anatomic variation of small biliary radicles entering directly into the gallbladder bed, or the bile ducts of Luschka, reported to be present in 25-35% of patients [1]. Bile extravasation also may occur from direct injury to the biliary tree, from larger accessory ducts, or from the cystic duct remnant. In our series, bile leakage was from the cystic duct remnant in two cases, an accessory bile duct in one case, and the right hepatic duct in one case. The origin

AJR:158,

April 1992

BILE

DUCT

DISRUPTION

AFTER

CHOLECYSTECTOMY

787

Downloaded from www.ajronline.org by University of Illinois at Chicago Library on 02/06/14 from IP address 128.248.155.225. Copyright ARRS. For personal use only; all rights reserved

Fig. 1.-Postoperative biloma. Case 2: 44-year-old man with right upper

quadrant pain andjaundice 9 days after laparoscopic cholecystectomy. A, CT scan of abdomen shows large, bibbed, low-attenuation collection surrounding, and to some degree cornpressing, left lobe of liver. B, Sonogram of same region shows large anechoic area with multiple fine septa. Septation may be seen in infected bliomas, as here, making differentlation from postoperative hematoma difficult. At surgery, a tear in right hepatlc ductwas found and T-tube placed across disruption.

Fig. 2.-Postoperative bile leak. Case 6: 64-year-old man with abdominal pain and nausea 6 days after laparoscopic cholecystectomy. A, Scintigrams 15, 30, 60, and 90 mm after administration of “Tc-DlSIDA show extrabiliary accumulation of radiopharmaceutical in gallbladder fossa with extension over dome of liver. Extravasation surrounding liver can be mistaken for normal hepatic uptake on early images, but delayed images show persistent perihepatic activity as normal liver activity decreases. B, ERCP shows contrast extravasation from dIstal cystic duct remnant (arrow).

was suggested by the DISIDA scan in the remaining three cases, but exact localization was not possible. Clinically insignificant bile leaks are common after open cholecystectomy. Gilsdorf et al. [3] demonstrated extrabiliary accumulation of radiotracer in 44% of patients who had DISIDA scanning 2-4 hr after open cholecystectomy. Only one of the 25 patients developed symptoms and required further therapy for the bile leak. The majority of perihepatic postoperative fluid collections are small, asymptomatic, and resolve spontaneously. However, patients who develop abdominal pain, fever, jaundice, or bilious drainage from a surgical drain should be considered to have a clinically significant

bile leak [4, 5]. It is in these patients that further therapy is necessary. Symptoms may be caused by local inflammatory or compressive effects of the collection, or infection. All the patients in our series had abdominal pain, fever, and mild leukocytosis on presentation, and thus were believed to have clinically significant fluid collections requiring therapy. We found a fairly even distribution of complications throughout the study period, with a slight increase at the end. Although we did not find a clustering of complications in the first patients, representing a learning curve, others have shown strong evidence to support its presence. The CoIlaborative Southern Surgeons Club study cited a 2.2% preva-

Downloaded from www.ajronline.org by University of Illinois at Chicago Library on 02/06/14 from IP address 128.248.155.225. Copyright ARRS. For personal use only; all rights reserved

788

WALKER

ET AL.

AJR:158,

April 1992

B

A

Fig. 3.-Bile with

abdominal

leak seen only with hepatobiliary scintigraphy. Case 4: 67-year-old woman pain, jaundice, and mild leukocytosis 3 days after laparoscopic cholecystec-

tomy. A, CT scan of abdomen shows free peritoneal fluid surrounding liver and extending into left paracolic gutter (arrows). B, Scintigrams 15, 30, 60, and 90 mm after administration of ““Tc-DISIDA show abnormal uptake in gallbladder fossa with extension into left upper quadrant surrounding spleen, lesser sac, and left paracolic gutter. C, ERCP does not show evidence of bile leak. However, the study was limited by difficulty in cannulating and maintaining position within common bile duct, so that much of the injected contrast material escaped into duodenum (arrows). Evaluation was also limited by residual barium within colon from previous CT. Although no bile leak was demonstrated, patient was treated with sphincterotomy.

lence of bile duct injury among the first 1 3 patients operated on by each surgical group, and then a decrease to 0.1% for subsequent patients [2]. The early increased prevalence of bile leaks may also be due to early problems with the technique and the equipment itself, such as the apparatus used to place titanium clips on the cystic duct. CT and sonography were helpful in showing perihepatic fluid collections or free peritoneal fluid. Although these tests are useful for screening, their findings are not specific and may represent other postoperative collections, such as serorna, resolving hematoma, lymphocele, abscess, or even pancreatic pseudocyst. In one case (case 2), sonography showed a large collection with multiple fine internal septa surrounding the left hepatic lobe. Complex internal septation has been described in infected bilomas [6]. This was only seen in the one case of documented infection in our series

(Fig. 1). Differentiating this collection from a postoperative hematoma, which may have a similar sonographic appearance, was exceedingly difficult and required surgical confirmation. Hepatobiliary scintigraphy was very useful in evaluating suspected postoperative bile duct disruption. It has the advantages of being physiologic, noninvasive, and usable in the setting of hyperbilirubinemia. mTciminodiacetic acid agents also have a high photon flux, allowing their detection in lower concentrations than needed for the iodinated contrast material used with conventional radiographic techniques [4]. Delayed images were often helpful in detecting small bile leaks and distinguishing extravasation from liver and small-bowel activity. Weissman et al. [5, 7] and Esensten et al. [8] stressed the importance of delayed scans whenever the diagnosis is suspected, even if findings on initial images appear normal.

Downloaded from www.ajronline.org by University of Illinois at Chicago Library on 02/06/14 from IP address 128.248.155.225. Copyright ARRS. For personal use only; all rights reserved

AJR:158,

BILE

April 1992

DUCT

DISRUPTION

AFTER

When communication with the biliary tree is not demonstrated, definitive diagnosis of biloma requires aspiration and chemical analysis of the fluid. Scintigraphy still confers useful information in these instances by demonstrating that the bile leak has closed off [6]. When communication with the biliary tree has already healed, biliary decompression or surgical repair is not required. Although hepatobiliary scintigraphy is a sensitive examination for detecting bile leaks, it is limited in anatomic resolution and often cannot show the exact site of bile extravasation. Higher resolution studies with iodinated contrast material, such as percutaneous transhepatic cholangiography (PTC) or ERCP, are necessary to provide more precise information for surgical planning [4]. The demonstration of contrast extravasation from the biliary system during ERCP also is diagnostic of bile duct disruption, obviating percutaneous aspiration. In one patient (case 4),

CT

showed

a large

perihepatic

fluid

collection

and

the

DISIDA scan showed unequivocal extrabiliary accumulation of radiotracer in the perihepatic space with extension into the left paracolic gutter on delayed views (Fig. 3). ERCP the next day failed to demonstrate bile duct disruption, but was technically limited by problems in cannulating and maintaining position within the common bile duct (Fig. 3). Although a bile leak was not demonstrated, the patient was treated with sphincterotomy. She improved clinically without the need for percutaneous or surgical drainage. Thus, there remains some diagnostic discrepancy in this case. We think including it in the series is warranted by the unequivocal nature of the DISIDA scan and correlative findings on CT. When unequivocal, hepatobiliary scanning is unlikely to give false-positive results, although no rigorous study of the sensitivity and specificity of scintigraphy in bile leaks has been performed. Esensten et al. [8] used cholescintigraphy alone in four of five cases to confirm the diagnosis of biliary tree disruption in their review of posttraumatic intrahepatic bilomas. ERCP offers the added advantage of potential therapeutic intervention. A recent review of 77 cases of endoscopically managed postoperative biliary leaks cited a 95% technical success rate [9]. The four patients treated endoscopically in our series all did well and showed no evidence of bile reaccumulation. Our experience is limited, but because the exact point of bile extravasation is often difficult to identify surgically, and morbidity is increased with an operative procedure, a trial of endoscopic management seems useful in most cases. Needle aspiration is also a very useful diagnostic technique, although it was not used in our series [1 0]. It is necessary when hepatobiliary scintigraphy or ERCP fails to show communication of a loculated abdominal fluid collection with the biliary tree and the clinical suggestion of biloma remains

CHOLECYSTECTOMY

789

strong. We think, however, that hepatobiliary scintigraphy is a simple, noninvasive way to detect the presence of a bile leak and should be used before more invasive steps are taken. Percutaneous drainage has been used successfully to manage bile leaks, but has the disadvantages for the patient of prolonged hospitalization and risk of infection. Bile leak and biloma formation are important considerations in patients who develop difficulties in the early postoperative period afterlaparoscopic cholecystectomy. Although the number of patients in our series is small and all studies were not done in every case, a number of important considerations are demonstrated. Postoperative collections are probably cornmon, and are not of clinical concern if found incidentally and the patient is asymptomatic. However, when patients develop clinical symptoms such as pain, fever, or jaundice, a substantial bile leak should be considered. Sonography and CT were helpful in detecting abdominal fluid collections, but could not differentiate bile from other fluids. We found hepatobiliary scintigraphy to be very useful in these patients, demonstrating disruption of the biliary tree without the need for invasive intervention. However, it is limited in anatomic resolution, and ERCP or PTC is needed to localize the exact point of bile leakage. Although only a small number of patients are reported, endoscopic management was successful in all cases in which it was used.

REFERENCES 1 . Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 1991:213:3-12 2. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies.

N Engl J Med

1991:324:

1073-1

078

3. Gilsdorf JR. Phillips M, McLeod MK, et al. Radionuclide

leakage and

the use of subhepatic

drains

after

evaluation cholecystectomy.

of bile Am J

:259-262 DJ, Brugge WR, Alavi A. Bile leak following

Surg 1986;151

4. Rosenberg

an elective laparoscopiccholecystectomy: the role ofhepatobiliary imaging in the diagnosis and management of bile leaks. J Nuci Med 1991:32:1777-1781 5. Weissmann HS, Gliedman ML, Wilk PJ, et al. Evaluation of the postoperative patient with “‘Tc-lDA cholescintigraphy. Semin Nuc! Med 1982;12:27-52 6. Kuiigowska E, Schlesinger A, Miller KB, Lee VW, Grosso D. Bilomas: a new approach to the diagnosis and treatment. Gastrointest Radiol

1983:8:237-243. 7. Weissmann HS, Chun KJ, Frand M, Koenigsberg M, Miistein DM, Freeman LM. Demonstration of traumatic bile leakage with cholescintigraphy and ultrasonography. AiR 1980:133:843-847 8. Esensten M, RaIls PW, Colletti P, Halls J. Posttraumatic intrahepatic biloma: sonographic diagnosis. AJR 1983;140:303-305 9. Binmoeller KF, Katon RM, Shneidman R. Endoscopic management of postoperative biliary leaks: review of 77 cases and report of two cases with biloma formation. Am J Gastroenterol 1991;86:227-231 10. Mueller PR, Ferrucci JT Jr. Simeone JF, et al. Detection and drainage of bilomas: special considerations. AJR 1983:140:715-720