Hepatobiliary scintigraphy An effective tool in the management of bile leak following laparoscopic cholecystectomy Madhavi Tripathi a , N. Chandrashekar a , Rakesh Kumar a, *, E.J. Thomas a , Sandeep Agarwal b , C.S. Bal a , A. Malhotra a a Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India b Department of Surgery, All India Institute of Medical Sciences, New Delhi, India Received 15 October 2002 Abstract Bile leaks and bile duct injury has been the major postoperative complications described after laparoscopic cholecystectomy. In this study, we evaluated the role of hepatobiliary scintigraphy (HBS) in patients who underwent laparoscopic cholecystectomy, and there was a clinical suspicion of bile leak in postoperative period. Method: Twenty-five patients (M/F = 11:14, mean age 39 ± 8 years; range 24 À 58 years) with suspected bile leak postlaparoscopic cholecystectomy underwent sequential HBS. Results: Thirteen patients had normal hepatobiliary scintigraphic studies. Five patients had small bile leak in gall bladder fossa with primary route of bile flow into the gut. All these 18 patients improved on conservative management alone. Significant bile leak from the cystic stump region was demonstrated in four patients. All of them were subjected to endoscopic cholangiography (ERCP), which confirmed the site of leak. All patients had stenting and sphincterotomy. One patient showed bile leak and obstruction at the lower end of common bile duct, he improved spontaneously. Another patient showed poor hepatocytes function and no excretion of radiotracer and underwent ERCP followed by hepaticojejunostomy for common hepatic duct ligation. One patient had frank bile leak in the right paracolic gutter and had to undergo hepaticojejunostomy. Conclusions: HBS is a valuable noninvasive method of investigating possible bile leaks or other biliary disruptions in postlaparoscopic cholecystectomy patients. Negative study for significant bile leak can assure the surgeon to manage the patient conservatively. However, it cannot be relied on absolutely when determining the need for reoperation for a significant bile leak in early postoperative period. D 2004 Elsevier Inc. All rights reserved. Keywords: Laparoscopic cholecystectomy; Bile leak; Hepatobiliary scintigraphy 1. Introduction Over the past few years, laparoscopic cholecystectomy has become the most common method of performing a cholecystectomy. It offers the advantage of a shorter post- operative hospital stay, lesser postoperative pain, a shorter convalescent period and more acceptable cosmetic results [1]. Bile leaks and bile duct injury has been the major postoperative complications described after laparoscopic cholecystectomy [2–7]. The complications of bile duct injury can be devastating, thus, timely diagnosis and appro- priate management are crucial. Patients who develop fever, anorexia, jaundice, abdominal pain or profuse bilious drain- age should be suspected of having significant bile leak. Documenting the presence and extent of leak can pose a difficult diagnostic challenge. The diagnostic tools currently available include ultra- sonography (USG), computerised tomography (CT), hep- atobiliary scintigraphy (HBS) and percutaneous or endoscopic cholangiography (ERCP). USG and CT are useful for detecting the presence and anatomical site of fluid collection, but they cannot demonstrate the nature and site of origin of the collection. These also cannot demonstrate the preferential route of bile flow [8]. HBS is a sensitive, noninvasive and physiological means of 0899-7071/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0899-7071(03)00035-4 * Corresponding author. F-74 Ansari Nagar (West), AIIMS Campus, New Delhi 110029, India. Tel.: +91-11-6259597; fax: +91-11-6862663. E-mail address: rkphulia@hotmail.com (R. Kumar). Journal of Clinical Imaging 28 (2004) 40 – 43