CASE OF THE WEEK – “Precise localization of biliary leak post laparoscopic cholecystectomy with hepatobiliary scintigraphy & adjunct hybrid SPECT-CT imaging” by Dr ShekharShikare, HOD & Consultant, Nuclear Medicine NMC Royal Hospital Sharjah

Introduction

Postsurgical bile leaks can be associated with significant morbidity and even mortality, if not identified and treated at an early phase. Hepatobiliary scintigraphy (HBS) scan is an important test for the detection of bile leaks in the postoperative abdomen. However, the lack of anatomical details on planar images can make interpretation difficult, especially in the setting of altered postsurgical anatomy. Familiarity with the expected postoperative appearance on HBS scan and correlation with single-photon emission computed tomography/computed tomography (SPECT/CT) or other imaging modalities when available are very important.

A 37-year-old female underwent laparoscopic cholecystectomy for cholelithiasis with cholecystitis and had uneventful recovery. The drainage tube kept postoperatively was removed next day before the discharge.

The patient was readmitted on the 3rd day with complaining of abdominal pain; her white blood cell was 19, C-reactive protein 39.2, serum glutamic-oxaloacetic transaminase 63, serum glutamic-pyruvic transaminase 90, and direct bilirubin 10.2.

CT scan of the abdomen with contrast was performed and showed free fluid within the peritoneal cavity, more prominent in the dependent portion of the abdomen (pelvic cavity). The operated cholecystectomy site appeared normal with surgical clip in situ. No intra- or extrahepatic biliary dilatation was seen. The above findings were similar to those seen in the previous magnetic resonance imaging examination. Ultrasound of the abdomen

Mild free fluid was seen, right adnexal, paracolic, and hepatic regions.

99m Tc-mebrofenin hepatobiliary scan

After intravenous administration of99m Tc-mebrofenin, sequential a) dynamic abdominal images were obtained over 60 min b) static images were obtained at 60 min & 120 min and SPEC T-CT FUSED images at 60 minutes. It shows good hepatocytic function by the liver and non-obstructive biliary to bowel tracer transit.

Abnormal tracer leak started seeing approximately from the confluence of cystic and common hepatic duct region [Figure 1] and [Figure 2] arrows, moving to the gall bladder fossa and then moving downwards from the inferior border of the liver [Figure 2] arrow and accumulating in peri-hepatic, infra diaphragmatic, right para-colic, left para colic region and eventually throughout the abdomen [Figure 2].

After intravenous administration of99m Tc-mebrofenin, sequential a) dynamic abdominal images were obtained over 60 min b) static images were obtained at 60 min & 120 min and SPEC T-CT FUSED images at 60 minutes. It shows good hepatocytic function by the liver and non-obstructive biliary to bowel tracer transit.

Abnormal tracer leak started seeing approximately from the confluence of cystic and common hepatic duct region [Figure 1] and [Figure 2] arrows, moving to the gall bladder fossa and then moving downwards from the inferior border of the liver [Figure 2] arrow and accumulating in peri-hepatic, infra diaphragmatic, right para-colic, left para colic region and eventually throughout the abdomen [Figure 2].

Figure 1: Hepatobiliary scintigraphy dynamic images showing active biliary leak (arrows)

Figure 2: Hepatobiliary scintigraphy static 60 min and 2 h images showing site of the lean (single arrow) and then through the inferior border of the liver (two arrows)

Adjunct SPECT/CT was performed at sixty minutes selectively for precise Anatomical localization and it showed active site of the biliary leak approximately at the confluence of cystic and common hepatic duct region [Figure 3] and [Figure 4] arrows.

Figure 3: Hepatobiliary scintigraphy single-photon emission computed tomography/computed tomography fusion images showing site of the biliary leak (arrows)

Figure 4: Hepatobiliary scintigraphy single-photon emission computed tomography/computed tomography fusion images showing site of the biliary leak (arrows)

Diagnostic laparoscopy was performed post HBS and 2 mm biliary leak point was identified approximately at confluence of cystic duct and common hepatic duct region, which is most probably due to burn injury. Endoscopic retrograde cholangiopancreatography was performed with stenting of the common bile duct and the patient settled and the stent was removed after 6 weeks.