AJR 2004; 182:451-458
© American Roentgen Ray Society
Bile Leaks After Surgery
Vibhu Kapoor1,
Richard L. Baron1,2 and
Mark S. Peterson1
1 Division of Abdominal Imaging, Department of Radiology, University of
Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213.
2 Department of Radiology, University of Chicago, Chicago, IL 60637.
Received January 30, 2003;
accepted after revision May 30, 2003.
Address correspondence to V. Kapoor.
Introduction
Increases in hepatobiliary surgeries during the past decade, including
laparoscopic cholecystectomies and adult living donor liver transplantations,
have been accompanied by an increase in postoperative complications such as
bile leaks. It is imperative to accurately diagnose and treat bile leaks in a
timely manner to limit associated morbidity and mortality. Diagnostic imaging
plays a key role in the treatment of patients with suspected postoperative
bile leaks.
The purpose of this article is to describe the common locations and
appearances of bile leaks, including the difficulty in differentiating leaks
from other postoperative fluid collections, and the usefulness of different
imaging techniques in evaluating patients with suspected bile leaks.
Causes
Bile leaks that may result from cholecystectomy have been described by
McKenzie [1] and by Foster and
Wayson [2] and are caused by a
slipped cystic duct ligature or a leak from an accessory or anomalous bile
duct; those resulting from hepatic surgery are caused by a leak from a biliary
anastomotic site, dislodgement or removal of an external drainage tube, or
damage to a bile duct during surgery or trauma. Bile leaks are most commonly
associated with hepatobiliary surgeries or invasive procedures such as open or
laparoscopic cholecystectomy, hepatic resection, hepatic transplantation,
liver biopsy, and percutaneous transhepatic cholangiography.
Both open and laparoscopic cholecystectomy can be complicated by bile leaks
(Figs. 1A,
1B,
1C and
2A,
2B,
2C,
2D) from unrecognized
inadvertent damage to the normal bile duct during surgery. Up to 30% of the
population may have anomalies of the union of the intrahepatic bile ducts or
cystic duct with the common hepatic duct and gallbladder (Fig.
3A,
3B,
3C,
3D) that may predispose them
to bile duct injury during surgery
[3]. Identifying variations in
intrahepatic ductal anatomy during hepatic resection and liver transplantation
is also important to avoid bile duct complications. Bile leaks after
transplantation may occur at the site of biliary anastomosis or T-tube
placement and may necessitate surgical revision of the anastomosis (Fig.
4A,
4B,
4C). Bile leaks also may be
caused by nonoperative circumstances such as blunt or penetrating trauma
(Figs. 5A,
5B,
5C and
6A,
6B).
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Fig. 1A. —44-year-old man 1 week after laparoscopic cholecystectomy who
presented with abdominal pain and bile leakage through abdominal incisions.
ERCP image shows bile leak (arrow) from cystic duct remnant and
allows determination of site of leak.
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Fig. 1B. —44-year-old man 1 week after laparoscopic cholecystectomy who
presented with abdominal pain and bile leakage through abdominal incisions.
Late ERCP image shows pooling of contrast material at site of leak
(arrow). When large amount of contrast material is present, anatomic
features are obscured and exact site of leak cannot be determined.
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Fig. 1C. —44-year-old man 1 week after laparoscopic cholecystectomy who
presented with abdominal pain and bile leakage through abdominal incisions.
Contrast-enhanced CT scan 1 day after B shows persistent free fluid
(straight arrow) in abdomen with free peritoneal air (curved
arrow) from recent ERCP. Stent (arrowhead) is in good position.
Stent migration or obstruction may not adequately protect site of leak and may
result in failure of conservative therapy to treat leak.
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Fig. 2A. —52-year-old woman with abdominal pain 1 week after
laparoscopic cholecystectomy. Sonogram of right upper quadrant shows
nonspecific fluid collection (arrow) in gallbladder fossa. L =
liver.
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Fig. 2B. —52-year-old woman with abdominal pain 1 week after
laparoscopic cholecystectomy. Axial maximum-intensity-projection mangafodipir
trisodium–enhanced MR cholangiogram at 5 min shows extravasation of
contrast material (arrowhead) into operative bed.
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Fig. 2C. —52-year-old woman with abdominal pain 1 week after
laparoscopic cholecystectomy. Oblique coronal maximum-intensity-projection MR
cholangiogram at 25 min shows progressive extravasation of contrast material
(arrowhead).
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Fig. 2D. —52-year-old woman with abdominal pain 1 week after
laparoscopic cholecystectomy. ERCP image confirms leak (large
arrowhead) from branch of right hepatic duct (small arrowheads).
Aberrant duct probably was not recognized and was inadvertently damaged at
surgery.
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Fig. 3A. —Illustrations of anomalous biliary anatomy that may result in
injury during surgery. G = gallbladder, D = duodenum. Drawing shows low
insertion of cystic duct (straight arrow) in medial wall of hepatic
duct (white curved arrows) or in its ventral wall spiraling
(black curved arrow) dorsal to hepatic duct.
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Fig. 3B. —Illustrations of anomalous biliary anatomy that may result in
injury during surgery. G = gallbladder, D = duodenum. Drawing shows accessory
(segmental) hepatic duct draining directly into cystic duct
(arrowhead), gallbladder (solid arrow), and common bile duct
(open arrows).
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Fig. 3C. —Illustrations of anomalous biliary anatomy that may result in
injury during surgery. G = gallbladder, D = duodenum. Drawing shows cystic and
common hepatic ducts running parallel to each other in common fibrous sheath
(arrows).
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Fig. 3D. —Illustrations of anomalous biliary anatomy that may result in
injury during surgery. G = gallbladder, D = duodenum. Drawing shows
gallbladder closely apposed to liver (L) with many tiny Luschka's ducts
draining directly into gallbladder.
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Fig. 4A. —48-year-old woman with bilious fluid draining from surgical
drains placed in abdomen and left bile duct after trisegmentectomy and left
biliary hepaticojejunostomy for Klatskin's tumor. Injection of contrast
material into left biliary drain (long arrow) shows leak (short
arrows) from site of biliary anastomosis into right upper peritoneal
cavity.
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Fig. 4B. —48-year-old woman with bilious fluid draining from surgical
drains placed in abdomen and left bile duct after trisegmentectomy and left
biliary hepaticojejunostomy for Klatskin's tumor. Contrast-enhanced CT scan
shows large bile collection (arrow) along resected right margin of
liver and sympathetic right pleural effusion (arrowhead).
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Fig. 4C. —48-year-old woman with bilious fluid draining from surgical
drains placed in abdomen and left bile duct after trisegmentectomy and left
biliary hepaticojejunostomy for Klatskin's tumor. Repeated cholangiogram
through biliary drain (single arrows) 3 weeks after B shows
persistent leak (double arrows) and contrast material draining into
percutaneously placed catheter (arrowheads). Patient subsequently
required surgical revision of biliary anastomosis.
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Fig. 5A. —24-year-old man involved in automobile collision who
underwent surgical repair of laceration of right side of liver had bloody
bilious fluid draining from surgically placed drain. Contrast-enhanced CT scan
shows large liver lacerations (arrow) and surgically placed drain
(arrowhead).
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Fig. 5B. —24-year-old man involved in automobile collision who
underwent surgical repair of laceration of right side of liver had bloody
bilious fluid draining from surgically placed drain. Hepatobiliary scintigram
shows radiotracer in Jackson-Pratt drain (straight arrows). Site of
leak cannot be seen because of poor spatial resolution. Photopenic area along
superior margin of liver (curved arrow) is site of laceration.
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Fig. 5C. —24-year-old man involved in automobile collision who
underwent surgical repair of laceration of right side of liver had bloody
bilious fluid draining from surgically placed drain. Contrast material
injected through percutaneous Jackson-Pratt drain (double arrows)
pools at site of liver laceration (single thick arrow); fills
intrahepatic bile ducts (single thin arrow), common hepatic ducts
(double arrowheads), gallbladder (single arrowhead), and
duodenum; and confirms biliary disruption and leak.
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Fig. 6A. —21-year-old man with liver laceration caused by automobile
collision. Contrast-enhanced CT scan shows large laceration (arrows)
in right posterior lobe of liver and extravasation of contrast medium
(arrowhead), indicating active bleeding. Hepatobiliary scan (not
shown) revealed bile leak from laceration site. Patient was treated with
endoscopic insertion of biliary stent and percutaneous drainage of fluid.
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Fig. 6B. —21-year-old man with liver laceration caused by automobile
collision. Contrast-enhanced CT scan obtained 2 months after A shows
complete healing of laceration and residual scar (arrow). Hepatic
lacerations resulting in bile leaks frequently resolve spontaneously or with
minimal intervention.
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Pathophysiology
Bile leaks from postoperative or blunt abdominal trauma that result in
intraperitoneal collections of bile are typically not contaminated by bacteria
and usually do not result in severe bile peritonitis
[4]. In contrast,
intraperitoneal collections after acute cholecystitis are usually infected.
Peritoneal culture is positive in 75% of patients, with Escherichia
coli being the most frequently isolated organism. As expected, the
outcome is worse than for trauma patients.
Imaging
The incidence of bile leaks after liver transplantation has been reported
to be 4.3% [5]; after major
hepatic resection, 3–11%
[6]; and after laparoscopic
cholecystectomy, approximately 0.35–0.47%
[7]. Usually several days pass
before a leak is diagnosed [4,
5] because symptoms are
nonspecific and could derive from other postoperative complications
(Fig. 7). Patients frequently
undergo some form of cross-sectional imaging such as CT or sonography, and
altough findings may be suggestive of bile leak they cannot reliably
distinguish bile from other postoperative fluid collections such as pus,
serous fluid, or blood (Fig.
2A,
2B,
2C,
2D).
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Fig. 7. —51-year-old woman with fever after liver transplantation and
clinical concern for infection. Contrast-enhanced CT scan of upper abdomen
shows biliary stent (arrowhead) penetrating wall of Roux-en-Y loop of
biliary hepaticojejunostomy with large amounts of intraabdominal fluid and
free air (arrows). Surgery confirmed Rouxen-Y perforation and mixed
bilious fluid in peritoneal cavity. This case emphasizes importance of
documenting proper positioning of stents and drains.
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CT is excellent for showing the site and morphology of a fluid collection.
In our experience, on CT, bile collections may be loculate, multiloculate
(Fig. 8), or diffuse in the
peritoneal cavity (Fig. 1A,
1B,
1C). Bile collections are
usually close to the site of the leak, but occasionally they may be remote or
may even be intrahepatic (Fig.
9). If a fluid collection is identified on CT, further
investigation may be undertaken to confirm and treat the collection. If a
T-tube is present, a cholangiogram can usually reveal the presence and site of
the leak. However, if a T-tube is not present, more invasive examinations such
as ERCP, percutaneous cholangiography (Fig.
10A,
10B), or imaging-guided
percutaneous drainage can confirm the diagnosis and potentially treat the bile
leak.
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Fig. 8. —72-year-old woman with fever 2 weeks after cholecystectomy.
Bile duct was injured and repaired during surgery. Contrast-enhanced CT scan
shows multiple loculated perihepatic fluid collections (arrows)
confirmed as bilomas on hepatobiliary scintigraphy. Arrowhead marks
endoscopically placed biliary stent.
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Fig. 9. —74-year-old man with remote history of cholecystectomy
developed fever and rigors after endoscopic sphincterotomy and removal of bile
duct stones. ERCP (not shown) revealed intrahepatic bile leak from left
hepatic duct. Contrast-enhanced CT scan shows multiple nonspecific
low-attenuation lesions (arrows) in left hepatic lobe. Imaging-guided
aspiration of left lobe collection revealed purulentappearing bilious fluid
with WBCs that gave negative results at pathogen culture. Infection can cause
breakdown of small bile ducts and subsequent leak; pericholangitic abscesses
often represent intrahepatic bile leaks.
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Fig. 10A. —58-year-old man was found to have gallbladder carcinoma
during cholecystectomy for cholecystitis. Contrast-enhanced CT scan obtained
because of persistent postoperative jaundice shows mild intrahepatic ductal
dilatation with small low-attenuation region in gallbladder fossa (black
arrows). No collection that would indicate bile leak is seen. White arrow
marks surgically placed drainage catheter.
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Fig. 10B. —58-year-old man was found to have gallbladder carcinoma
during cholecystectomy for cholecystitis. Percutaneous transhepatic
cholangiogram shows hepatic ducts dilated from complete obstruction at
confluence (long arrow) of bile ducts. Contrast material
extravasation (short arrows) indicating bile leak is seen along
surgically placed drain (white arrowheads) that corresponds to
low-attenuation region on CT scans. Patient was successfully treated with
external biliary drainage catheter (black arrowheads).
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Hepatobiliary scintigraphy has the advantage of presenting the physiologic
course of biliary excretion and showing the actual leakage of bile from the
biliary tract (Fig. 5A,
5B,
5C). This technique, however,
is limited by poor spatial resolution that makes identification of the site of
leak difficult, and CT correlation may be required, especially if the leak is
small.
Mangafodipir trisodium–enhanced MR cholangiography is a recently
described alternative approach that combines anatomic and functional imaging
of the biliary tract [8].
Mangafodipir trisodium is an MR contrast agent comprising a water-soluble
chelate complex salt between a paramagnetic manganese ion (II) and the ligand
dipyridoxyl diphosphate, a vitamin B6 analogue. Mangafodipir begins
to increase the signal intensity of the liver 1–3 min after IV injection
and reaches steady-state enhancement in approximately 5–10 min. Scanning
is initiated 5 min after the injection, and volumetric 3D T1-weighted axial
and coronal or oblique coronal images are obtained every 10–15 min until
a bile leak becomes apparent (Fig.
11A,
11B,
11C). Mangafodipir
trisodium–enhanced MR cholangiography combines the advantages of
hepatobiliary scintigraphy and multiplanar cross-sectional imaging with the
functional evaluation of biliary excretion and excellent spatial resolution
and anatomic depiction (Figs.
12A,
12B,
12C and
13A,
13B) of the biliary tree.
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Fig. 11A. —50-year-old woman with complicated clinical course after
partial left hepatic lobectomy for adenomatosis. CT scan shows large
perihepatic fluid collection (arrow) that proved to be biloma after
percutaneous drainage.
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Fig. 11B. —50-year-old woman with complicated clinical course after
partial left hepatic lobectomy for adenomatosis. ERCP image does not reveal
bile leak. Hepatobiliary scintigraphy (not shown) also failed to show
leak.
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Fig. 11C. —50-year-old woman with complicated clinical course after
partial left hepatic lobectomy for adenomatosis. Oblique sagittal
maximum-intensity-projection MR cholangiogram obtained at 40 min shows
increasing accumulation of contrast material (arrow) in perihepatic
space. Contrast material is also seen in percutaneous drainage catheter
(arrowheads).
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Fig. 12A. —62-year-old man, transplant recipient of right hepatic lobe
with choledochocholedochostomy. Increasing perihepatic fluid appeared on
sonography and bile drained from abdominal drain after liver transplantation.
Initial T-tube cholangiography did not show bile leak. Contrast-enhanced CT
scan after initial T-tube cholangiogram shows significant, albeit nonspecific,
perihepatic fluid (arrow). Surgical drain is marked with
arrowhead.
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Fig. 12B. —62-year-old man, transplant recipient of right hepatic lobe
with choledochocholedochostomy. Increasing perihepatic fluid appeared on
sonography and bile drained from abdominal drain after liver transplantation.
Initial T-tube cholangiography did not show bile leak. Axial
maximum-intensity-projection mangafodipir trisodium–enhanced MR
cholangiogram 1 week after transplantation at 15 min shows extravasation of
contrast material (arrow) from resected free left margin of
liver.
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Fig. 12C. —62-year-old man, transplant recipient of right hepatic lobe
with choledochocholedochostomy. Increasing perihepatic fluid appeared on
sonography and bile drained from abdominal drain after liver transplantation.
Initial T-tube cholangiography did not show bile leak. Repeated T-tube
cholangiogram confirms bile leak (arrow). Multiple areas of
intrahepatic biliary narrowing (arrowheads) suggest hepatic artery
stenosis and resultant bile duct ischemia and stricture formation.
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Fig. 13A. —29-year-old man with fever 3 weeks after liver
transplantation. CT scan shows fluid collection containing gas
(arrow) adjacent to left hepatic lobe, which is suggestive of
abscess. Percutaneous drainage revealed bilious fluid.
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Fig. 13B. —29-year-old man with fever 3 weeks after liver
transplantation. Axial curved reformatted MR cholangiogram at 40 min shows
accumulation of contrast material (straight arrow) corresponding to
collection seen on CT scan. Curved reformatted image shows entire length of
track from intrahepatic ducts (curved arrow) to drainage catheter
(arrowheads).
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Conclusion
Detecting and locating bile leaks is difficult. It is important to
differentiate bile leaks from abscesses because bile leaks can often be
treated by temporary stenting. Cross-sectional imaging may be a reasonable
first step for detecting postoperative complications, but documenting bile
leaks often requires techniques that directly visualize biliary excretion from
the injured bile ducts. Mangafodipir trisodium–enhanced MR
cholangiography can be helpful in such instances and provide accurate anatomic
and functional information that allows prompt diagnosis and treatment of bile
leaks.
Acknowledgments
We thank Eric Jablonowski for his help with the illustrations in Figure
3A,
3B,
3C,
3D.
References
- McKenzie G. Extravasation of bile duct after operations of the
biliary tract. Aust N Z J Surg1955; 24:181
–191[Medline]
- Foster JH, Wayson EE. Surgical significance of aberrant bile ducts.
Am J Surg1962; 104:14
–19[Medline]
- Berci G, Sackier JM. Laparoscopic cholecystectomy and laparoscopic
choledocholithotomy. In: Blumgart LH, ed. Surgery of the liver and
biliary tract, 2nd ed. New York, NY: Churchill Livingstone,1994
: 633–661
- Andersson R, Tranberg KG, Bengmark S. Isolated intraperitoneal
accumulation of bile after surgical or diagnostic procedures. Acta
Chir Scand 1988;154:375
–377[Medline]
- Sheng R, Sammon JK, Zajko AB, Campbell WL. Bile leak after hepatic
transplantation: cholangiographic features, prevalence, and clinical outcome.
Radiology1994; 192:413
–416[Abstract/Free Full Text]
- Coppa GF, Eng K, Ranson JHC, Gouge TH, Localio SA. Hepatic
resection for metastatic colon and rectal cancer: an evaluation of
preoperative and postoperative factors. Ann Surg1985; 202:203
–208[Medline]
- Shea JA, Healey MJ, Berlin JA, et al. Mortality and complications
associated with laparoscopic cholecystectomy: a meta-analysis. Ann
Surg 1996;224:609
–620[Medline]
- Vitellas KM, El-Dieb A, Vaswani K, et al. Detection of bile duct
leaks using MR cholangiography with mangafodipir-trisodium (Teslascan).
J Comput Assist Tomogr2001; 25:102
–105[Medline]
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Introduction
Causes
