ARRS 2022 Abstracts

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E1663. Nuts and Bolts of Iatrogenic Bile Leaks
Authors
  1. Neel Shroff; The University of Texas Medical Branch
  2. Aeman Muneeb; The University of Texas Medical Branch
  3. Lydia Dawood; The University of Texas Medical Branch
  4. Samuel Bezold; The University of Texas Medical Branch
  5. Javier Villanueva-Meyer; The University of Texas Medical Branch
  6. Peeyush Bhargava; The University of Texas Medical Branch
Background
Biliary leak is a complication that can arise from traumatic or iatrogenic injury. In regards to iatrogenic injury, biliary leak can occur secondary to biliary ductal injury from procedures such as laparoscopic cholecystectomy, hepatic transplant, and hepatic lobe resection, and hepatic biopsies. Post-surgical bile leaks will typically manifest with clinical symptoms of right upper quadrant pain, nausea, vomiting, and fever within 1 week of the procedure. Further complications of biliary ductal injury resulting in significant morbidities such as peritonitis, cholangitis, and sepsis necessitate quick diagnostic and interventional planning by radiologists. We will review the etiology of iatrogenic bile leaks and highlight the role of hepatobiliary scintigraphy in diagnosis and management of bile leaks.

Educational Goals / Teaching Points
The objectives of this educational exhibit are to describe the etiology of bile leak as related to iatrogenic injury, review treatment options, and emphasize the utilization of hepatobiliary scintigraphy as an essential tool for diagnosis and determining subsequent management of small and large bile leaks.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Imaging Findings/Techniques: Laparoscopic cholecystectomy has higher incidence of biliary ductal injury in comparison to open cholecystectomy. Iatrogenic ductal injury in laparoscopic cholecystectomy can lead to bile leak from the accessory ducts of Luschka, cystic duct stump, or common bile duct. In liver transplant, the need for multiple biliary reconstructions increases the likelihood for bile leak. Liver biopsies may lead to intrahepatic bile duct injury. Hepatobiliary scintigraphy is an essential tool in diagnosing biliary leak, with overall sensitivity of 97% and specificity of 94%. The scan uses 99mTc-iminodiacetic acid chelate complex as a radiotracer and is able to detect biliary leak in lower concentrations than contrast-enhanced CT. Biliary leak is evident on the scan as extra-luminal excretion of the tracer outside the biliary tree and its accumulation in dependent parts of the peritoneal cavity. Small leaks can be managed conservatively, whereas patients with large leaks may need to be treated with percutaneous or endoscopic drainage and/or placement of biliary stents.

Conclusion
Bile leak is an uncommon iatrogenic complication that can occur following surgical procedures involving the liver and gallbladder. Sequela of biliary leakage such as peritonitis, cholangitis, and sepsis are associated with high morbidity. Prompt diagnosis and discernment of small from large leaks using hepatobiliary scintigraphy along with therapeutic radiological intervention is critical to avoid complications for the patient.