Imaging of the complications of laparoscopic cholecystectomy

Multimodality Imaging of Cholecystectomy Complications

Cholecystectomy is one of the most common surgeries performed in the United States. Although complications are uncommon, the high incidence of this surgery means that a radiologist will likely encounter these complications in practice. Complications may arise in the immediate postoperative period or can be delayed for weeks, months, or years after surgery. Vague and nonspecific symptoms make clinical diagnosis challenging. As a result, multimodality imaging is important in postoperative evaluation. US and multidetector CT are the usual first-line imaging modalities. Hepatobiliary scintigraphy, SPECT/CT, and MRI with conventional or gadoxetate hepatobiliary contrast material are important and complementary modalities that are used for workup. The authors begin with a brief discussion of surgical technique and expected postoperative findings and then describe complications organized into four groups: (a) biliary complications, (b) stone-related complications, (c) iatrogenic complications, and (d) gallbladder complications. Biliary complications include bile leaks and bilomas, acute biliary obstruction, and biliary stricture. Stone-related complications include retained and recurrent stones and spillage of stones into the peritoneum. Iatrogenic complications include hemorrhage, vasculobiliary injury, arterial pseudoaneurysms, duodenal injury, and migration of clips. Gallbladder complications include recurrent cholecystitis after subtotal reconstituting cholecystectomy and unexpected gallbladder cancer. An invited commentary by Mullens and Ibrahim is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Achromobacter xylosoxidans Subdiaphragmatic Collection as a Result of a Dropped Stone During Laparoscopic Cholecystectomy

After a cholecystectomy, dropped stones can serve as a nidus for abscess formation. Intrabdominal abscesses tend to cause irritation and inflammation of the peritoneum and are thus rarely asymptomatic. This report discusses a 38-year-old female complaining of a recurrent right upper quadrant pain that led to multiple hospital admissions. Her surgical history was significant for cholecystectomy six years back complicated by a retroperitoneal abscess which was drained twice. A computed tomography (CT) scan was done, and she was diagnosed with a subdiaphragmatic collection as a result of a dropped stone.

Hepatobiliary Scintigraphy-Role in Preliminary Diagnosis and Management of Biliary Tract Injuries

PURPOSE

This study was conducted to identify the role of hepatobiliary scintigraphy (HBS) in the management of biliary tract injuries.

METHODS

We retrospectively studied 54 patients (28 male and 26 female patients) aged 3 to 78 years with evidence of bile leak on HBS performed between January 2015 and October 2017. Following intravenous injection of Tc-mebrofenin, dynamic images were acquired for 30 minutes followed by static images until 24 hours. SPECT/CT was performed in patients with suspicion of bile leak on the planar images. Patients were classified as those with free intraperitoneal or localized bile leak. Any abdominal drain output was documented, and its statistical significance was assessed using Mann-Whitney U test. Subsequent management was also documented.

RESULTS

Of the 54 patients, 28 demonstrated free intraperitoneal bile leak and 26 localized leak on HBS. Thirty-four patients (24 with free intraperitoneal leak and 10 with localized leak) had an abdominal drain. Drain output was significantly higher in patients with free intraperitoneal leak compared with patients with localized leak (370 vs 78 mL/d per patient, P < 0.01). All patients with free intraperitoneal bile leak underwent interventional procedures such as endoscopic retrograde cholangiopancreatography and stenting or Roux-en-Y hepaticojejunostomy later on. Patients with localized bile leak were managed conservatively and were free of symptoms at 1-year follow-up.

CONCLUSIONS

Our findings indicate that, in addition to detecting biliary leak, HBS may be used to identify patients with localized bile leak (48% of patients in our study) who do not require active intervention.

Early cross-sectional imaging following open and laparoscopic cholecystectomy: a primer for radiologists

Abstract

Performed on either an elective or urgent basis, cholecystectomy currently represents the most common abdominal operation due to the widespread use of laparoscopy and the progressively expanded indications. Compared to traditional open surgery, laparoscopic cholecystectomy minimised the duration of hospitalisation and perioperative mortality. Albeit generally considered safe, cholecystectomy may result in adverse outcomes with non-negligible morbidity. Furthermore, the incidence of worrisome haemorrhages and biliary complications has not been influenced by the technique shift. Due to the growing medico-legal concerns and the vast number of cholecystectomies, radiologists are increasingly requested to investigate recently operated patients. Aiming to increase familiarity with post-cholecystectomy cross-sectional imaging, this paper provides a brief overview of indications and surgical techniques and illustrates the expected early postoperative imaging findings. Afterwards, most iatrogenic complications following open, converted, laparoscopic and laparo-endoscopic rendezvous cholecystectomy are reviewed with examples, including infections, haematoma and active bleeding, residual choledocholithiasis, pancreatitis, biliary obstruction and leakage. Multidetector computed tomography (CT) represents the “workhorse” modality to rapidly investigate the postoperative abdomen in order to provide a reliable basis for an appropriate choice between conservative, interventional or surgical treatment. Emphasis is placed on the role of early magnetic resonance cholangiopancreatography (MRCP) and additional gadoxetic acid-enhanced MRCP to provide a non-invasive anatomic and functional assessment of the operated biliary tract.

Teaching Points

• Having minimised perioperative mortality and hospital stay, laparoscopy has now become the first-line approach to performing cholecystectomy, even in patients with acute cholecystitis.

• Laparoscopic, laparo-endoscopic rendezvous, converted and open cholecystectomy remain associated with non-negligible morbidity, including surgical site infections, haemorrhage, residual lithiasis, pancreatitis, biliary obstruction and leakage.

• Contrast-enhanced multidetector computed tomography (CT) is increasingly requested early after cholecystectomy and represents the “workhorse” modality that rapidly provides a comprehensive assessment of the operated biliary tract and abdomen.

• Magnetic resonance cholangiopancreatography (MRCP) is the best modality to provide anatomic visualisation of the operated biliary tract and is indicated when biliary complications are suspected.

• Additional gadoxetic acid (Gd-EOB-DTPA)-enhanced MRCP non-invasively provides functional biliary assessment, in order to confirm and visualise bile leakage.

Nosocomial rapidly growing mycobacterial infections following laparoscopic surgery: CT imaging findings

OBJECTIVE

To identify the distribution and frequency of computed tomography (CT) findings in patients with nosocomial rapidly growing mycobacterial (RGM) infection after laparoscopic surgery.

METHOD

A descriptive retrospective study in patients with RGM infection after laparoscopic surgery who underwent CT imaging prior to initiation of therapy. The images were analyzed by two radiologists in consensus, who evaluated the skin/subcutaneous tissues, the abdominal wall, and intraperitoneal region separately. The patterns of involvement were tabulated as: densification, collections, nodules (≥1.0 cm), small nodules (<1.0 cm), pseudocavitated nodules, and small pseudocavitated nodules.

RESULTS

Twenty-six patients met the established criteria. The subcutaneous findings were: densification (88.5%), small nodules (61.5%), small pseudocavitated nodules (23.1 %), nodules (38.5%), pseudocavitated nodules (15.4%), and collections (26.9%). The findings in the abdominal wall were: densification (61.5%), pseudocavitated nodules (3.8%), and collections (15.4%). The intraperitoneal findings were: densification (46.1%), small nodules (42.3%), nodules (15.4%), and collections (11.5%).

CONCLUSION

Subcutaneous CT findings in descending order of frequency were: densification, small nodules, nodules, small pseudocavitated nodules, pseudocavitated nodules, and collections. The musculo-fascial plane CT findings were: densification, collections, and pseudocavitated nodules. The intraperitoneal CT findings were: densification, small nodules, nodules, and collections.

KEY POINTS

• Rapidly growing mycobacterial infection may occur following laparoscopy. • Post-laparoscopy mycobacterial infection CT findings are densification, collection, and nodules. • Rapidly growing mycobacterial infection following laparoscopy may involve the peritoneal cavity. • Post-laparoscopy rapidly growing mycobacterial intraperitoneal infection is not associated with ascites or lymphadenopathy.

Peritoneal chronic inflammatory mass formation due to gallstones lost during laparoscopic cholecystectomy

We here describe the radiologic findings of peritoneal chronic abscess formation due to gallstones lost within the peritoneum during laparoscopic cholecystectomy (LC). A radiologic workup 7 months after LC revealed a soft-tissue mass with contrast enhancement, harboring internal necrosis and punctate calcium located in the Morrison's pouch. The mass exhibited restricted water molecule diffusion, absence of fat deposition, and increased F-18 fluorodeoxy-D-glucose uptake, thus mimicking a malignant tumor. The biopsy revealed an inflammatory granuloma. Another patient with similar findings was treated with percutaneous abscess drainage. Thus, radiologists should be aware of this disease condition and its imaging findings.

Imaging in laparoscopic cholecystectomy--what a radiologist needs to know

Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properly assess for the complications related to the procedure, an understanding of the normal biliary anatomy, its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefits and limitations of multiple imaging modalities in characterizing the complications of this procedure as each of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient. The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and its variants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as well as miscellaneous complications of laparoscopic cholecystectomy. We focus on the information that the radiologist needs to know about the radiographic manifestations of potential complications of this procedure.

Unusual consequences of 'incomplete' laparoscopic cholecystectomy

In recent years, laparoscopic cholecystectomy (LC) has become the standard surgical practice for the treatment of cholecystolithiasis. As a recognized technical difficulty, it may be associated with the mechanical injury of the gallbladder and/or spilling some of the gallstones into the abdominal cavity. The actual incidence of the latter complication is ~10%. The removal of lost stones from the abdominal cavity is rather elaborate if not infeasible. There is little information about the behaviour of retained gallstones in the free abdominal cavity. Publications report on subsequent intraperitoneal abscesses and fistulas or on the extreme localization of the impacted gallstones. This paper presents two cases with late complications of the abandoned gallstones or gallbladder. Case 1: A 56-year-old female patient underwent an LC 7 years ago. She was recently admitted with a chronic septic condition and suspected autoimmune disease. Preoperative examinations indicated hepatic abscess. Surgery showed gallstones impacted in the gallbladder bed. Case 2: A 59-year-old male patient underwent an LC a year before his admission. His operation was followed by the development of a septic condition and a subphrenic abscess was identified. During his reoperation, a remnant gallbladder containing bile stones was found and removed. Special attention should be paid to careful revision of residual stones during LC.

Inflammatory pseudotumor of the liver in association with spilled gallstones 3 years after laparoscopic cholecystectomy: report of a case

We report on a case of a female patient diagnosed with inflammatory pseudotumor of the liver in association with spilled gallstones 3 years after laparoscopic cholecystectomy for calculous acute cholecystitis. She was asymptomatic, but CT revealed an intrahepatic mass and two other extrahepatic masses between the liver and the diaphragm. Furthermore, diffusion-weighted MRI and PET suggested all three lesions could be malignant tumors. As the preoperative diagnosis was intrahepatic cholangiocellular carcinoma with peritoneal disseminations, we performed a posterior segmentectomy of the liver combined with partial resection of the diaphragm. Histological examination showed the intrahepatic tumor was an inflammatory granuloma with abscess formations. There were bilirubin stones between the liver and the diaphragm. Therefore, the tumor was diagnosed as inflammatory pseudotumor of the liver in association with spilled gallstones. In conclusion, the liver tumor emerged after laparoscopic cholecystectomy and may involve inflammatory pseudotumor of the liver in association with spilled gallstones.

Contrast-enhanced MR cholangiography (MRCP) with GD-EOB-DTPA in evaluating biliary complications after surgery

PURPOSE

We assessed the usefulness of contrast-enhanced magnetic resonance cholangiography (CE-MRC) with liver-specific contrast agent in evaluating the biliary tree after hepatic surgery.

MATERIALS AND METHODS

A total of 142 patients with suspected biliary complications after liver surgery underwent hepatobiliary MR before and after administration of gadolinium ethoxy benzylic diethylenetriamine pentaacetic acid (Gd-EOB-DTPA). Unenhanced MR cholangiopancreatography (MRCP) and postcontrast MRC were obtained in all patients. Blinded image evaluation and semiquantitative analysis comparing MRCP and CE-MRC were performed by two experienced radiologists.

RESULTS

In all cases, optimal postcontrast visualisation of the biliary tract was obtained. In 22 patients, a postsurgical biliary complication was confirmed. MRCP detected 64% of lesions, but in 36% of cases, an alteration was only suspected but not clearly defined. CE-MRC allowed definite diagnosis in 100% of cases.

CONCLUSIONS

Hepatobiliary-specific contrast agents allow for accurate and extensive study of biliary tract alterations, especially in assessing postsurgical complications.

Biliary complications postlaparoscopic cholecystectomy: mechanism, preventive measures, and approach to management: a review

Laparoscopic cholecystectomy has emerged as a gold standard therapeutic option for the management of symptomatic cholelithiasis. However, adaptation of LC is associated with increased risk of complications, particularly bile duct injury ranging from 0.3 to 0.6%. Occurrence of BDI results in difficult reconstruction, prolonged hospitalization, and high risk of long-term complications. Therefore, more emphasis is placed on preventing these complications. In addition to adequate training, several techniques have been proposed to prevent bile duct injury including use of 30° scope, adequate delineation of structures in Calot's triangle (critical view), avoidance of diathermy close to common hepatic duct, and intraoperative cholangiogram, and to maintain a low threshold to conversion to open approach when uncertain. Management of Bile duct injury depends on the nature of injury, time of detection, and the expertise available, and would range from simple subhepatic drainage to Roux-en-Y hepaticojejunostomy particularly performed at specialised centers. This article based on the literature review aims to review the biliary complications following laparoscopic cholecystectomy with reference to its mechanism , preventive measures to be taken, and the management approach.

Fever and diarrhea after laparoscopic bilioenteric anastomosis

Bile duct injuries are well-known complications of laparoscopic and open cholecystectomies. Here, we report anastomosis of the common bile duct to the transverse colon that occurred as a complication of laparoscopic cholecystectomy. To the best of our knowledge, a similar case has not been reported in the literature so far. As in our patient, persistent diarrhea (in addition to fever and icterus) can be a warning sign of complication after these procedures. Surgeons who do advanced laparoscopic techniques must be familiar with this complication.

Bile duct injuries in the era of laparoscopic cholecystectomies

Bile duct injuries incurred during laparoscopic cholecystectomies remain a major complication in an otherwise safe surgery. These injuries are potentially avoidable with proper techniques and correct interpretation of the anatomy. The scope of the injury can range from a simple cystic duct leak to the injury of the left and right hepatic duct confluence. The key to successful outcomes from these injuries is to know when a referral to a specialized tertiary center is necessary. Evaluation and treatment of bile duct injuries is complex and often requires the expertise of an advanced endoscopist, interventional radiologist, and hepatobiliary surgeons. Before any planned intervention or operative repair, detailed evaluation of the biliary system and its associated vasculature is required. Better outcomes are achieved when patients are referred to centers specialized in biliary injury evaluation, treatment, and performing pretreatment planning early.

Image-guided preparation of the Calot's triangle in laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the most common way to remove the gallbladder nowadays. Compared to open surgery, laparoscopy results in shorter hospital stays, reduced postoperative pain, and smaller incisions. Proper localization of the cystic artery is of great importance in laparoscopic cholecystectomy in order to ensure safe stapling and avoiding injury to the artery. In this study, we evaluate an image-guided method for artery detection. The performance of this method was evaluated in detecting arteries in 35 laparoscopic cholecystectomy patients. This method uses the artery's pulse to distinguish it from veins and biliary ducts. By subtracting the systolic and diastolic images, the change regions are detected and shown on a monitor. In 35 laparoscopic cholecystectomy procedures the method can correctly detect all arteries that are not too deep and can move superficial tissues with zero false-negative and 12% false-positive rates. Using the second mode of the method that needs more time for processing, the false-positive rate decreased to 4% with zero false-negative. The image-guided technique is a sensitive, noninvasive, and cost-effective method to detect arteries in laparoscopic cholecystectomy, even if it is covered with fat or other tissues. It is possible to install the program on any ordinary laparoscopy set and it displays the artery's region on the monitor.

[Imaging of the postoperative biliary tract]

For a long time, imaging of the biliary tract after surgical procedures was performed with invasive procedures such as endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Due to recent advances in diagnostic imaging, non-invasive techniques are now favored. While US remains the initial imaging modality, it is frequently followed by CT and/or MRCP. Image interpretation should always be performed in keeping with clinical and laboratory findings as well as the type of surgical procedure. The most appropriate imaging modality is selected based on these data. In patients with jaundice or biliary tract stenosis, MRCP, with use of an optimal technique and 3D acquisition, is the imaging modality of choice. In non-jaundiced patients with non-distended biliary tract and suspected bile leak, MRCP should be completed by the injection of a liver-specific contrast agent with biliary excretion to achieve non-invasive biliary tract opacification. In patients with malignancy, CT is preferred due to its high spatial resolution and ability to demonstrate small anastomotic tumor recurrences. CT should also be performed in patients with suspected hepatic artery or portal vein injury in addition to biliary tract injury or to detect distant complications.

Spectrum of biliary and nonbiliary complications after laparoscopic cholecystectomy: radiologic findings

OBJECTIVE

The purpose of this article is to illustrate the radiologic features of various biliary and nonbiliary complications after laparoscopic cholecystectomy.

CONCLUSION

Various complications should be considered in patients who do not make an uneventful postoperative recovery after laparoscopic cholecystectomy. Sonography is the easiest and most noninvasive method for screening for such complications. MR cholangiography is most effective in showing biliary complications and CT, for the evaluation of nonbiliary complications. Endoscopic retrograde cholangiography enables not only detailed biliary estimation but also biliary decompression.

Dropped Gallstones and Surgical Clips After Cholecystectomy

AIM

To describe the spectrum of computed tomographic (CT) findings in patients with dropped gallstones or dropped surgical clips after cholecystectomy.

MATERIALS AND METHODS

Seventeen patients diagnosed with dropped gallstones and 26 patients with dropped surgical clips on computed tomography after cholecystectomies were included in this study. The CT scans were evaluated for the number, location, size, and density of dropped gallstones or surgical clips and for the presence of an abscess. The cases were evaluated for the outcome on clinical and/or CT follow-up.

RESULTS

The location for dropped gallstones and dropped surgical clips after cholecystectomy was the Morrison's pouch in 17 and 12 patients, respectively. There were 9 abscesses in the study, all located in the Morrison's pouch. Duration from surgery to observation of abscess on computed tomography ranged from 5 days to more than 4.7 years. None of the patients with a dropped surgical clip from cholecystectomy developed an associated abscess.

CONCLUSIONS

Subhepatic location was the most common location for dropped gallstones with associated abscess and for dropped surgical clips. Dropped cholecystectomy clips are not associated with increased risk of abscess formation and therefore do not need screening follow-up or operative removal. Abscess formation around dropped gallstone is a more common complication and requires surgical treatment in most when associated with an abscess.

Normal and pathologic features of the postoperative biliary tract at 3D MR cholangiopancreatography and MR imaging

Magnetic resonance (MR) imaging with cholangiopancreatographic sequences plays a critical role in evaluating alterations in the biliary tract after surgical procedures such as cholecystectomy, liver transplantation, hepatic resection, and the creation of a biliary-enteric anastomosis. MR cholangiopancreatography, a rapid, noninvasive, and accurate imaging technique for the assessment of early and late complications of hepatobiliary surgery, usually enables the identification of normal and abnormal postoperative changes. In cases of complete obstruction of the bile duct, MR cholangiopancreatography allows analysis of the biliary tract above and below the level of the obstruction, a capability essential for treatment planning and one that is not provided by either endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. MR cholangiopancreatography is particularly useful for the evaluation of biliary-enteric anastomoses, for which an endoscopic approach is generally precluded. It also can help detect and localize bile duct strictures and stones and can help accurately classify bile duct injuries. It is useful for detecting bile leaks, although it generally does not directly depict the extravasation of bile. In addition to MR cholangiopancreatography, T1- and T2-weighted MR imaging may be performed to depict extrabiliary soft-tissue structures and abnormalities such as an abscess, tumor recurrence or metastasis, hematoma, or hemobilia. Mangafodipir trisodium-enhanced MR cholangiopancreatography, a recently developed technique that provides a combination of anatomic and functional information, is particularly helpful for documenting bile leaks because it allows a functional evaluation of biliary excretion and may directly depict bile leakage from injured ducts.

Imaging findings of biliary and nonbiliary complications following laparoscopic surgery

Laparoscopic techniques are evolving for a wide range of surgical procedures although they were initially confined to cholecystectomy and exploratory laparoscopy. Recently, surgical procedures performed with a laparoscope include splenectomy, adrenalectomy, gastrectomy, and myomectomy. In this article, we review the spectrum of complications and illustrate imaging features of biliary and nonbiliary complications after various laparoscopic surgeries. Biliary complications following laparoscopic cholecystectomy include bile ductal obstruction, bile leak with bile duct injury, dropped stones in the peritoneal cavity, retained CBD stone, and port-site metastasis. Nonbiliary complications are anastomotic leakage after partial gastrectomy, gangrenous cholecystitis after gastrectomy, hematoma at the anastomotic site following gastrectomy, gastric infarction after gastrectomy, port-site metastasis after gastrectomy, hematoma after splenectomy, renal infarction after adrenalectomy, and active bleeding after myomectomy of the uterus.