Tc-99m-BrIDA hepatobiliary (HIDA) scan has a low sensitivity for detecting biliary complications after orthotopic liver transplantation in patients with hyperbilirubinemia

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

Comprehensive Imaging Review of Pleural Fistulas from Diagnosis to Management

Pleural fistula is an abnormal communication between the pleural cavity and an adjacent structure. The interplay of anatomic and physiologic factors including proximity to various intrathoracic structures, deep pleural recesses, and negative pleural pressures makes the pleura an easy victim of fistulization. Iatrogenic creation followed by necrotizing infections and malignancies are the most common causes. While the overall incidence and size of postsurgical pleural fistulas are decreasing with increased adoption of vascularized flaps for high-risk resections, the smaller fistulas that develop in the setting of post-radiation therapy changes, with necrotizing infections in immunosuppressed patients, and with use of newer antiangiogenic chemotherapies can be challenging to visualize directly. Imaging signs in clinical practice are often subtle and indirect. Multimodality imaging and biochemical pleural fluid analysis can offer important adjunctive information when a diagnosis is only suggested with the first imaging study. Certain pleural fistulas are inconsequential, some spontaneously close with or without diversion of flow or use of positive-pressure ventilation, while others carry a higher risk of complications or recurrence. Estimated fistula size, factors that impair healing, and the possibility of diversion are important considerations when deciding between endoscopic or surgical closure. The authors have tailored this article for a general imager or clinical practitioner and review 10 types of pleural fistulas, ranging from routine to rare, with regard to their etiology, pathophysiology, clinical cues, imaging features, nuances of pleural fluid analysis, and management options available today. ^©RSNA, 2022.

Hepatobiliary Scintigraphy to Evaluate Biliary Complications of Pediatric Liver Transplantation: An Account of an Experience

INTRODUCTION

 Hepatobiliary scintigraphy (HS) is a noninvasive imaging technique whose use in the follow-up of liver transplantation has not been duly documented. The main objective of this study is to describe the experience of using this technique to detect biliary complications in pediatric patients following liver transplantation.

MATERIALS AND METHODS

 A retrospective, observational, and descriptive study involving 86 pediatric patients who had undergone liver transplantation between 2013 and 2018. Of the 86, 31 had undergone at least one HS during their postoperative period.

RESULTS

 A total of 45 studies were performed on 31 patients (36% of the patients undergoing transplantation during that time period). Patient ages ranged from 5 to 204 months (mean = 50 months). A total of 22 transplants (71%) were from living donors and 9 (29%) were from cadaveric donors. Of the 45 studies, 22 were positive for biliary complications, and all of them had an impact on clinical decision-making. The remaining 23 studies were negative. Of these 23, 19 continued under medical treatment and the other four underwent an additional intervention with positive surgical outcomes in all cases. All scintigraphy studies revealed hepatocellular dysfunction and cholestasis.

CONCLUSION

 The HS is a useful, noninvasive, and diagnostic procedure for the early diagnosis of biliary complications that may impact the evolution of disease in liver transplant patients. It allows the treating physician to make a more informed decision regarding expectant management, surgical management, or a less invasive course of action for transplantation complications.

Hepatobiliary scintigraphy in the study of complications in adult patients after liver transplant. Description of the experience

OBJECTIVE

To show the experience of the use of hepatobiliary scintigraphy in patients with suspected complications after liver transplantation in a high complexity centre.

MATERIAL AND METHOD

Retrospective, observational and descriptive study. All consecutive adult patients with liver transplantation between January 2013 and February 2018 were included, with one or more hepatobiliary scintigraphy during the early or late postoperative period. A total of 58 studies were analyzed in 38 patients (22 men and 16 women). Mean age: 48 years. In 34/38: cadaverous donor (89%), and in 4 (11%): a living donor. Demographic data and relevant information regarding the transplant were obtained, and the result was related to the surgical findings to determine the correlation between them. The influence of the test on the final clinical decisions was evaluated.

RESULTS

Findings: 9 scans (14%) were normal, 36 studies were negative, and 21 were positive for biliary complications. Of the total of 58 studies, 50 (86%) had impact on the clinical behaviour of observation or intervention. All the patients with findings of biliary complications (21/21; 100%) had clinical repercussion since 18/21 patients were taken to invasive studies or treatments, and 3/21 patients continued in medical management for findings of non-surgical biliary complications. In 14/18 patients taken to studies or procedures, correlation was found with the scintigraphic study. In 24/36 (66%) of patients with negative scintigraphy, an impact on clinical behaviour was found.

CONCLUSION

Hepatobiliary scintigraphy is a simple, non-invasive, reliable, current and available form for the early study of biliary complications in patients with liver transplantation. Important hepatocellular dysfunction should be taken into account as a frequent cause of false negative studies.

Accuracy of Hepatobiliary Scintigraphy after Liver Transplantation and Liver Resection

Background and Aims. Biliary complications are the most frequent complications after common liver surgeries. In this study, accuracy of hepatobiliary scintigraphy (HBS) and impact of hyperbilirubinemia were evaluated. Methods. Between November 2007 and February 2016, 131 patients underwent hepatobiliary scintigraphy after having liver surgery. 39 patients with 42 scans after LTX (n = 13) or hepatic resection (n = 26) were evaluated in the study; 27 were male, with mean age 60 years. The subjects underwent hepatobiliary scintigraphy with Tc-99m labeled Mebrofenin. The results were compared to ERCP as gold standard performed within one month after HBS. We calculated sensitivity, specificity, PPV, and NPV. We compared LTX patients to patients with other liver surgeries. Furthermore the influence of hyperbilirubinemia on HBS scans was evaluated. Results. HBS always provided the correct diagnosis in cases of bile leak in the liver-resected group (14/14). Overall diagnostic accuracy was 76% (19/25) in this group and 54% (7/13) in the LTX group. False negative (FN) diagnoses occurred more often among LTX patients (p = 0.011). Hyperbilirubinemia (>5 mg/dL) significantly influenced the excretion function of the liver, prolonging HBS's time-activity-curve (p = 0.001). Conclusions. Hepatobiliary scintigraphy is a reliable tool to detect biliary complications, but reduced accuracy must be considered after LTX.

Biliary complications after liver transplantation: old problems and new challenges

Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.