Biliary Leak Following Liver Transplantation Demonstrated by Symbia T6 SPECT•CT

Symbia T6 SPECT•CT imaging helps define the relationship of the site of biliary leak

Jerry Froelich, MD

Case study data provided by University of Minnesota, Minneapolis, Minn., USA

 |  Oct 26, 2012

History

A 64-year-old man who underwent a living donor liver transplantation 2 weeks earlier presented with bilious discharge through the peritoneal drain placed at the surgery site. In view of the suspicion of bile leak or biliary obstruction, hepatobiliary scintigraphy was performed. 

 

Fig. 1: Sequential planar images acquired every 5 minutes showed normal tracer uptake in the liver parenchyma during the initial phase after injection. The intrahepatic ducts and common bile duct were visualized 15 minutes after injection with the bowel visualized by 20 minutes. An abnormal focal area of tracer uptake in the left upper part of the liver (site of the recent liver transplantation) was visualized by 15 minutes and showed progressive increase with spread into adjacent areas. This reflected extravasation of bile at the liver transplant site with pooling into the subphrenic space. Delayed images acquired at 75 minutes post-injection showed pooling of bile, not only in the region of transplantation, but also in the peritoneal space between anterior wall of right lobe of liver and anterior abdominal wall.

Fig. 2: SPECT image clearly shows the collection of bile in the transplantation site and left subphrenic space and also in the right anterior sub diaphragmatic space.

 

Diagnosis
Study was acquired on a Symbia™ T6 SPECT•CT system. Following intravenous injection of 7 mCi of 99mTc mebrofenin, sequential images were acquired for 60 minutes with delayed static images at 75 minutes. At four hours post-injection, a SPECT•CT study was performed with integrated non-contrast diagnostic CT of abdomen and pelvis. The superb image quality of the Symbia SPECT•CT study helps clearly delineate the site of biliary leak and localizes it to the transplant anastomosis as well as helps delineate the regions of pooling of extravasated bile in the left subphrenic space and in the anterior and lateral right subdiaphragmatic space. Patient was immediately taken up for resurgery and reanastomosis of the transplant hepatic ducts.
 

Fig. 3: SPECT•CT fused images show extravasated bile at the left upper portion of the liver which corresponds to the region of the anastomosis of the transplanted donor liver with the recipient bile duct. CT demonstrates adjacent sutures as well as fluid collection in the subphrenic space which also shows tracer retention on SPECT and suggests pooling of extravasated bile. Contrast is seen in the hepatic ducts, common bile duct, as well as in the pancreatic duct, which may be related to previous endoscopic retro-grade cholangiopancreatography (ERCP).


Fig. 4: These CT and fused SPECT•CT images show the extravasated tracer at the subphrenic space and stasis of bile in the left intrahepatic duct.
 

Fig. 5: The volume-rendered fused SPECT•CT image shows pooling of tracer in the left subhepatic space at the region of the transplant anastomosis. There also is stasis of tracer in the left hepatic duct.

 

Comments
Symbia state-of-the-art diagnostic CT integrated with the latest SPECT technology helped define the relationship of the site of biliary leak to the trans-planted liver and biliary ducts as well as confirm the regions of pooling of extravasated bile to assist the surgeon for reanastomosis and drainage of leaked bile.