CASE REPORT Annals of Nuclear Medicine Vol. 7, No. 4, 265-267, 1993 Bile leakage after laparoscopic cholecystectomy demonstrated with 99m-Tc-PMT hepatobiliary scintigraphy Motoo OSHIMA and Hiroshi YASUKOCHI Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan A 41-year-old woman underwent laparoscopic cholecystectomy for the treatment of gall-stone and adenomyomatosis. One month after laparoscopic cholecystectomy, hepatobiliary scintigraphy was performed with 99mTc-Sn-N-pyridoxyl-5-methyltryptophan (PMT) to evaluate the presence of a bile leak and/or other complication. A biliary extravasation was noted in the left upper quadrant within 60 minutes. At five hours post injection, a progressive accumulation of 99~Tc-PMT was noted in the lesser sac, the right and left paracolic gutter and in the pouch of Douglas. A diagnosis of biliary leakage was made. The patient under-went exploratory laparotomy to repair the leak from the cystic duct stump. Key words : bile leakage, hepatobiliary scintigraphy, 99mTc-PMT, Iaparoscopic chole-cystectomy, gallstone INTRODUCTION LAPAROSCOPIC cholecystectomy is a new method used in the treatment of gallstone disease. Its use is certain to become widespread.1-4 The merit of this procedure is that it results in less surgical trauma than con-ventional cholecystectomy. However, Iaparoscopic cholecystectomy also requires special skills and trainings. This new technique is not without compli-cations.5 Complication following this procedure can occur in the bile duct and most comnronly leads to bile duct obstruction or bile leakage.6 Hepatobiliary scintigraphy is a noninvasive method for examining the bile ducts and looking for bile leakage.6-9 99mTc-Sn-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) has more rapid blood clearance and hepato-biliary transit than any other hepatobiliary agent.10 Less 99mTc-PMT than 99mTC-DEIDA is less excreted in the urine, and 99mTc-PMT is superior in that biliary excretion of the radioactivity is less likely to be suppressed in hyperbilirubinemia.10 In this study, we report a case of bile leakage using hepatobiliary scintigraphy with 99mTc-PMT in a patient who under-went laparoscopic cholecystectomy for the treatment of gallstones and adenomyomatosis. CASE REPORT CASE REPORT A 41-year-old woman underwent laparoscopic cholecystectomy for gallstones and adenomyoma-tosis. On the fourth postoperative day, the patient was jaundiced. She also complained of distension of her abdomen. One month after laparoscopic chole-cystectomy, the patient was given 185 MBq of 99mTc-PMT to evaluate the presence of a bile leak and/or other complication. A biliary extravasation was noted in the left upper quadrant within 60 minutes after the injection of 99~Tc-PMT (Fig. 1). The accumulation in the left upper quadrant was considered to be a bile leakage into the lesser sac. At five hours post injection, extravasation was noted in the lesser sac (Fig. 2A), the right and left paracolic gutter and in the pouch of Douglas (Fig. 2B). A diagnosis of biliary leakage was made and 300 ml of bile was drained from the right paracolic gutter. Neither operative cholangiography nor CT scan was performed. The patient underwent exploratory laparotomy during which a disruption at the cystic stump next to the surgical clip was found and subsequently repaired. DISCUSSION Laparoscopic cholecystectomy is associated with less postoperative pain, a shorter hospital stay, and a more rapid recovery and return to normal activity than open cholecystectomy. However, this new procedure requires special skills and training because it is not without complications.5 Ponsky5 pointed out that complications of laparoscopic cholecystec-tomy were such as bile duct injury, hemorrhage due to disruption of the cystic or hepatic ductic artery, and bile duct leaks from the gallbladder bed and cystic duct stump. Larson et al.4 reported that complications of laparoscopic cholecystectomy to-taled 2.1% (41/1983). There were seven patients who developed bleeding at the gallbladder site. Also they reported that there were seven cases of a bile leak arising from the cystic duct stump or gallbladder bed, as in our patient. Several investigators have recommended routine operative cholangiography to define the common duct anatomy and thereby prevent bile duct injury. ll However, this method is rather invasive. There are many procedures such as cholescintigraphy, ultra-sonography, and computerized tomography used in the evaluation of biliary tract disorders.12 Among them, hepatobiliary scintigraphy has proven a valu-able procedure as it provides a sensitive noninvasive assessment of bile leakage, ductal obstruction and complications.6-9 Weissmann et al.13 reported that 99mTc-IDA imaging is a simple, noninvasive way to detect the presence of a bile leak following chole-cystectomy. Pasmans et al.6 reported the role of 99mTc-HIDA cholescintigraphy in diagnosing bile leakage after laparoscopic cholecystectomy. Results of seven out of 51 cholescintigrams were abnormal. They also reported that, in four patients without clinical symptoms, there was a minimal accumu-lation of activity in the right paracolic gutter.6 In our patient, following the injection of 99mTc-PMT, increased activity was seen in the lesser sac, in the right and left paracolic gutter, and in the pouch of Douglas (Figs. l, 2). The diagnosis of bile leakage was easily made. Thus, the findings on the hepatobiliary scintigrams corresponded with her clinical symptoms. In conclusion, hepatobiliary scintigraphy with 99mTc-PMT may be a highly noninvasive. sensitive procedure for the early detection of bile leakage after laparoscopic cholecystectomy. REFERENCES 1 . Reddick EJ, Olsen DO : Laparoscopic laser chole-cystectomy : a comparison with mini-lap chole-cystomy. Surg Endosc 3 : 131-133, 1989 2. DuBois F, Icard P, Berthelot G, et al: Coelioscopic cholecystectomy : preliminary report of 36 cases. Ann Surg 211 : 60-62, 1990 3. Voyles CR, Petro AB, Meena AI, et al: A practical approach to laparoscopic cholecystectomy. Am J Surg 161 : 365-370, 1991 4. Larson GM. Vitale GC, Casey J, et al : Multipractice analysis of laparoscopic cholecystectomy in 1 983 patients. Am J Surg 163 : 221-226, 1992 5. Ponsky JL: Complications of laparoscopic cholecys-tectomy. Am J Surg 161 : 393-395, 1991 6. Pasmans HL, Go PM, Gouma DJ, et al : Scintigraphic diagnosis of bile leakage after laparoscopic chole-cystectomy : a prospective study. Clin Nucl Med 17: 697-700, 1992 7. Edell SL, Milunsky C, Garren L : Cholescintigraphic diagnosis of cholecystoco]ic fistula. Clin Nucl Med 6: 303-304, 1981 8. Garide VJ, Gibson DW: Noninvasive evaluation of bile leakage. Surg Gynecol Obstet 1 54: 517-520. 1982 9. Suehiro M, Ishimura J, Fukuchi M : Detection of bile leakage into the thoracic cavity by hepatobiliary scintigraphy. Ann Nucl Med 5 : 167-169, 1991 10. Kato-Azuma M: 99~Tc-Sn-N-pyridoxy]aminates: A new series of hepatobiliary imaging agents. J Nucl Med 23: 517-524, 1982 11. Berci G, Sackier JM. Paz-Parlow M : Routine or selected intraoperative cho]angiography during lap-aroscopic cholecystectomy ? Am J Surg 1 6 : 355-360, 1991 12. Weissmann HS, Frank M, Rosenblatt R : Chole-scintigraphy, ultrasonography, and computerized tomography in the evaluation of biliary tract dis-orders. Semin Nucl Med 9: 22-35, 1979 13. Weissmann HS, Gliedman ML, Wilk PJ, et al: Evaluation of the postoperative patient with 99~Tc-IDA cholescintigraphy. Semin Nucl Med 12: 27-52. 1982