The Yield of Non-Invasive Testing in Post-Cholecystectomy Patients with Suspected Bile Duct Injury
John M. Iskander*1, Gregory a. Cote1, Riad R. Azar1, J Christopher Eagon2, Dayna S. Early1, Steven a. Edmundowicz1, Daniel Mullady1, Faris Murad1, Jerry Wallis3, Sreenivasa S. Jonnalagadda1
1Gastroenterology, Washington University, St Louis, MO; 2Surgery, Washington University, St. Louis, MO; 3Nuclear Medicine, Washington University, St. Louis, MO
Introduction:Cholecystectomy is associated with significant morbidity in patients who experience a bile duct injury. The incidence of bile duct injury (leak) with a laparoscopic technique is 0.5 to 3% as compared to open cholecystectomy rates of 0.1 to 0.5%. In this retrospective review, we determined the yield of non-invasive imaging in the diagnosis of bile leaks.Methods:A retrospective review of 137 post-cholecystectomy patients with clinical suspicion of bile duct injury was performed. Suspicion of injury was based on fever, pain, leukocytosis or elevated liver function tests. We included patients who had a cholecystectomy via an open or laparoscopic approach, post operative suspicion of bile duct injury with imaging (CT or HIDA) following cholecystectomy and/or ERCP between 2002 and 2009. Patient age, sex, duration to ERCP, radiologic method and findings, pre-ERCP liver function tests, operative indication, surgical method and the site of leak on those with positive ERCP were evaluated. The sensitivity and the positive predictive value (PPV) were calculated for CT scans, HIDA scans, and CT/HIDA scans combined.Results:137 patients were included in this study, of which 97 (70.8%) had a bile leak and 40 (29.2%) had no evidence of extravasation on ERCP. 131 patients (95.6%) had a CT or HIDA scan or both and 6 had no imaging. Seventy-five of the 137 (54.7%) had a CT scan, 87 (63.5%) had a HIDA scan and 31 (34.1%) had both imaging studies. Using ERCP as the gold standard, the sensitivity for CT scans was 79.1%(CI 69.4 - 88.8%), HIDA scans 85.4%(CI 69.8 - 93.0%), and CT/HIDA combined 81.5%(CI 73.0 - 89.9%). The false negative rates were 20.9% for CT, 14.6% for HIDA and 18.5% for combined CT/HIDA. The positive predictive value for CT scan was 93%, HIDA 94.6% and combined CT/HIDA 91.7%. Discussion:In the post-cholecystectomy setting, non-invasive imaging studies, while providing a strong positive predictive value in appropriately selected patients, carry a significant false negative rate. In patients with a strong clinical suspicion of bile leak, consideration for a more definitive diagnostic approach such as ERCP should be undertaken even if non-invasive studies are unremarkable.
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