Bile duct disruption after laparoscopic cholecystectomy.

The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. We have reviewed the first 823 laparoscopic cholecystectomies performed at our institution and found 13 symptomatic biliary complications necessitating further therapy (prevalence 1.6%). This finding represents a decrease from the 2.7% prevalence found in our earlier series. The incidence of biliary complications will likely continue to vary depending on patient selection, operator experience, and new developments in laparoscopic technique. Bile duct injury and bile leaks are often difficult to diagnose but must be strongly considered in postoperative patients with abdominal pain, fever, jaundice, or continued bilious drainage from a surgical drain. Whereas computed tomography (CT) and sonography are sensitive in detecting perihepatic or free peritoneal fluid collections, they are nonspecific and definitive diagnosis of biliary tract injury requires hepatobiliary scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), or percutaneous aspiration. Disruption of the biliary tree has commonly been treated with reoperation or percutaneous drainage. More recently, endoscopic management has shown encouraging results for bile leaks and strictures in small series.

Bile duct disruption and biloma after laparoscopic cholecystectomy: imaging evaluation.

Disruption of the biliary tree after laparoscopic cholecystectomy has been reported in 0-7% of cases, and likely represents the most significant postoperative complication. Documenting the presence and extent of a bile leak is often difficult. We reviewed the first 264 laparoscopic cholecystectomies performed at our institution and found seven cases of bile extravasation and/or biloma formation (prevalence, 2.7%). All patients were first seen in the early postoperative period with abdominal pain and low-grade fever. Sonography was performed in five of seven, CT in five of seven, hepatobiliary scintigraphy with diisopropyliminodiacetic acid in five of seven, and ERCP in four of seven cases. While sonography and CT were initially helpful in determining the presence of abdominal fluid collections, they were unable to differentiate between postoperative seroma, lymphocele, hematoma, and bile leak. Hepatobiliary scintigraphy was useful in demonstrating continuity of these fluid collections with the biliary tree and guiding further therapy. Four cases were managed with endoscopic biliary decompression, with the use of sphincterotomy or nasobiliary stent placement, with good clinical result. The other three cases were treated surgically with T-tube or external drainage. All patients did well clinically, without evidence of bile reaccumulation. Our experience suggests that sonography and CT are useful in detecting postoperative fluid collections, but cannot differentiate bile from other fluids. Hepatobiliary scintigraphy is valuable as a noninvasive means of investigating possible bile leaks and in guiding further therapy.

Leukemic intestinal pneumatosis.

A benign form of pneumatosis intestinalis has been reported in children with leukemia but also occurs in adults as we report here. Radiologists must be familiar with this entity or a mistaken diagnosis of an abdominal catastrophe will be made, committing the patient to unneccessary emergency surgery.

Acute rupture of a cystic ovarian teratoma complicating premature labor.

A cystic ovarian teratoma (COT), previously undiagnosed either clinically or by ultrasonography, presented as acute intra-abdominal disease complicating premature labor. This report emphasizes the potentially catastrophic complications of COT and stresses that, despite the availability of ultrasonography, there is still a need for conventional radiography in abdominal catastrophes in pregnant women.

Recurrent appendicitis: reexamination of a controversial disease.

The existence of recurrent appendicitis as a true disease entity is still disputed. The controversy surrounding recurrent appendicitis is discussed. This disease is thought to represent repeated inflammation of a nonperforated appendix. Case material supporting this concept is presented. The barium enema can provide evidence of the diseased appendix.

Roentgen diagnosis of linear ulcers.

Linear peptic ulcerations are not uncommon lesions of the stomach and duodenum and can be demonstrated by upper gastrointestinal series. This is facilitated by the double contrast technique, but they may also be appreciated via compression methods. The criteria found helpful to establish the presence of a linear ulcer include: (a) contour deformity; (b) niche projection; (c) fuzzy line; and (d) folds radiating to a line (crater). Routine use of these criteria with the double-contrast method enabled the authors to diagnose 42 linear ulcers.