In Reply to: 597 08 -- Postoperative bile leak posted by Editor on May 15, 1997 at 16:59:24:
Nice example. It emphasizes that ERCP and PTC are often complementary
in the management of these difficult patients. An additional trick may
be used if the patient has had a biliary drain placed in what appears
to be a complete collecting system but biloma outputs continue, which
is "CT cholangiography". Just prior to CT scanning, dilute comtrast
is injected into the existing biliary drain. The CT will show if there
are any unopacified ductal systems which can then be sought out using
PTC.
One of the most frustrating and difficult aspects of managing these
patients is finding the decompressed isolated ductal system. We usually
initially try to get the biloma decompressed, and if PTC is unsuccessful
we next inject the biloma drain hoping to reflux into the isolated ducts.
This works about 1/2 the time. When this fails, options are very
limited. We have even tried iv cholangiography based on our abdominal
imaging groups success with this agent in another type of CT
cholangiography, but it did not work. Anyone have any other ideas?
The saddest aspect of this case is that these injuries continue to occur
at an alarming rate. We are a multistate referral center for this
type of thing and see 3-4 new cases each month. It is a travesty
that the insurance companies reap the benefits of lap chole while
an unconscienably high percentage of patients suffer the consequences
of becoming "biliary cripples", often at a very young age.