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1 Department of Radiology, The Ohio State University Medical Center, S-211
Rhodes Hall, 450 W. 10th Ave., Columbus, OH 43210.
2 Department of Digestive Diseases, The Ohio State University Medical Center,
Columbus, OH 43210.
3 Department of General Surgery, The Ohio State University Medical Center,
Columbus, OH 43210.
Received December 3, 2001;
accepted after revision February 11, 2002.
Presented at the annual meeting of the American Roentgen Ray Society,
Seattle, April-May 2001.
Abstract
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SUBJECTS AND METHODS. Our study group included 11 patients with suspected bile duct leaks after cholecystectomy. Axial single-shot fast spin-echo and gradient-echo images were acquired in all patients before and 1-2 hr after IV administration of mangafodipir trisodium. The contrast-enhanced MR cholangiograms were evaluated for image quality, degree of ductal or small bowel opacification, and the presence and location of bile duct leaks, strictures, and stones. MR cholangiograms were correlated with conventional contrast-enhanced cholangiograms obtained in all patients, including endoscopic retrograde cholangiography (n = 10) and percutaneous transhepatic cholangiography (n = 1).
RESULTS. Excretion of mangafodipir trisodium was noted in the intrahepatic and extrahepatic bile ducts in all patients from 1 to 2 hr after IV administration. Bile ducts and fluid collections that contained excreted mangafodipir trisodium showed increased signal intensity on gradient-echo sequences and decreased signal intensity on single-shot fast spin-echo sequences. Conventional contrast-enhanced cholangiography showed the presence of bile duct leaks in six patients and the absence of bile duct leaks in five patients, with false-negative findings in one patient and false-positive findings in one patient for bile duct leak (sensitivity, 86%; specificity, 83%).
CONCLUSION. Contrast-enhanced MR cholangiography with IV mangafodipir trisodium can successfully detect the presence and location of bile duct leaks in patients suspected of having such leaks after undergoing cholecystectomy. More research is necessary before acceptance of this examination as routine in the workup of these patients.
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The clinical presentation of bile duct leaks is nonspecific and usually mimics other postoperative complications, such as bowel obstruction and abscess. Patients usually present 3-12 days (mean, 4.4 days) after laparoscopic cholecystectomy with abdominal pain that is out of proportion to routine postoperative pain [12, 13]. Serologic findings may include elevated liver function and elevated bilirubin and leukocytosis values. Elevated results of liver function tests more than 72 hr after cholecystectomy should prompt a search for a bile duct complication [11]. Patients with existing peritoneal drains may have bile exiting the drains.
Researchers have shown that 44% of patients with bile duct leaks may develop a serious postoperative complication, including peritonitis, sepsis, abscess, pulmonary infiltrates, and death [14]. A 30-day mortality rate of 2.6% and an in-hospital mortality rate of 7.8% have been described [4]. Sepsis leading to multisystem organ failure is the most common cause of death [15, 16]. Therefore, it is important to suspect bile duct leaks in any patient having an abnormal postoperative course so that early diagnosis and treatment may prevent the morbidity and mortality associated with this complication.
Most patients with bile duct leaks are diagnosed between 4 and 13 days (mean, 4.2 days) after the onset of symptoms [17]. This delay may be related to the multitude of tests usually performed to arrive at the final diagnosis. Most patients undergo a combination of noninvasive imaging tests (e.g., sonography, CT, and hepatobiliary scintigraphy) and invasive imaging tests (e.g., percutaneous aspiration, endoscopic retrograde cholangiography, and percutaneous cholangiography) before the diagnosis of bile duct leak is made.
Contrast-enhanced MR cholangiography performed after the administration of IV mangafodipir trisodium (Teslascan; Amersham Health, Princeton, NJ) to detect and localize bile duct leaks in patients who have undergone cholecystectomy was first described by Vitellas et al. [18], who used fat-suppressed gradient echo-imaging. In that report, a patient with a bile duct leak arising from the base of the right hepatic duct showed free extravasation of mangafodipir trisodium on fat-suppressed gradient-echo imaging performed 1 hr after it was administered IV. Vitellas et al. suggested that contrast-enhanced MR cholangiography, which provides the cross-sectional information of CT, the functional information of hepatobiliary scintigraphy, and the anatomic information of conventional contrast-enhanced cholangiography, may be the only diagnostic examination required before corrective therapy in patients suspected of having a bile duct leak.
The purpose of our study was to determine whether contrast-enhanced MR cholangiography after IV administration of mangafodipir trisodium can accurately detect the presence and location of bile duct leaks in patients who have undergone cholecystectomy. If found to be accurate, this examination would potentially result in earlier diagnosis and treatment because it would obviate the conventional imaging tests and percutaneous procedures routinely used in the workup of these patients, which would also reduce costs.
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The 11 patients in our study group included three men and eight women; their ages ranged from 23 to 69 years (mean age, 44 years). Nine patients had undergone laparoscopic cholecystectomy, and two patients had undergone open cholecystectomy. Patients developed signs and symptoms 2-21 days (average, 8 days) after surgery. Clinical history before imaging included abdominal pain, fever, nausea, vomiting, or abnormal findings on liver function tests in eight patients and bile exiting a peritoneal drain, with or without abdominal symptoms, in three patients. All patients with elevated values on liver function tests also showed signs or symptoms compatible with bile duct injury. Serum liver enzyme and bilirubin values were obtained in 10 patients within 24 hr of the MR examination: elevation of liver enzymes was noted in 80% of patients and elevated bilirubin was found in 60% of patients. Contrast-enhanced MR cholangiography was performed before contrast-enhanced cholangiography in six patients and after conventional contrast-enhanced cholangiography in five patients. The two examinations were performed within 2 days of each other (range, 0-6 days) in most patients. All patients signed a consent form approved by our institutional review board before undergoing MR cholangiography.
All MR cholangiography was performed on a 1.5-T unit (Signa; General Electric Medical Systems, Milwaukee, WI) with a torso phased array coil. An axial single-shot fast spin-echo sequence was performed before contrast agent administration in all patients (TR/TE, infinite/95; echo train length, 128; flip angle, 90°; matrix, 256 x 128; slice thickness, 5 mm; interslice gap, 2 mm; fat saturation; excitations, 0.5). A breathing-dependent axial gradient-echo sequence was performed before contrast agent administration in the nine patients who were able to provide an adequate breath-hold of approximately 30 sec (100-150/4.2; flip angle, 80°; matrix, 256 x 128-192; field of view, 30-40 cm; slice thickness, 5 mm; interslice gap, 2 mm; fat saturation; excitations, 1). In the two patients who were unable to cooperate with the breathing-dependent gradient-echo imaging sequence, a breathing-independent gradient-echo imaging sequence was used (8.3/1.6; flip angle, 20°; matrix, 256 x 192; field of view, 30 cm; slice thickness, 5 mm; interslice gap, 2 mm; excitations, 1). Imaging was repeated in all patients using the same single-shot fast spin-echo and gradient-echo imaging parameters 1-2 hr after the IV administration of 10 mL mangafodipir trisodium (0.05 mmol/mL) over 3-5 min by hand injection.
The contrast-enhanced MR cholangiograms were evaluated for image quality (excellent, good, fair, poor); degree of ductal opacification (extrahepatic, central, peripheral); small-bowel opacification; and the presence and location of bile duct leaks, strictures, and stones. Evaluations were performed by one radiologist who was unaware of the patients' clinical history, serology findings, and results of conventional contrast-enhanced cholangiography. A bile duct leak was defined as contrast agent extravasation adjacent to a bile duct, contrast agent opacification of a peritoneal drain, or incomplete opacification of the extrahepatic bile duct without biliary obstruction in a patient with bile exiting a peritoneal drain. MR cholangiograms were correlated with conventional contrast-enhanced cholangiograms in all 11 patients (endoscopic cholangiography in 10 patients and percutaneous transhepatic cholangiography in one patient).
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Bile duct leaks, including free peritoneal extravasation (n = 3) and contained leaks with direct communication to existing drains (n = 3), were identified on contrast-enhanced MR cholangiography in six patients. MR cholangiography correlated with conventional contrast-enhanced cholangiography in five of the six patients (Figs. 1A,1B,1C,2A,2B,3A,3B,4A,4B,4C,5A,5B). In these five patients, both MR cholangiography and conventional contrast-enchanced cholangiography successfully depicted the origin of the leak as arising from the cystic duct (n = 2), the common hepatic duct (n = 2), or the right hepatic duct (n = 1). One of the six patients whose bile duct leaks were revealed on MR cholangiography had normal findings on endoscopic retrograde cholangiography. In this patient, MR cholangiography showed contrast agent opacification of a peritoneal catheter without free extravasation, a finding that is compatible with a direct communication (fistula) between the cystic duct and the peritoneal drain (Fig. 6A,6B). Thus, because we were comparing MR cholangiography to the gold standard of contrast-enhanced cholangiography, this patient was categorized as having false-positive findings on contrast-enhanced MR cholangiography.
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Contrast-enhanced MR cholangiography showed no bile duct leak in five patients. Conventional contrast-enhanced cholangiography was performed in all five patients, and correlation between MR cholangiography and conventional contrast-enhanced cholangiography occurred in four of these five patients (Fig. 7). A cystic duct leak was seen on endoscopic retrograde cholangiography in one of the five patients. After a common bile duct stent was placed across the leak, the patient's abdominal pain lessened and the amount of bile draining from an existing peritoneal drain decreased from 12 mL/hr to less than 1 mL/hr. Even though this patient showed clinical evidence of closure of the cystic duct leak, the result of this MR examination was considered false-negative for bile duct leak because we were comparing MR cholangiography to the gold standard of contrast-enhanced cholangiography. One patient showed both a common hepatic duct stricture and left hepatic duct calculus on both MR cholangiography and percutaneous cholangiography.
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Hepatobiliary scintigraphy was performed in three patients and correlated with MR cholangiography and conventional contrast-enhanced cholangiography in two of the three patients. In one of these three patients, hepatobiliary scintigraphy was interpreted as showing a leak near the gallbladder fossa; neither MR cholangiography nor endoscopic retrograde cholangiography showed a leak. Retrospective review of the cholangiograms and scintigraphic images showed that a prominent cystic duct remnant was misinterpreted as a biloma on hepatobiliary scintigraphy. One of the other two patients who underwent hepatobiliary scintigraphy showed a bile duct leak; findings were normal in the other patient. These findings agreed with the results of both MR cholangiography and conventional contrast-enhanced cholangiography. Thus, hepatobiliary scintigraphy showed one false-positive finding and no false-negative finding for the presence of bile duct leaks. MR cholangiography in all 11 patients resulted in one false-negative finding and one false-positive finding for the presence of bile duct leaks (sensitivity, 86%; specificity, 83%).
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Hepatobiliary scintigraphy and conventional contrast-enhanced cholangiography are usually performed in patients with suspected bile duct leaks because these tests are highly sensitive and specific. Several disadvantages exist: In 81% of patients, hepatobiliary scintigraphy does not allow documentation of the location of the leak, thus limiting practicality in deciding whether to use an endoscopic, percutaneous, or surgical treatment approach [5]. Other disadvantages of hepatobiliary scintigraphy are that it does not image extrabiliary structures, and thus cannot provide information about them; it has decreased sensitivity in patients with hepatic dysfunction; and the operator cannot concomitantly perform a therapeutic procedure if a leak is present. Finally, large bile duct defects, transections, or fistulas that cause preferential flow of bile in a path of least resistance may not show activity in the duodenum on hepatobiliary scintigraphy and thus may be misinterpreted as complete bile duct obstruction.
Disadvantages of endoscopic retrograde cholangiography include invasiveness, cost, inability to detect extrabiliary abnormalities, false-negative interpretations caused by non-visualization of ducts that are not connected to the central biliary tree and that may be the source of leaks (e.g., clipped anomalous ducts, Luschka's ducts), and nonvisualization of ducts upstream from an obstructing lesion (stricture, stone). It is common for a patient to have a leak at clinical examination (bile exiting a peritoneal drain or wound) and yet have negative findings on contrast-enhanced cholangiography. In fact, it has been shown that 27% of bile leaks may not be visualized on initial endoscopic cholangiography, and 50% of leaks arising from aberrant bile ducts may be missed on endoscopic retrograde cholangiography [7, 21]. These outcomes may be caused by a disconnected, nonfunctioning duct (ligation, transection, stricture, stone, congenital anomaly); low-pressure injection on endoscopic retrograde cholangiography; or close proximity of the percutaneous drain to the leak site. In the latter circumstance, contrast material exiting at the leak site may enter directly into a radiopaque drain without filling a biloma or extravasating into the peritoneum; therefore, it will be missed during conventional contrast-enhanced cholangiography.
MR cholangiography is a noninvasive cholangiographic technique that uses heavily T2-weighted images to illustrate biliary anatomy without the use of contrast agents. The sensitivity and specificity of MR cholangiography for abnormalities of the intrahepatic and extrahepatic bile ducts are similar to those of endoscopic retrograde cholangiography [22,23,24,25,26]. Therefore, MR cholangiography has become the imaging modality of choice at many institutions in the workup of patients with suspected bile duct abnormalities. In the patient who has undergone cholecystectomy and has suspected bile duct complications, MR cholangiography can successfully determine the presence and location of bile duct strictures and stones. In addition, T1-and T2-weighted sequences that display the extrabiliary soft-tissue structures can be used to detect abnormalities such as abscess and bowel obstruction. Thus, MR imaging of the abdomen with MR cholangiography combines the cross-sectional abilities of CT and sonography with the cholangiographic imaging capabilities of conventional contrast-enhanced cholangiography. Kalayci et al. [27] showed the utility of conventional MR cholangiography in the diagnosis of bile duct leaks. That study reported two patients who presented with bile exiting peritoneal drainage catheters after cholecystectomy but had normal findings on endoscopic cholangiography. In each patient, conventional MR cholangiography suggested that the leak originated from an aberrant right hepatic ductal branch arising near the cystic duct-common duct junction [27]. The aberrant ducts were severed from the central ducts and, therefore, were not opacified during retrograde contrast agent injection. Kalayci et al. concluded that MR cholangiography should be considered when a patient continues to have bile leakage from a percutaneous drain but has negative findings for a bile duct leak on endoscopic cholangiography. A disconnected biliary segment is likely to be found in such patients.
Conventional MR cholangiography, like other cross-sectional imaging studies (CT or sonography), can show only indirect evidence of bile duct leaks, such as peritoneal fluid or loculated fluid collections. Because conventional MR cholangiography displays the ducts in a static, physiologic state without the administration of biliary contrast agents, it cannot identify direct evidence of extravasation of bile at the site of a leak.
Contrast-enhanced MR cholangiography with IV mangafodipir trisodium is a recently developed technique currently under investigation. It can provide functional information similar to that obtained on hepatic scintigraphy, anatomic information similar to what is found on conventional contrast-enhanced cholangiography, and cross-sectional information similar to that of CT and sonography. Mangafodipir trisodium is an MR hepatobiliary contrast agent marketed under the brand name of Teslascan (Amersham Health) that consists of manganese bound to dipyridoxyl diphosphate, a vitamin B6 analog. After the IV administration of mangafodipir trisodium, manganese from the N,N'-dipyridoxyl-ethylenediamine-N,N'-diacetate 5,5'-bis phosphate ligand is bound to circulating proteins, accumulates within the liver, and is excreted primarily via bile [28]. Studies have shown that liver enhancement begins at 1 min after injection, with steady-state enhancement at 5-10 min [29, 30]. Peak enhancement of the liver occurs at 5-10 min, and plateaus over several hours [29, 30]. Because manganese is a paramagnetic metal ion, it shortens the longitudinal relaxation time (T1), leading to increase in signal of the bile on T1-weighted images (Figs. 1A,1B,1C,2A,2B,3A,3B,4A,4B,4C,5A,5B,6A,6B,7) [28, 31]. Mitchell and Alam [32] noted contrast enhancement of the central and extrahepatic bile ducts on three-dimensional fat-suppressed gradient-echo images 20 min after the administration of mangafodipir trisodium. Lee et al. [33] showed that normal, unobstructed biliary systems show biliary enhancement on three-dimensional gradient-echo images within 10 min after IV administration of mangafodipir trisodium [33].
The use of contrast-enhanced MR cholangiography after the administration of IV mangafodipir trisodium in the detection and localization of bile duct leaks in patients who had undergone cholecystectomy was first described by Vitellas et al. [18], using fat-suppressed gradient-echo imaging (Fig. 2A,2B). Fat-suppressed gradient-echo images obtained 1 hr after the administration of IV mangafodipir trisodium in a patient with a bile duct leak arising from the base of the right hepatic duct showed free extravasation of mangafodipir trisodium. This case report by Vitellas et al. indicates that contrast-enhanced MR cholangiography with mangafodipir trisodium provides information about biliary dynamics similar to that obtained on hepatobiliary scintigraphy. In addition, because this technique combines the cross-sectional information of CT and sonography with the functional information of hepatobiliary scintigraphy, it has the potential advantage of eliminating unnecessary imaging tests (CT, sonography) and invasive procedures (percutaneous aspiration, contrast-enhanced cholangiography) in the workup of patients with suspected bile duct leaks. Therefore, this technique could potentially be the first and only test performed to detect the presence of bile duct leaks—resulting in a decrease in cost and a potential decrease in the morbidity and mortality associated with both delay in diagnosis and performance of unnecessary invasive procedures.
Gradient-echo imaging has been shown to have greater sensitivity for mangafodipir trisodium enhancement than does spin-echo imaging [34]. The in-phase, fat-saturated, mangafodipir trisodium-enhanced gradient-echo parameters that we used have been shown to give the highest contrast-to-noise ratio of the liver and pancreas [34]. This sequence produced excellent image quality in 89% (n = 8) and good image quality in 11% (n = 1) of our patients. In the two patients who could not sustain a breath-hold long enough for the breathing-dependent gradient-echo technique, a breathing-independent sequence was successfully performed, producing good image quality in both of these patients. We did not use a three-dimensional gradient-echo sequence as described by other authors [32, 33, 35]. Volumetric mangafodipir trisodium-enhanced cholangiography using a three-dimensional gradient-echo sequence in the coronal plane produces excellent image quality for defining biliary anatomy [32, 33]. More work is necessary to determine which gradient-echo sequence is most reliable and reproducible and will produce the highest contrast-to-noise ratio between bile and background.
Our study showed that contrast-enhanced MR cholangiography was 86% sensitive and 83% specific for the detection of bile duct leaks. One false-positive finding on contrast-enhanced MR cholangiography occurred in a patient with a fistula from the cystic duct to a peritoneal drain, which was detected on MR cholangiography but not on endoscopic cholangiography (Fig. 6A,6B). However, we believe the MR cholangiography findings are accurate and that failure to identify the biliary fistula on endoscopic cholangiography may have been the result of the failure of the radiologist to visualize the contrast because of the small size of the fistula, suboptimal contrast-material infusion pressure, or inability to detect the contrast material in an opaque catheter. Therefore, contrast-enhanced MR cholangiography may have an advantage over endoscopic cholangiography and may assist in the diagnosis of suspected bile duct leaks in patients with negative findings on standard contrast-enhanced cholangiography. Because this MR technique is an antegrade study, it has the potential to detect leaks that do not communicate with the central biliary tree and thus are not detected on retrograde endoscopic cholangiography (e.g., clipped anomalous ducts, Luschka's ducts, strictures, stones).
If additional studies show that contrast-enhanced MR cholangiography has an advantage over conventional contrast-enhanced cholangiography, this technique may be used in place of conventional cross-sectional imaging studies, hepatobiliary scintigraphy, and contrast-enhanced cholangiography to arrive at a diagnosis. Thus, if additional studies show favorable results, this examination can potentially be the first and only study performed for the diagnosis of bile duct leaks. This simplification in testing would provide earlier diagnosis and treatment, with potential improvement in morbidity and mortality. Patients would be triaged directly to an appropriate treatment regimen on the basis of the results of this examination. In addition, using contrast-enhanced MR cholangiography as the initial and only diagnostic test in patients with suspected bile duct leaks could potentially result in substantial cost savings. In our study group of 11 patients, a total of 31 procedures were performed to arrive at a diagnosis: three sonographic examinations, nine CTs, three hepatobiliary scintigraphic examinations, two MR cholangiographies, five percutaneous aspirations, eight endoscopic cholangiographies, and one percutaneous cholangiographic examination—at an average cost of $3,452.89 per patient. At our institution, contrast-enhanced MR cholangiography costs $1,024.91 per patient: if this examination had been performed as the only diagnostic test in our study group, the cost savings would have been $2,427.98 per patient.
In our study, one false-negative finding on contrast-enhanced MR cholangiography occurred in a patient with a cystic duct leak diagnosed on endoscopic retrograde cholangiography. The MR cholangiography was performed less than 24 hr after endoscopic stent placement. At that time, the patient showed clinical evidence of closure of the cystic duct leak (improvement in symptoms, significant decrease in bile exiting a peritoneal drain). Thus, we believe the MR cholangiography results in this patient were accurate.
All leaks occurring in our study population were identified 1-2 hr after contrast agent administration. Unenhanced images offered no advantage when compared with contrast-enhanced images. Therefore, we recommend that contrast-enhanced MR cholangiography should be performed at least 1 hr after the administration of IV mangafodipir trisodium, and we think that unenhanced images are not required. This technique would allow a rapid diagnosis with minimal stress on busy MR imaging departments.
It may be argued that conventional T2-weighted MR cholangiography should be performed in patients suspected of having bile leaks after cholecystectomy because bile duct stones are present in 27-31% of patients with bile duct leaks [5, 11], and these stones may induce or maintain a leak. On the other hand, Lee et al. [33] noted that the three-dimensional gradient-echo sequence performed after the administration of mangafodipir trisodium provided better resolution than conventional T2-weighted MR cholangiography. In addition, mangafodipir trisodium—enhanced gradient-echo sequence that we used successfully detected the only bile duct calculus in our study group.
Radiologists should be aware of several potential pitfalls regarding contrast-enhanced MR cholangiography after administration of IV mangafodipir trisodium. First, patients with hepatic dysfunction may not have normal excretion of contrast material in the biliary system, and delayed excretion of bile may occur [35]. Therefore, in a patient with suspected liver failure, delayed imaging may be necessary to allow excretion of the contrast agent into the distal biliary tree. In our study group, six of eight patients who showed elevated liver enzymes showed complete opacification of the extrahepatic, main right, and main left intrahepatic bile ducts. In two of these eight patients, incomplete opacification of the extrahepatic bile duct was caused by bile duct transection in one patient and bile duct stricture in the other. Second, suboptimal opacification of the common bile duct or central intrahepatic bile ducts may be associated with obstruction (stones, strictures, masses), stasis (sludge), air bubbles, stents, fistulas, or transection. In our study, six patients showed incomplete opacification of the extrahepatic bile ducts on contrast-enhanced MR cholangiography because of stents (n = 4), transection (n = 1), or common bile duct stricture associated with a biliary fistula to a peritoneal drain (n = 1) (Figs. 1A,1B,1C, 4A,4B,4C, and 5A,5B). In addition, Holland et al. (Holland GA et al., presented at the American Roentgen Ray Society meeting, May 1999) showed that contrast-enhanced MR cholangiography performed with three-dimensional gradient-echo sequences after IV mangafodipir trisodium administration resulted in complete visualization of all normal common bile ducts. In that study, obstructing lesions were present in all ducts that were incompletely visualized. Third, other extrabiliary abnormalities, such as hematomas and iodinated contrast agent, that show increased T1-signal may mimic contrast agent extravasation on mangafodipir trisodium—enhanced gradient-echo images. Fourth, because mangafodipir trisodium produces T2-shortening and decreased signal on T2-weighted images, if conventional MR cholangiography using heavily-T2 weighted sequences is being performed in addition to contrast-enhanced MR cholangiography, it should be performed before contrast agent administration [32]. However, in our experience, the resolution of contrast-enhanced MR cholangiography is comparable to conventional MR cholangiography. Therefore, we suggest that conventional MR cholangiography should not be performed at the time of contrast-enhanced MR cholangiography. Fifth, because the peripheral intrahepatic bile ducts show limited opacification, the exact location of a peripheral intrahepatic bile duct leak may be difficult to characterize. No patient in our study group had a peripheral intrahepatic bile duct leak. Sixth, because mangafodipir trisodium is less dense than bile, contrast agent extravasation will opacify nondependent areas of fluid collections. Therefore, although coronal imaging allows good visualization of the opacified ducts in a manner that radiologists, gastroenterologists, and surgeons are comfortable interpreting, it has the potential of excluding anterior extravasation of contrast material in fluid collections. If images are acquired in the coronal plane, the most anterior portion of fluid collections must be imaged to detect contrast agent extravasation. In this study, we acquired images in the axial plane that allowed us to easily detect this extravasation (Figs. 1A,1B,1C,2A,2B,3A,3B).
The primary limitation of this study is the small size of our study group. Additional, preferably multiinstitutional, studies using a larger patient population are needed to validate our results.
We conclude that in patients suspected of having bile duct leaks after cholecystectomy, contrast-enhanced MR cholangiography with IV mangafodipir trisodium can successfully detect the presence and location of bile duct leaks. More work is necessary before this examination is routinely used in the workup of these patients.
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