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Hepatobiliary scintigraphy in the study of complications in adult patients after liver transplant. Description of the experience
Gammagrafía hepatobiliar en el estudio de las complicaciones del trasplante hepático en adultos. Descripción de la experiencia
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Descripción de la experiencia" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "207" "paginaFinal" => "211" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Hepatobiliary scintigraphy in the study of complications in adult patients after liver transplant. Description of the experience" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 895 "Ancho" => 1505 "Tamanyo" => 108727 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A. Imagen estática de gammagrafía hepatobiliar en proyección anteroposterior a los 120<span class="elsevierStyleHsp" style=""></span>min de la inyección, en un paciente adulto trasplantado hepático que evidencia acumulación anormal del radiofármaco a nivel de epigastrio y mesogastrio (flechas azules) indicativa de colección biliar (bilioma sin paso adecuado a intestino). B. Para completar el estudio se realizaron imágenes tomográficas SPECT/TC, que confirmaron la presencia de radiofármaco fuera de la vía biliar y del intestino, localizado inferior al lóbulo hepático izquierdo y superior a la cámara gástrica, así como adyacente al páncreas. La presencia de colección biliar-bilioma fue confirmada en cirugía urgente, a la que fue llevado el paciente tras la realización del estudio gammagráfico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Vélez-Gutierrez, C. Gutierrez-Villamil, S. Arevalo-Leal, G. Mejía-Hernandez, V. 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(A) Planar images show increased uptake in lateral and medial condyl of right femur and proximal area of right tibia. (B) SPECT/CT precisely localizes this focus to corresponding structural alteration in right knee. 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Description of the experience" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "207" "paginaFinal" => "211" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Vélez-Gutierrez, C. Gutierrez-Villamil, S. Arevalo-Leal, G. Mejía-Hernandez, V. Marín-Oyaga" "autores" => array:5 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Vélez-Gutierrez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Gutierrez-Villamil" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Arevalo-Leal" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Mejía-Hernandez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:4 [ "nombre" => "V." "apellidos" => "Marín-Oyaga" "email" => array:1 [ 0 => "vmarin@cardioinfantil.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía y Transplantes, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gammagrafía hepatobiliar en el estudio de las complicaciones del trasplante hepático en adultos. Descripción de la experiencia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 1250 "Tamanyo" => 67312 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Static hepatobiliary scintigraphy image in anterior projection at 120<span class="elsevierStyleHsp" style=""></span>min after radiotracer injection in an adult liver transplant patient with leakage of bile-like material in the subcutaneous drain. Persistence of radioactivity is observed in the liver (dysfunction, black arrow) with scarce transit of the radiotracer to the intestine (red arrow) and great transit to the right percutaneous drain (blue arrow) compatible with the presence of a high output fistula. (B) Hepatobiliary scintigraphy performed in the same patient following corrective surgery and closure of the fistula. This image was also obtained at 120<span class="elsevierStyleHsp" style=""></span>min after radiotracer injection; comparatively, less hepatic radioactivity is observed (adequate function, black arrow), and there is adequate transit of the radiotracer to the intestine without obstructions (red arrow) and the absence of bile by external drains, indicating resolution of the fistula following surgery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Orthotopic liver transplantation is a surgical procedure used for the definitive and curative management of in both adult and pediatric populations with different advanced and irreversible liver diseases.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1–4</span></a> The first liver transplant was performed in Denver USA in 1963, and since then important advances have been achieved in the surgical technique and organ preservation, leading to a significant increase in the survival of these patients.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Liver transplantation may be performed using a cadaveric donor or with a specific segment of the liver from a living donor, further increasing the number of procedures carried out each year.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The technique of choice for biliary reconstruction is end-to-end choledocho-choledochostomy since this procedure preserves the function of the sphincter of Oddi and facilitates easy access to the biliary tree for specific studies and treatments. Another technique is Roux-en-Y choledochojejunostomy which is mainly used in children and patients with certain conditions such as sclerosing cholangitis, cholangiocarcinoma, biliary atresia and retransplantation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">On being an invasive procedure with high complexity there is an elevated risk of parenchymatous (graft rejection, cholestasis), vascular (arterial or portal thrombosis, stenosis, pseudoaneurysm, hemorrhage) and biliary complications (stenosis, biliary fistulas, dysfunction of the sphincter of Oddi). Biliary complications are the most frequent,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2,3</span></a> with an incidence of 15–35%.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,5</span></a> They are associated with important morbidity with mortality reaching 10–30%, thereby making biliary complications one of the principal concerns during the postoperative period of transplanted patients, despite the advances achieved in the surgical techniques used.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7,8</span></a> It is important to take into account that living donor liver transplantation requires different surgical techniques and involves the anastomosis of much smaller biliary ducts, which could explain the higher rate of biliary complications compared to cadaveric donor transplants (34% vs. 14%, respectively).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Among the biliary complications which may develop the most frequent are biliary fistulas and stenosis. Biliary fistulas usually present in the first postoperative weeks but may manifest later. They are mainly produced at the level of the anastomosis or at the border of the hepatic transection, having an incidence of 7.8–9.5% (with complete or partial graft, respectively), and if not treated in time they may evolve to an abscess or peritonitis.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Stenosis of the anastomosis usually presents gradually in late postoperative periods, possibly as a consequence of a local inflammatory process due to ischemia, biliary fistula or of immunological origin (rejection). Therefore, the accumulated incidence of stenosis rises over time (6.6% at one year, 10.6% at 5 years and 12.3% at 10 years).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> The clinical manifestations of both conditions are very unspecific (fever, jaundice, abdominal pain, alterations in liver function tests), and thus, the use of non-invasive imaging techniques is important in their initial study.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,9–12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Hepatobiliary scintigraphy is a widely known technique for the study of the physiology and biliary dynamics. However, its use is not very frequent in non-specialized centers. This is probably because of a lack of awareness as to its clinical potential in this group of patients which is largely due to the little convincing evidence regarding its use in transplanted patients. Therefore, the aim of this study was to describe our experience and the utility of hepatobiliary scintigraphy in patients suspected of presenting complications post liver transplantation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective, descriptive, observational study of diagnostic images was performed. We included all the adults patients who had undergone liver transplantation and one or more hepatobiliary scintigraphies during the early or late postoperative period in a fourth level center from January 2013 to February 2018. The hepatobiliary scintigraphies were requested for diagnostic purposes and not for routine follow-up.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After verifying fulfillment of the inclusion criteria, a total of 58 hepatobiliary scintigraphies performed in 38 patients (22 men and 16 women) were analyzed. Twelve patients underwent more than one hepatobiliary scintigraphy (2–3 per patient) due to the appearance of new conditions and the persistence of complications, with subsequent retransplantation in 3 of these patients. The mean age of the patients was 48 years (range: 18–69 years). In 34/38 patients transplantation was from a cadaveric donor (89%) and in 4 (11%) the graft was from a living donor. Thirty-seven of the 38 patients underwent end-to-end biliary reconstruction (97%), and in one patient (3%) hepato-jejunostomy was performed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In our center the routine follow-up of transplanted patients showing an elevation in transaminase levels includes biopsy to rule out graft rejection. Cases presenting a cholestatic pattern in the tests are considered to have biliary alterations, and their study includes Doppler ultrasonography to rule out vascular complications or compressive collections such as hematomas or biliomas. If abdominal drainage shows biliary content of more than 7 days a hepatobiliary scintigraphy is performed to record the fistula and quantify its output, in order to determine the need for surgery or endoscopic retrograde cholangiopancreatography (ERCP) with or without stent placement. If the drainage is not biliary, a hepatobiliary scintigraphy is made to rule out other cause of cholestasis such as biliary stenosis. If the time of evolution is greater than 30 days, a cholangioresonance is performed, and according to the findings this is complemented with a hepatobiliary scintigraphy to determine the presence of fistulas or significant obstruction requiring management or additional studies.</p><p id="par0050" class="elsevierStylePara elsevierViewall">To perform hepatobiliary scintigraphy in adults the radiotracer <span class="elsevierStyleSup">99m</span>Tc-mebrofenin was administered at a mean dose of 92.5<span class="elsevierStyleHsp" style=""></span>MBq (2.5–10<span class="elsevierStyleHsp" style=""></span>mCi). Induction of biliary excretion was not performed. The studies were made with one of two different gamma cameras: a Symbia<span class="elsevierStyleSup">®</span> T6 (Siemens) or a Discovery<span class="elsevierStyleSup">®</span> 670 Pro (General Electric). Technically adequate low energy high resolution collimators were used at the greatest proximity tolerated by the patient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The hepatobiliary scintigraphies started with sequential dynamic images each minute during the first 30<span class="elsevierStyleHsp" style=""></span>min (anterior projection with a 128<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>128 matrix and 1<span class="elsevierStyleHsp" style=""></span>min per image) in order to evaluate the vascular and functional phases and the initiation of biliary excretion. Afterwards, static images were made at the level of the abdomen (of 1<span class="elsevierStyleHsp" style=""></span>min with a matrix of 256<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>256) at 60, 90 and 120<span class="elsevierStyleHsp" style=""></span>min, with late images at 4 and 6<span class="elsevierStyleHsp" style=""></span>h according to the findings. Images were not obtained at 24<span class="elsevierStyleHsp" style=""></span>h. Biliary drains were left open during image acquisition. Occasionally, the scintigraphy was complemented by a single photon emission computed tomography/computed tomography (SPECT/CT) with the objective of fusing the images to increase the accuracy of the anatomical localization (step and shoot mode every 3°, circular orbit of 360° and 15<span class="elsevierStyleHsp" style=""></span>s per image, CT of 30<span class="elsevierStyleHsp" style=""></span>mA and 120<span class="elsevierStyleHsp" style=""></span>mV, ordered subset expectation maximization [OSEM] reconstruction of 2 iterations and 10 subsets, Butterworth filter with frequency 0.48 and order of 10). In these patients reconstruction of the SPECT and the SPECT/CT was made with correction of attenuation in axial, sagittal and coronal planes.</p><p id="par0060" class="elsevierStylePara elsevierViewall">We obtained the demographic data (age, sex) from the clinical history and the databases of the Department of Nuclear Medicine as well as relevant information regarding the context of the transplantation (type of donor, type of biliary reconstruction), data related to the diagnostic study (indication, previous morphological studies, such as ultrasonography) in addition to relevant posterior clinical data for verification of the findings and final clinical management of the patients.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Lastly, we compared the findings of the hepatobiliary scintigraphy with those of surgery in order to determine the proportion of cases showing a correlation between the two and evaluated the influence of the study in the final clinical decisions and its impact on clinical management.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All the information obtained was recorded in a Microsoft Excel<span class="elsevierStyleSup">®</span> database and statistical software was added to the variables categorized. Descriptive analysis of all the study variables was performed expressed as absolute and relative frequencies and percentages for the qualitative variables. The statistical package IBM-SPSS<span class="elsevierStyleSup">®</span> v.21 was used for the statistical analyses.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The study was approved by the ethical and investigation committees of our institution.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">The main reasons for requesting hepatobiliary scintigraphy were: for alteration in liver function tests on 26 occasions (38%), for bile drainage from the percutaneous drain in 18 cases (28%) (evaluation of fistula) and due to the clinical or subclinical presence of cholestasis in 12 (17%). In 7 cases (10%) the request was made because of abnormal findings in the imaging study, for abdominal pain in 3 (4%) and for other reasons in 2 (3%), and there was more than one indication for 10 hepatobiliary scintigraphies including some of those previously mentioned, reaching a total of 68 reasons for hepatobiliary scintigraphy in 58 studies (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Among the scintigraphic findings recorded, 9 were normal (15%) and 48 (85%) showed some alteration and were positive. In 18 cases cholestasis was observed (28%), and 12 (18%) showed different grades of hepatocellular dysfunction. Eleven hepatobiliary scintigraphies (17%) were positive for biliary fistula, 4 with low output and 7 with high output. Five cases (8%) showed the presence of bile collections (associated with high output fistula in 4 and as a single finding in one) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Six hepatobiliary scintigraphies (9%) showed findings indicative of complete or partial obstruction of the biliary tree and in 3 cases (5%) there were signs indicating dilatation of the biliary tree. Lastly, in one of the hepatobiliary scintigraphies (1%) obstruction was undetermined as a consequence of severe hepatocellular dysfunction. Seven patients showed more than one of the previously mentioned findings (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Of the 58 hepatobiliary scintigraphies performed, 50 (86%) had repercussion on the clinical management of the patients, being determinant of the observational or interventional approaches implemented. Twenty-nine (58%) hepatobiliary scintigraphies were negative for biliary complications (normal, hepatocellular dysfunction and/or cholestasis as the only finding), and in 21 patients (42%) the hepatobiliary scintigraphy was positive for biliary complications (fistula, obstruction, dilatation or bile collection).</p><p id="par0095" class="elsevierStylePara elsevierViewall">The hepatobiliary scintigraphy studies had clinical repercussion in all the patients presenting biliary complications (21/21; 100%), with 18 undergoing further studies or surgical treatment. Among these, 14/18 showed a correlation between the scintigraphic results and the findings of the posterior diagnostic-therapeutic procedure (ERCP). In 3/21 (14%) patients, medical management was continued since, despite evidence of biliary complications, they were considered to be non-surgical (low output fistulas), there were no new complications and posterior resolution was achieved (true positive results). In 2/18 (9%) the findings did not correlate (false positive results), and reintervention was not required during follow-up. In 2 patients the ERCP was not successful, and it was not possible to determine a possible correlation with the findings.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Three patients underwent SPECT/CT, and this was useful to corroborate the presence of the radiopharmaceutical inside and outside the intestine in doubtful cases but not to determine the localization of the point of leakage since this can only be established by invasive techniques (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Thirty-six scintigraphies were negative for biliary complications. Nine were completely normal (4 requested for suspicion of cellular dysfunction and 5 for suspicion of alterations in the biliary tree). In 26 cases (72%) medical management was continued without complications or posterior findings; one (3%) required collection drainage, two (6%) underwent biopsy (true negative results) and 7 (19%) underwent ERCP. Of these latter 7 patients, 6 showed findings compatible with stenosis of the biliary tree and one had an associated fistula (false negative results). In one case the ERCP was not successful. In the patient with collection drainage, material with purulent non-biliary characteristics was obtained, ruling out the presence of biliomas (in agreement with normal findings in the hepatobiliary scintigraphy). Among the patients undergoing biopsy, one showed reactivation of hepatitis C virus infection, and antiviral treatment was initiated. In the other patient, graft rejection was ruled out, showing posterior clinical improvement (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In our experience, hepatobiliary scintigraphy in adults who had undergone liver transplantation was of great utility for early non-invasive detection of biliary complications, mainly fistulas and stenosis.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Biliary complications affect one out of 5 liver transplant recipients, and ERCP is the first line treatment for biliary complications.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Kurzawinski et al. reported a sensitivity and specificity for hepatobiliary scintigraphy of 50% and 79%, respectively, for the detection of biliary fistula, and 62% and 64% for the detection of stenosis.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> However, later on, Kim et al. described a sensitivity of 93% and a specificity of 88% for biliary stenosis and of 100% for both in patients with suspicion of biliary fistula or bilioma.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The present study showed that the results of hepatobiliary scintigraphy have a high repercussion on the clinical management of the patients (86% of hepatobiliary scintigraphies). These data had a great impact on the patients in our center and demonstrate the validity and great clinical utility of this technique as a fundamental tool in these patients.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Of the total of 21 positive scintigraphies, the scintigraphic results correlated with the findings of the posterior procedure or follow-up in a large number of the cases (67%). However, in 2 cases (9%) there was no correlation with the findings; in one case hepatobiliary scintigraphy showed a fistula with moderate output for which ERCP was performed for correction, showing no evidence of contrast leakage. In this case the reason for requesting hepatobiliary scintigraphy was the presence of bile drainage by the percutaneous drain which was later solved with an endoscopic procedure. This was likely a fistula with low output which would be one of the reasons why leakage was not identified intraoperatively. With regard to the 3 patients who continued with medical management despite the scintigraphic findings, in one the scintigraphic study showed dilatation of the intrahepatic biliary tree with adequate hepatocellular function and a permeable extrahepatic biliary tree with no other findings. In this patient, posterior liver biopsy ruled out graft rejection, and the patient was discharged and was clinically followed with no evidence of posterior complications. In another patient the hepatobiliary scintigraphy showed dilatation of the intrahepatic bile ducts up to the site of the anastomosis, with delay in intestinal transit, with evacuation in the late postprandial images, demonstrating partial obstruction. On follow-up of the hepatic profile the patient showed improvement and outpatient management was implemented. In the third patient a biliary fistula with low output was observed, and medical management was continued, achieving spontaneous resolution. These findings are very important since even with studies which are positive for biliary complications, hepatobiliary scintigraphy may safely guide medical or invasive patient management.</p><p id="par0135" class="elsevierStylePara elsevierViewall">A large percentage (72%) of the 36 hepatobiliary scintigraphies which were negative for biliary complications continued with medical management. Of the 7 patients undergoing ERCP, 6 presented positive surgical findings, with stenosis being a common finding and with one presenting an associated fistula. Of these 6 patients with positive ERCP results and negative hepatobiliary scintigraphies for biliary complications, 2 (33%) showed an associated cholestatic pattern which clearly explains the low detectability of biliary complications in these cases due to scarce transit of the radiotracer in the biliary tree to the extrahepatic region. Hopkins et al. demonstrated that hyperbilirubinemia greater than 5<span class="elsevierStyleHsp" style=""></span>mg/dl reduces the sensitivity of the study for the detection of biliary complications in transplanted patients, reporting that the sensitivity decreased from 100% to 62.5%. However, the specificity remained at 100%. This occurs due to an alteration in the pharmacokinetics of the radiotracer secondary to a competitive inhibition induced by physiological mechanisms of bilirubin.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Up to now, in our center treatment to induce biliary excretion is not performed in adults, and therefore, we do not know if these data would have been somewhat modified with this treatment.</p><p id="par0140" class="elsevierStylePara elsevierViewall">It is important to highlight that in some cases the detection of biliary fistulas may have been low compared to other radiological studies such as cholangiography due to the presence of fistulas with very low output which are not clinically relevant in contrast to clinically significant fistulas, most of which are visible in hepatobiliary scintigraphy.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">One limitation of this study was its retrospective nature, and thus, in some cases the information was limited and did not allow complete analysis of the clinical decisions made following the results of the studies.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Hepatobiliary scintigraphy is a non-invasive, reliable, simple, and currently available method to detect or rule out the most frequent biliary complications of adult patients early after liver transplantation. Important hepatocellular dysfunction should be taken into account as a frequent cause of false negative results.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1214678" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1130576" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1214677" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1130575" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-11-26" "fechaAceptado" => "2019-02-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1130576" "palabras" => array:3 [ 0 => "Hepatobiliary scintigraphy" 1 => "Liver transplantation" 2 => "Biliary complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1130575" "palabras" => array:3 [ 0 => "Gammagrafía hepatobiliar" 1 => "Trasplante hepático" 2 => "Complicaciones biliares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To show the experience of the use of hepatobiliary scintigraphy in patients with suspected complications after liver transplantation in a high complexity center.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective, observational and descriptive study. All consecutive adult patients with liver transplantation between January 2013 and February 2018 were included, with one or more hepatobiliary scintigraphy during the early or late postoperative period. A total of 58 studies were analyzed in 38 patients (22 men and 16 women). Mean age: 48 years. In 34/38: cadaverous donor (89%), and in 4 (11%): a living donor. Demographic data and relevant information regarding the transplant were obtained, and the result was related to the surgical findings to determine the correlation between them. The influence of the test on the final clinical decisions was evaluated.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Findings: 9 scans (14%) were normal, 36 studies were negative, and 21 were positive for biliary complications. Of the total of 58 studies, 50 (86%) had impact on the clinical behavior of observation or intervention. All the patients with findings of biliary complications (21/21; 100%) had clinical repercussion since 18/21 patients were taken to invasive studies or treatments, and 3/21 patients continued in medical management for findings of non-surgical biliary complications. In 14/18 patients taken to studies or procedures, correlation was found with the scintigraphic study. In 24/36 (66%) of patients with negative scintigraphy, an impact on clinical behavior was found.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hepatobiliary scintigraphy is a simple, non-invasive, reliable, current and available form for the early study of biliary complications in patients with liver transplantation. Important hepatocellular dysfunction should be taken into account as a frequent cause of false negative studies.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Mostrar la experiencia del uso de la gammagrafía hepatobiliar en pacientes con sospecha de complicaciones biliares postrasplante hepático en un centro de alta complejidad.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo, observacional y descriptivo. Se incluyeron todos los pacientes consecutivos adultos con trasplante hepático entre enero de 2013 y febrero de 2018, con una o más gammagrafías hepatobiliares durante el postoperatorio temprano o tardío. Se analizaron un total de 58 gammagrafías hepatobiliares en 38 pacientes (22 hombres y 16 mujeres). Edad media: 48 años. En 34/38: donante cadavérico (89%), y en 4 (11%): donante vivo. Se obtuvieron otros datos demográficos e información relevante respecto al trasplante y se relacionó el resultado con los hallazgos quirúrgicos para determinar la correlación entre ambos. Se evaluó la influencia de la prueba en las decisiones clínicas finales.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Hallazgos: 9 gammagrafías hepatobiliares (14%) fueron normales, 36 fueron negativas y 21 fueron positivas para complicaciones biliares. Del total de las 58 gammagrafías hepatobiliares, 50 (86%) tuvieron repercusión en la conducta clínica de observación o intervención. En todos los pacientes con hallazgos de complicaciones biliares (21/21; 100%) hubo una repercusión clínica, ya que a 18/21 se les realizaron estudios o tratamientos invasivos y 3/21 pacientes continuaron en manejo médico por hallazgos de complicaciones biliares no quirúrgicas. En 14/18 pacientes a los que se realizó estudios o procedimientos se encontró correlación con el estudio gammagráfico. En 24/36 (66%) pacientes con una gammagrafía hepatobiliar negativa se encontró impacto en la conducta clínica.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La gammagrafía hepatobiliar es una forma simple, no invasiva, confiable, vigente y disponible para el estudio de forma temprana de las complicaciones biliares en pacientes con trasplante hepático. Se debe tener en cuenta la disfunción hepatocelular importante como causa frecuente de obtener estudios falsos negativos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vélez-Gutierrez C, Gutierrez-Villamil C, Arevalo-Leal S, Mejía-Hernandez G, Marín-Oyaga V. Gammagrafía hepatobiliar en el estudio de las complicaciones del trasplante hepático en adultos. Descripción de la experiencia. Rev Esp Med Nucl Imagen Mol. 2019;38:207–211.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 1250 "Tamanyo" => 67312 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Static hepatobiliary scintigraphy image in anterior projection at 120<span class="elsevierStyleHsp" style=""></span>min after radiotracer injection in an adult liver transplant patient with leakage of bile-like material in the subcutaneous drain. Persistence of radioactivity is observed in the liver (dysfunction, black arrow) with scarce transit of the radiotracer to the intestine (red arrow) and great transit to the right percutaneous drain (blue arrow) compatible with the presence of a high output fistula. (B) Hepatobiliary scintigraphy performed in the same patient following corrective surgery and closure of the fistula. This image was also obtained at 120<span class="elsevierStyleHsp" style=""></span>min after radiotracer injection; comparatively, less hepatic radioactivity is observed (adequate function, black arrow), and there is adequate transit of the radiotracer to the intestine without obstructions (red arrow) and the absence of bile by external drains, indicating resolution of the fistula following surgery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 895 "Ancho" => 1505 "Tamanyo" => 108727 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A) Static image of hepatobiliary scintigraphy in anterior projection 120<span class="elsevierStyleHsp" style=""></span>min after radiotracer injection in an adult liver transplant patient showing abnormal accumulation of the radiotracer at the epigastric and mesogastric levels (blue arrows) indicative of bile collection (bilioma with inadequate transit to intestine). (B) To complete the study SPECT/CT images were made confirming the presence of the radiotracer outside the biliary tree and intestine, localized below the left hepatic lobe and above the gastric chamber as well as adjacent to the pancreas. The presence of a biliary-bilioma collection was confirmed on emergency surgery which was performed after the scintigraphic study.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alteration in liver function tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biliary drainage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cholestasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Altered imaging studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple indications (combination of the above) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2073704.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Reasons for requesting hepatobiliary scintigraphy in adult liver transplant patients.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Normal</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cholestasis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Hepatocellular dysfunction</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Biliary fistula</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low output \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High output \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Bile collection</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Obstruction of biliary tree</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Dilatation of biliary tree</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Undetermined due to severe dysfunction</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">More than one finding</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2073706.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Scintigraphic findings obtained.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ERCP: endoscopic retrograde cholangiopancreatography.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A negative or positive result refers to the presence of post-transplant biliary complications.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Repercussion on final management</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Hepatobiliary scintigraphy negative for biliary complications</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29/36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Medical management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (72%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Drainage of non-biliary collection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Hepatobiliary scintigraphy positive for biliary complications</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21/21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Correlation with ERCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (67%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No correlation with ERCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Medical management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (15%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unsuccessful non-diagnostic ERCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2073705.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Repercussion on clinical management.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La gammagrafía hepatobiliar en los pacientes con trasplante hepático y sospecha de fuga biliar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I. 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