Cholelithoptysis and pleural empyema

Intrapulmonary Gallstones and Pleuro-Biliary Fistula Formation Due to Complication From Prior Cholecystectomy: A Case Report and Literature Review

Intrapulmonary gallstones and the formation of pleuro-biliary fistula is a rare complication of laparoscopic cholecystectomy. The stones are most commonly found in the right lower lobe of the lungs. The symptoms tend to be insidious in nature and can manifest as hemoptysis, irritating cough, and cholelithoptysis years after the procedure. The stones can be removed through lobectomy or may also be treated non-invasively with antibiotics only. Here, we describe a case of a patient who developed hemoptysis and was found to have intrapulmonary gallstones from laparoscopic cholecystectomy and subsequent fistula formation.

Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report

BACKGROUND

Dropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC.

CASE PRESENTATION

We present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up.

CONCLUSIONS

We report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC.

Bronchobiliary fistula: a rare postoperative complication of spilled gallstones from laparoscopic cholecystectomy

Bronchobiliary fistula (BBF) is defined as the abnormal connection between the biliary system and the bronchial tree, which presents clinically as an irritant cough with bilioptysis. Many conditions can lead to its development. We present a case of an acquired BBF in a 61-year-old man with a significant history of spilled gallstones from a prior laparoscopic cholecystectomy and subsequent presentation of intermittent right upper quadrant pain and recurrent pneumonia. Imaging studies revealed a liver and subdiaphragmatic abscess with right middle lobe pneumonia and a BBF traversing the right hemidiaphragm. The patient was surgically managed by takedown of fistula with drainage of the abscess and removal of spilled gallstone, followed by a resection of the right middle lobe. While previous studies indicate spilled gallstones are benign, this case demonstrates its potential for serious complications. Therefore, early diagnosis and proper management is essential as BBF has a high morbidity and mortality rate.

Spilled gallstones simulating peritoneal carcinomatosis: A case report and literature review

INTRODUCTION

Laparoscopic cholecystectomy (LC) has become the "gold standard" for the treatment of symptomatic gallstones. However, this surgical technique increases the risk of bile duct injury and lost gallstones. Since over 90% of split gallstones never become symptomatic, they often present as incidental findings on CT-scans. Careful removal of as many stones as possible, intense irrigation and suction are recommended. It has been reported that 8.5% of lost gallstones will lead to a complication, most common are abscesses.

PRESENTATION CASE

We report a case of spilled gallstones simulating peritoneal metastases on radiological investigations. Diagnosis was very difficult, not even an US-guided biopsy of the lesion was decisive. Only a diagnostic laparoscopy confirms the diagnosis.

DISCUSSION

The reaction associated with lost gallstones can mimic other causes, such as soft tissue sarcoma, malignant lymphoma or, as in our case peritoneal carcinomatosis.

CONCLUSION

Spilled gallstones are associated with uncommon, but significant complications, and even the diagnosis of such a condition can cause serious difficulties. Serious effort must be made to prevent gallbladder perforation, and accidental stone spillage should be promptly recognized and properly managed.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Attitudes and Practices of Surgeons towards Spilled Gallstones during Laparoscopic Cholecystectomy: An Observational Study

The sequelae of spilled gallstones after Laparoscopic cholecystectomy (LC) and the occurring complications may go unnoticed for a long time and can be a diagnostic challenge. The aim of this survey was to study the knowledge, attitude, and practices of surgeons regarding spilled gallstones during LC. An observational, cross-sectional survey, using a questionnaire based on 11 self-answered close-ended questions, was conducted among general surgeons. Of the 138 respondents only 29.7% had observed a complication related to gallstone spillage during LC. There was varied opinion of surgeons regarding management of spilled gallstones, documenting the same in operative notes and consent. It was observed that there is lack of knowledge regarding the complications related to gallstone spillage during LC. There is need to educate surgeons regarding safe practices during LC to avoid gallstone spillage, early diagnosis, and management of complications. There is need to standardize practice to retrieve lost gallstones to reduce complication and legal consequences.

Chronic cutaneous chest wall fistula and gallstone empyema due to retained gallstones

We report a case of a 72-year-old man who presented with a persistent pleural effusion and painful abscess in the right lower chest wall 6 months following a laparoscopic cholecystectomy. The patient subsequently developed a chronic cutaneous chest wall fistula requiring a large resection and complex closure. The complication was likely secondary to intraoperative spillage of gallstones. While previous reports describe gallstone spillage in the abdominal cavity as benign, this case illustrates that stones left in the abdominal cavity can potentially lead to significant morbidity. Therefore, stones should be diligently removed from the abdominal cavity when spillage occurs. In addition, it is important that operative notes reflect the occurrence of stone spillage so stones may be suspected when a patient presents with an abdominal or thoracic infection following a cholecystectomy.

Chronic percutaneous gallstone discharge following videothoracoscopic decortication

Computed tomographic imaging is not recommended as an essential prerequisite in surgery for pleuro-pulmonary sepsis in the current guidelines. We highlight one consequent pitfall and its sequelae. We report the discharge of gallstones through a healed intercostal drain site four months following video-assisted thoracic surgery for early pleural empyema secondary to missed calculous gallstone disease. The importance of awareness and a high index of suspicion to diagnose the underlying extra-thoracic cause of a right-sided pleural collection in a patient with a previous history of gallstone disease cannot be overemphasised.

Lost gallstones in laparoscopic cholecystectomy: all possible complications

BACKGROUND

Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gallstones for 15 years. During that time, several studies and case reports have been published which outline the possible complications of lost gallstones. The aim of this review is to categorize these complications and to evaluate the frequency and management of lost gallstones.

DATA SOURCES

A Medline search from 1987 to 2005 was performed. A total of 111 case reports and studies were found, and all reported complications were listed alphabetically. Eight studies with more than 500 LCs that reported lost gallstones and perforated gallbladder were analyzed for frequency and management of lost gallstones.

CONCLUSION

Lost gallstones have a low incidence of causing complications but have a large variety of possible postoperative problems. Every effort should be made to remove spilled gallstones to prevent further complications, but conversion is not mandatory.

Gallstone-Induced Inflammatory Fibrosis: A Relentless Clinical Course of Retained Gallstones after Laparoscopic Cholecystectomy

Multiple reports in the literature confirm that retained gallstones spilled during laparoscopic cholecystectomy perpetuate chronic inflammation and suppuration long after the initial operation. Two patients who had previously undergone laparoscopic cholecystectomy presented to our institution with complications of retained stones. Patient 1 presented with right upper quadrant pain and a mass involving the right hepatic lobe. Patient 2 presented with a draining right flank abscess. Both underwent exploratory laparotomy at which time multiple abscess cavities were found, many of which contained retained gallstones. Patient 1 required reoperation for recurrent abscesses 7 months after the initial procedure and has been disease free for 6 months. Patient 2 had abscess recurrence that required percutaneous drainage 1 year after the original procedure and has not had recurrence for 4 years.

This paper was presented at the 6thWorld Congress of the International Hepato Pancreato Biliary Association, June 5, 2004, Washington, DC.

Laparoscopic cholecystectomy: early and late complications and their treatment

Laparoscopic cholecystectomy gained wide acceptance as treatment of choice for gallstone disease and cholecystitis. With this new technique, not only did the new era of minimal invasive surgery begin, but also the spectrum of complications changed. Laparoscopy-related complications such as access injuries and procedure-related problems are discussed in our article. Typical mishaps are reviewed according to the literature. Set-up of the pneumoperitoneum (morbidity up to 0.2%); bleeding-from trocar sites and vascular injury (mortality up to 0.2%); biliary leaks and bile duct injuries are the main topics in this article (still on a level of 0.2%-0.8%). Aetiology, diagnosis and treatment are discussed, and an overview of the most cited classifications of bile duct injuries is summarised graphically. Finally, bowel injuries as a specific complication in laparoscopy are discussed (incidence up to 0.87%).

CONCLUSION

Careful selection of patients, the knowledge of typical procedure-related complications, and their best treatment are the key points for a safe laparosopic cholecystectomy.

Spilled gallstones after laparoscopic cholecystectomy

Spilled gallstones have emerged as a new issue in the era of laparoscopic cholecystectomy. We treated a 77-year-old woman who underwent laparoscopic cholecystectomy. Subsequently, a right flank abscess developed. During the cholecystectomy, the gallbladder was perforated and stones were spilled. After a failed attempt to drain the abscess percutaneously, the patient required open drainage, which revealed retained gallstones in the right flank. The abscess resolved, although the patient continued to have intermittent drainage without evidence of sepsis. Review of the literature revealed 127 cases of spilled gallstones, of which 44.1% presented with intraperitoneal abscess, 18.1% with abdominal wall abscess, 11.8% with thoracic abscess, 10.2% with retroperitoneal abscess, and the rest with various clinical pictures. In case of gallstone spillage during laparoscopic cholecystectomy, every effort should be made to locate and retrieve the stones.

Remote complications of spilled gallstones during laparoscopic cholecystectomy: causes, prevention, and management

In the last 11 years (November 1989-December 2000), 5526 laparoscopic cholecystectomies were performed in a community residency training program. Two cases (0.04%) of remote complications secondary to spilled gallstones were identified. A 75-year-old woman presented with a sterile abscess in the abdominal wall containing gallstones 4 years and 4 months after an elective laparoscopic cholecystectomy. The second patient, a 43-year-old woman, presented with a subdiaphragmatic/subhepatic abscess containing gallstones. The abscess grew the same bacteria that were present 2 years and 3 months previously during a laparoscopic cholecystectomy for acute gangrenous cholecystitis. In both cases, pigmented gallstones were identified. Causes of gallstone spillage, means of prevention, and ways of managing this complication are discussed.

Massive hemoptysis from a lung abscess due to retained gallstones

This case report describes a subhepatic abscess from spilled gallstones which eroded through the diaphragm causing a right lower lobe pulmonary abscess and presenting as massive hemoptysis.

[Recurrent pneumonia and empyema due to Klebsiella pneumoniae as a complication of laparoscopic cholecystectomy]

We report a patient with pneumonia and empyema secondary to an abdominal abscess due to Klebsiella pneumoniae from stones released into the abdominal cavity during laparoscopic cholecystectomy.