Cholelithoptysis. A complication following laparoscopic cholecystectomy

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.

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.

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.

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.

Thoracic empyema due to migrated endoclips after laparoscopic cholecystectomy

We describe the case of a patient who developed right thoracic empyema 1 year after laparoscopic cholecystectomy. The patient experienced right chest pain and swelling; radiography and CT showed an intrathoracic abscess penetrating the extrathoracic space and the presence of metal clips over the diaphragm. After drainage of the subcutaneous abscess, fluid accumulation decreased; bacterial examination showed no positive findings. Another year later, the patient's condition relapsed. We thought that the empyema may have been caused by endoclips that had migrated. We performed thoracoplasty and retrieved three endoclips from the intrathoracic empyema cavity. The patient showed good recovery after the operation.

Asymptomatic omental granuloma following spillage of gallstones during laparoscopic cholecystectomy protects patients and influences surgeons' decisions: a review

Spillage of gallstones in the peritoneal cavity during laparoscopic cholecystectomy (LC) occurs at rates varying from 5.7% to 16%. These gallstones often cannot be retrieved and can cause early and late abscesses at rates ranging from 0.08% to 1.4%. The case of an 86-year-old woman with colon cancer is described because during an elective right hemicolectomy a granuloma of the omentum with retained gallstones from LC performed 8 years earlier was unexpectedly found. Importantly, the gallstones were found high up in the abdominal cavity. Moreover, this report reaffirms the excellent response of the peritoneal cavity defence mechanisms for protecting patients against gallstones through asymptomatic omental granuloma. Current data indicate that every effort should be made to retrieve spilled gallstones, but routine conversion to an open cholecystectomy is not recommended. Identifying factors that impair host defence mechanisms should help surgeons' decision-making.

Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.

Venocutaneous fistula

This is the first description of venocutaneous fistula, a late complication of elective laparoscopic cholecystectomy that arose 18 months after the initial operation. Postoperatively, the patient twice developed an abscess in the abdominal wall at the former site of the umbilical trocar. The first abscess occurred on the 6th postoperative day; the second, after 14 months. After an additional 4 months, a fistula opening appeared just below the umbilicus. Fistulography revealed a connection with the venous system of the omentum majus. During subsequent resection of the fistula, a pigment gallstone was retrieved from the base of the fistula.

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.

Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy

Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.

Pelvic adhesion formation after intraperitoneal installation of gallstones in a rabbit model

OBJECTIVE

To investigate whether intraperitoneal gallstones increase the risk of pelvic adhesions in a rabbit model.

DESIGN

Prospective, randomized, blinded, sham and human antigen controlled trial.

SETTING

An academic research environment.

SUBJECT(S)

Twelve New Zealand white rabbits.

INTERVENTION(S)

Twelve rabbits were divided into three groups of four each; a sham operation group, a gallstone and bile group (study group), and a human serum albumin and bile group (antigenic control). Three weeks after the operation individual subjects were randomized, with groups concealed to observers, and a necropsy was performed on each rabbit.

MAIN OUTCOME MEASUREMENT(S)

Necropsy was performed on each rabbit, and the adhesions were scored for extent, type, tenacity, inflammation, and gallstone involvement.

RESULT(S)

There was a statistically and biologically significant increase in gallstone involvement in adhesions, especially pelvic adhesions, in the study group.

CONCLUSION(S)

This study, along with an increasing number of case reports, suggests that gallstones inadvertently left in the peritoneal cavity may increase the morbidity of laparoscopic cholecystectomy. In females of reproductive age these gallstones may induce pelvic adhesions that may interfere with fertility or be associated with pelvic pain.

Iatrogenic Gallbladder Perforation during Laparoscopic Cholecystectomy: Etiology and Sequelae

Iatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.

Empyema due to spilled stones during laparoscopic cholecystectomy

We describe a patient who suffered right pleuritic chest pain and an exudative pleural effusion, leading to empyema formation. Thoracotomy revealed this to be due to a subphrenic abscess around spilled gall stones.

Cholelithoptysis: a rare complication of laparoscopic cholecystectomy

Two months after laparoscopic cholecystectomy, a 54-year-old man presented for medical care with cholelithoptysis (the coughing up of gallstones). This rare complication was managed without a further operation. Possible mechanisms and preventive measures are discussed.

Peritoneal lithiasis and cliptomas following laparoscopic cholecystectomy

A review was made of five patients with post-laparoscopic cholecystectomy peritoneal soiling with clips and/or stone. Three patients were symptomatic with recurrent abdominal pain or back pain. One of these had clips alone, one had clips and stone and the third had stones alone. The location of the stones in the pelvis and right iliac fossa created confusion in the diagnosis, simulating ureteric calculi and appendicitis, respectively. Surgical operation revealed granulomas around the stones. The consequences of peritoneal clips is not yet known. However, peritoneal lithiasis and potential complications should be considered as a differential of abdominal and pelvic calculi.

Empyema from lost gallstones: a thoracic complication of laparoscopic cholecystectomy

Laparoscopic cholecystectomy may result in lost (dropped) gallstones. Such stones may precipitate abdominal abscesses including subphrenic abscesses. In our case, the abscess eroded through the diaphragm causing an empyema 17 months after the laparoscopic cholecystectomy. Treatment included decortication, drainage, and removal of the stones.

Complex pleural effusion associated with a subphrenic gallstone phlegmon following laparoscopic cholecystectomy

A 90-year-old man presented with a large right-sided complex pleural effusion 4 months after a laparoscopic cholecystectomy. An initial thoracic CT scan confirmed the presence of the effusion, and the results of thoracentesis on three separate occasions were consistent with an exudative process. Another CT scan of the chest with thin-section cuts through the diaphragm along with an abdominal ultrasound revealed a retrohepatic subdiaphragmatic gallstone collection that eroded into the right hemidiaphragm. Thoracoscopic evacuation of the phlegmon, removal of the spilled gallstones, and repair of the diaphragm resulted in resolution of the effusion.

Lost gallstones found in a hernial sac

Spillage of bile and gallstones is not a rare event during laparoscopic cholecystectomy. The natural history of spilled and retained stones is not well defined. We report of such lost stones that were found several months later in a hernia sac.

Cholelithoptysis and empyema formation after laparoscopic cholecystectomy

Thoracic complications of laparoscopic operations are rare. We describe a case of cholelithoptysis due to a gallstone sequestered in the middle lobe after laparoscopic cholecystectomy.

The treatment of gall stones

Images

Delayed peritoneal and retroperitoneal abscesses caused by spilled gallstones: a complication following laparoscopic cholecystectomy

Many complications following laparoscopic cholecystectomy have been reported. We report a case of delayed peritoneal and retroperitoneal abscesses caused by spilled gallstones from a laparoscopic cholecystectomy performed 1 year earlier. This diagnosis was suggested only at sonography because the aggressive behavior of the lesions containing nonopaque gallstones suggested, by computed-tomography scan, peritoneal metastatic disease.

Spilled gallstones--complications of abdominal-wall abscesses. Case report and review of the literature

Laparoscopic cholecystectomy has become the preferred method for removal of the diseased gallbladder. While its morbidity and mortality rates are lower than those of the open technique, it does have associated complications which may cause significant morbidity. The morbidity associated with spilled gallstones is not well studied and little can be found in the literature on this subject. We encountered a patient who developed abscesses within the abdominal wall following laparoscopic cholecystectomy. We recommend that spilled gallstones be removed when possible and that surgeons be aware of this possible complication.

Delayed gallstone abscess following laparoscopic cholecystectomy

Delayed infectious complications following elective laparoscopic cholecystectomy have not been well delineated in the medical literature. Irretrievable spillage of gallbladder contents at the time of laparoscopic cholecystectomy is not rare, and has generally been felt to be of little consequence, particularly in the nonacute setting. The case presented documents an instance of delayed gallstone abscess formation after elective laparoscopic cholecystectomy. While rare, such cases highlight the need for refined techniques to prevent gallbladder, perforation during this procedure and to allow laparoscopic recovery of small gallstones spilled at the time of cholecystectomy.

Cholecyst-thoracic fistula. A rare complication of lithiasic cholecystitis

A 64-year-old male patient was studied for repeated right basal pneumonia of long duration. A computed tomography scan showed a cholecystitis of concealed evolution. Surgery revealed fistulization toward the thorax, with the passage of multiple calculi of a biliary origin to the chest cavity. We report the first described case to our knowledge of cholecyst-thoracic fistula secondary to cholecystitis of long evolution.