Thoracic Gallstones: A Delayed Complication of Laparoscopic Cholecystectomy

Extrahepatic abscess and dropped gallstones: a case report and a narrative review of an unusual delayed complication of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the most common minimally invasive abdominal surgery procedure performed in Western countries; it offers several advantages over laparotomy but still carries some risks, such as intraoperative spillage of bile and gallstones. Diagnosis of dropped gallstones could be challenging, it is frequently delayed, and this can lead to further complications such as abscesses formation.

METHODS

We report the history of a 51-year-old male with persistent dull abdominal pain in association to appetite loss, vomiting episodes and changes in regular bowel habits, a past medical history of laparoscopic cholecystectomy for biliary lithiasis (1.5 years earlier) and minimum elevation of inflammatory markers and gamma-GT values.

RESULTS

Ultrasound examination showed perihepatic stones and magnetic resonance imaging revealed the presence of multiple perihepatic abscesses, findings compatible with fibrotic-inflammatory phenomena from 'dropped gallstones'. A re-laparoscopy was then performed with an abscess collection containing multiple gallstones; a liver wedge resection was also required due to strong adhesions. At follow up, the patient had improved both on clinical and biochemical perspective.

CONCLUSION

Dropped gallstones are an underreported cause of morbidity and diagnostic dilemmas in subjects who underwent to laparoscopic cholecystectomy, in relation to infectious complications that can occur even several months or years after surgery. Imaging represents a valuable aid in the correct non-invasive diagnostic process, but proper awareness of this insidious condition is necessary. Surgeons and radiologists should always consider this eventuality in the differential diagnosis of a patient presenting with abdominal abscesses and history of cholecystectomy.

Formation of a rare curve-shaped thoracolith documented on serial chest computed tomography images: A case report

BACKGROUND

Thoracolithiasis is a rare benign condition that manifests with one or more small nodules in the pleural cavity. In most cases, it is asymptomatic and found incidentally on chest imaging or during thoracic surgery. The thoracolithiasis formation process is rarely documented. Herein, we present a case of a rare, large, curve-shaped thoracolith, the formation of which was documented on serial computed tomography (CT) images.

CASE SUMMARY

A 46-year-old male patient who denied any prior systemic disease was evaluated due to intermittent right-sided lateral chest pain lasting for a year. Chest radiography and CT revealed a circumscribed calcified nodule measuring 3.5 mm in the right lower lung lobe. Nodule biopsy revealed fungal infection, which was treated with antifungal medication. After 2 years of follow-up, the patient developed intermittent chest discomfort caused by pleural adhesions, and underwent video-assisted thoracic surgery with pneumolysis. Postoperatively, he developed empyema, which fully resolved with antibiotic therapy. Thereafter, he was followed up at the outpatient clinic and underwent chest CT twice per year. Over time, we observed thickening of the right distal pleura near the lower posterior mediastinum, and several sporadic calcified nodules with gradually increasing intensity, which eventually merged into a single calcified curve-shaped thoracolith measuring approximately 9 cm in length during the 5-year follow-up.

CONCLUSION

This study documented the formation of a rare thoracolith shape observed for the first time.

A Case of Intractable Lung Abscess Following Dropped Gallstone-Induced Subphrenic Abscess: A Rare Postoperative Complication Caused by Dropped Gallstone During Laparoscopic Cholecystectomy

Dropped gallstones into the abdominal cavity due to perforation of the gallbladder occasionally occur during laparoscopic cholecystectomy. Abscess formation caused by residual gallstones is one of the late postoperative complications after laparoscopic cholecystectomy. Most of them are intra-abdominal abscesses; however formation of intra-thoracic abscesses, in particular, lung abscess, is less described, and surgery for an intra-thoracic abscess is rarely performed. We describe a case of intractable lung abscess following dropped gallstone-induced subphrenic abscess caused by a residual gallstone after 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.

Spilled gallstones after laparoscopic cholecystectomy: a systematic review

<b> Aim: </b> The study was conducted to analyse the recent peer-reviewed literature related to symptomatic spilled gallstones after Laparoscopic Cholecystectomy (LC). </br></br> <b>Materials and methods:</b> Articles published in the peer-reviewed journals of repute from 20122022 were evaluated for nine variables including: [I] age of the patient, [II] gender, [III] interval since index LC, [IV] index LC if emergent/difficult or elective/straightforward, [V] clinical presentation, [VI] spilled gallstones if detected by imaging, [VII] management, [VIII] approach to management, [IX] number of spilled gallstones. </br></br> <b>Results:</b> There were a total of 71 cases (37 males and 34 females) with a mean age of 63.7 years. The time of onset of symptoms from spilled gallstones, after index LC, ranged from 2 days to 15 years and 57 patients (80.3%) presented within 6 years. Forty (56.3%) patients were unaware of the fact that gallstone spillage had occurred during index LC. The retained gallstones were detected by imaging in 47 (66.1%) cases and they were multiple in 51 (71.8%). In 52 patients (73.2%), the stones manifested as abdominal abscess/foreign body granuloma; the other presentations being pelvic pain/fistula, intestinal obstruction, abdominal lump simulating malignancy, incidental finding of metastatic lesions and generalized peritonitis. The major approaches adopted to retrieve the retained stones included open surgery, laparoscopy and percutaneous drainage. There were two deaths (2.9%) due to spilled gallstones. </br></br> <b>Conclusion:</b> Retained gallstones represent a complication of laparoscopic cholecystectomy (LC) that has a potential to create morbidity and diagnostic difficulties, even after a substantial delay. There is a need to spread awareness about the adverse effects of spilled stones so that they are actively looked for and retrieved if gallbladder perforates during cholecystectomy. Whenever such a complication occurs, the patient should be properly informed and the details should be very clearly mentioned in the operation notes.

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.

Intra-thoracic migration of a gallstone and its thoracoscopic management

Intra-thoracic migration of a gallstone spilled during laparoscopic cholecystectomy is an extremely rare complication. This is a video documenting the successful thoracoscopic management of a patient who presented with this entity.

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.

Thoracolithiasis-Computed Tomography Findings of Intrapleural Loose Bodies

Thoracoliths are rare benign intrapleural loose bodies, often containing calcification, that are mobile in the pleural cavity. The presence of these intrapleural nodules is referred to as thoracolithiasis. The exact etiology of thoracoliths is unknown, but they presumably result from a prior episode of mediastinal (epipericardial) fat necrosis. Thoracoliths are usually asymptomatic and incidentally encountered on computed tomography. However, they sometimes pose diagnostic challenges, as a thoracolith may be located within a pleural fissure, and is then indistinguishable from a pulmonary nodule. In addition, migration and rotation of thoracoliths within the pleural space observed on serial computed tomography studies has been reported to raise concern that these might be neoplastic lesions, leading to their surgical removal. Awareness of this benign condition is important in order to avoid unnecessary invasive procedures.

Thin-section CT findings of thoracolithiasis

PURPOSE

To review thin-section CT findings of thoracolithiasis.

MATERIALS AND METHODS

Thirty-three thin-section CT scans of 9 patients with thoracolithiasis diagnosed between 2008 and 2016 were reviewed for the location, shape, longest diameter, and calcification of each freely mobile nodule (thoracolith) and for the presence of coexisting abnormalities.

RESULTS

The mean age of 9 patients (5 women) was 65.8 years (SD 14.9; range 37-83 years). Eight were > 50 years of age. Three patients had two thoracoliths, and the remaining 6 patients had one. Thoracoliths were in the left (n = 9) or right (n = 3) pleural cavity, with most in the lower pleural cavity. Nine thoracoliths were found to be larger at follow-up. The median diameters of the 12 thoracoliths were 4.9 mm (range 2.1-10.6 mm) and 6.2 mm (range 3.6-11.0 mm) on the initial and latest follow-up CT scans, respectively. Concomitant old granulomatous disease (n = 6) and diffuse systemic sclerosis-related interstitial lung disease (n = 2) were noted.

CONCLUSION

Thoracolithiasis can manifest as one or two small calcified nodules. It tends to occur in the left lower pleural cavity, occur in a patient aged > 50 years, be larger on follow-up, and coincide with other diseases.

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.

Back to the gallstone: a mischievous cause of morbidity

Laparoscopic cholecystectomies (LCs) are the gold standard treatment of symptomatic gallstone disease worldwide. However, with this technique comes the increased risk of retained spilled gallstones. We describe a case of a 77-year-old man who presented 2 months after undergoing a LC, with right upper quadrant pain. Abdominal ultrasound scan showed no significant complications, but he continued to have grumbling pains. These were investigated with an abdominal CT scan, prompting suspicion of a colorectal malignancy with pleural metastasis. However, on review by two different multidisciplinary teams, the final conclusion was probable residual gallstones with associated inflammation. This diagnosis was rather dramatically confirmed when the patient went on to expel gallstones percutaneously from his back and coughed out of his respiratory tract. This case highlights the importance of operative documentation of spilled gallstones, which can, in addition to more surprising consequences, mimic malignancy on investigation. This can lead to delay in correct management and cause undue patient distress.

Dropped Gallstones Causing a Perihepatic Abscess and Empyema

Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation.