Intraperitoneal Spilled Gallstones Presenting as Fever of Unknown Origin After Laparoscopic Cholecystectomy: FDG PET/CT Findings

Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication-case report and review of the literature

Introduction

Laparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC.

Methods

Case report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022.

Case Report

An 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation.

Conclusion

Intraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC.

Hepato-Biliary Imaging in an Acute Setting: Is There a Role for Nuclear Medicine?

Nuclear medicine (NM) is not commonly considered as a first-line imaging modality in hepato-biliary (HB) emergencies. The aim of this review is to provide an update on the potential of NM for the imaging of HB emergencies. 99mTc-HIDA scintigraphy showed high diagnostic accuracy for acute cholecystitis, thus being particularly useful in patients at high-risk for surgery due to comorbidities and with no clear findings at US or CT. Although limitedly explored, White blood cell (WBC) scan might have a role in case of acute pancreatitis, especially for the imaging of pancreatic leukocyte infiltration and the prediction of pancreatic necrosis. Scientific literature on 18F-FDG-PET/CT in HB acute disease mainly consists of case reports or case series, describing incidental findings in oncological PET/CT scans. In patients with obstructive jaundice, PET/CT has been proposed to disclose and characterize occult tumoral etiology. Further studies are needed to evaluate the clinical usefulness of the various NM approaches in HB acute settings, particularly with respect to the emerging new technologies (eg, PET/MRI) and radiopharmaceuticals.

Consequences of the spilled gallstones during laparoscopic cholecystectomy: a systematic review

INTRODUCTION

Complications secondary to spilled gallstones can be classified in the category of disease of medical progress because prior to advent of laparoscopic cholecystectomy very few reports published on the topic. The aim of the present study was to investigate the predisposing factors and the complication rate of spilled gallstones during laparoscopic cholecystectomy over the past 21 years.

METHODS

Embase, Pubmed, Medline, Google scholar and Cochrane library were systematically searched for pertinent literature.

RESULTS

Seventy five out of 181 articles were selected including 85 patients; of those 38% were men and 62% women. The median age of the cohort was 64 years old and ranged between 33 and 87 years. Only 23(27%) of the authors reported the incident of spillage of the gallstones during the operation. Time of onset of symptoms varied widely from the second postoperative day to 15 years later. Ten of 85 patients were asymptomatic and diagnosed with spilled gallstones incidentally. The rest of the patients presented with complications of severe morbidity and almost, 87% of the patients needed to be treated with surgical intervention and 12% with US ± CT scan guidance drainage. Only one perioperative death reported.

CONCLUSIONS

Symptomatic patients with lost gallstones present with severe morbidity complications and required mostly major surgical procedures. Therefore, standardisation of the management of spilled gallstones is needed urgently. Hospitals need to review their policy with audits and recommendations and clinical guidelines are needed urgently.

Foreign-body granulomas and abscesses caused by dropped gallstones after cholecystectomy: Four cases diagnosed with multimodality imaging

Four cases (age range, 60-78 years, male:female = 1:3) who had undergone cholecystectomy presented with fever (n = 1), right abdominal pain with fever (n = 1), appetite loss with fever (n = 1), and absence of symptoms (n = 1). Computed tomography (CT) showed an irregular-shaped invasive mass or fluid collection in the right Morrison's pouch, right paracolic gutter, gallbladder fossa, subphrenic space, or abdominal wall. CT and ultrasound revealed gallstones in the granuloma in 3 cases and an abscess in one case. The inflammatory process induced by dropped gallstones may mimic peritoneal malignancies. Awareness of cholecystectomy and the detection of gallstones in the lesion are essential for the diagnosis of dropped gallstones.

Role of PET/CT in Workup of Fever without a Source

Fever without source is a febrile illness without localizing signs or initial obvious cause. Early workup will often include chest radiography and computed tomography (CT) of the abdomen and pelvis, with or without CT of the chest. To evaluate localizing signs or symptoms or to further evaluate findings from initial studies, targeted imaging according to body part can be performed by using radiography, ultrasonography, CT, or magnetic resonance (MR) imaging. Nuclear medicine studies can provide imaging of the whole body and may be helpful when the clinical and conventional imaging workup findings are negative or equivocal in identifying a source of fever. Nuclear medicine studies can be used to detect pathologic changes early in a disease course, even in the absence of an anatomic abnormality. Gallium 67 scintigraphy, indium 111- and technetium 99m-labeled leukocyte scintigraphy, and fluorine 18 fluorodeoxyglucose positron emission tomography (PET)/CT studies are all useful in the evaluation of fever, but the radiopharmaceutical cost for PET/CT is much lower than that for radiolabeled leukocyte studies. The increased use of bundled payments for inpatient admissions requires updated cost evaluations for the preferred nuclear medicine study. For inpatients in whom the findings from the initial clinical workup and imaging studies are nondiagnostic, PET/CT examination may be preferable to radiolabeled leukocyte studies because of its high sensitivity and lower cost. Negative findings at PET/CT can be helpful in excluding a suspected site of infection, and positive findings at PET/CT can be helpful in confirming a suspected site of infection or in identifying an unexpected cause of fever. (©)RSNA, 2016.

High (18)F-FDG uptake in urinary calculi on PET/CT: An unrecognized non-malignant accumulation

AIM

To assess the high (18)F-fluorodeoxyglucose ((18)F-FDG) uptake in urinary calculi on positron-emission tomography/computed tomography (PET/CT).

METHODS

In this study, (18)F-FDG PET/CT examinations were retrospectively reviewed from November 2013 to February 2016 in a single center, and patients with high (18)F-FDG uptake in urinary calculi were identified. The following data were collected from each patient, including age, sex, primary disease, method to verify the urinary calculus, and imaging characteristics of the calculus.

RESULTS

A total of 2758 PET/CT studies (2567 patients) were reviewed, and 52 patients with urinary calculi were identified, in which 6 (11.5%, 6/52) patients (5 males, 1 female, age 34-73 years, median age 60.5 years) demonstrated high (18)F-FDG uptake in the urinary calculi. Among the 6 patients, 3 patients had bladder calculi, 2 patients had renal calculi, and 1 patient had both bladder and renal calculi. The size of the urinary calculi varied from sandy to 19mm on CT. The maximal Hounsfield units of the calculi ranged from 153 to 1078. The SUVmax of the calculi on the routine PET/CT scan ranged from 11.7 to 143.0. Delayed PET/CT scans were performed on 4 patients, which showed the calculi SUVmax increasing in 2 patients, while decreasing in the other 2 patients. One patient with bladder calculus underwent a follow-up PET/CT, which showed enlargement of the calculus as well as the increased SUVmax.

CONCLUSION

This study shows an uncommon high (18)F-FDG uptake in urinary calculi. Recognition of this non-malignant accumulation in urinary calculi is essential for correct interpretation of PET/CT findings.

Subdiaphragmatic gallstone mimicking hepatic malignancy on FDG PET/CT

A 70-year-old man underwent an FDG PET/CT for a possible primary liver malignancy or metastasis found on an abdominal MRI obtained as part of a workup for intermittent abdominal pain. The MRI showed an enhancing lesion at the dome of the right lobe of the liver. The lesion was FDG avid with a discrete central calcification. In conjunction with the patient's history of laparoscopic cholecystectomy 1 year prior, the findings were consistent with inflammation around a migrated subdiaphragmatic gallstone. One month after the scan, a CT-guided percutaneous biopsy of this lesion revealed chronic inflammatory cells with no evidence of malignancy.