Spilled gallstones mimicking a retroperitoneal sarcoma following laparoscopic cholecystectomy

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.

Spilled gallstone mimicking intra-abdominal seeding of gallbladder adenocarcinoma: A case report

BACKGROUND

Gallbladder rupture is common in laparoscopic cholecystectomy because the gallbladder is usually in acute or chronic inflammation status. The gallstones may sometime be spilled into the peritoneal cavity, resulting in intra-abdominal abscess if the gallstones were not retrieved. The diagnosis of intra-abdominal abscess caused by unretrieved gallstone can usually be correctly identified in the routine imaging studies, such as abdominal ultrasonography or computed tomography (CT). Here we present a case of abscess formation from unretrieved gallstone following laparoscopic cholecystectomy, which mimics the imaging findings of metastatic gallbladder adenocarcinoma.

CASE SUMMARY

This case described a 78-year-old man who received laparoscopic cholecystectomy and gallbladder adenocarcinoma was diagnosed after surgery. After adjuvant chemotherapy, the following up abdominal CT showed several small nodules at right upper abdomen and peritoneal carcinomatosis is considered. Repeated laparoscopic surgery for the excision of seeding tumor was conducted and the pathological diagnosis of the nodules and mass was inflammatory tissues and gallbladder stone.

CONCLUSION

Spilled gallstones are a common complication during laparoscopic cholecystectomy and some gallstones fail to be retrieved due to the size or the restricted view of laparoscopic surgery. For spilled gall bladder stones, surgeons may consider regular computerized tomography follow-up, and if necessary, laparoscopic examination can be used as a means of confirming the diagnostic and treatment.

Practices and Attitudes of Surgeons With Regard to Spilled Gallstones During Laparoscopic Cholecystectomy: A Cross-Sectional Study From Saudi Arabia

BACKGROUND

Gallbladder perforation and gallstone leakage are frequent complications following laparoscopic cholecystectomy (LC). Failure to remove gallstones may result in several issues that manifest immediately or years later. The goal of this study was to evaluate the attitudes of surgeons and the procedures used by them to deal with gallstone spillage during LC.

METHODS

A cross-sectional design was followed. Surgeons in nine healthcare facilities in the Qassim region of Saudi Arabia were approached through non-probability convivence sampling and the survey was distributed in each of the general surgery divisions. The study included general surgeons who currently performed LC and incomplete responses and interns were excluded. A self-administered questionnaire was developed with 18 questions regarding demographics, center, and designation at the hospital, surgeons' experience of LC, and exposure to gallstone spillage. Furthermore, items regarding knowledge, attitude, and self-reported practices related to gallstone spillage such as incidence, complications, and intervention taken to prevent gallstone spillage were also included. The level of significance was set at P <0.05.

RESULTS

There were 82 participants of both genders, including consultants, specialists, and residents. While only 23 (28%) participants had actually observed patients with complications from spilled stones, 46 (56.1%) participants were aware of this possibility, 53 (64.6%) deemed it inappropriate to bring up gallstone spillage when securing consent for LC, and 67 (81.7%) believed that such an incident needed to be documented in the operation notes. Only 11 (13.4%) thought that the complications arising out of the unretrieved gallstones should fall under the legal purview of the operative surgeon. There were very few complications of spilled gallstones that the participants were aware of, and none of them anticipated problems to arise more than three years after LC.

CONCLUSIONS

Awareness of the risks associated with gallstone spillage during LC needs to be raised, and it is imperative to standardize the practices related to their management.

[Minimally invasive interventions for complications associated with intra-abdominal calculi after laparoscopic cholecystectomy]

OBJECTIVE

To study the possibilities of minimally invasive methods for removing intra-abdominal calculi after laparoscopic cholecystectomy.

MATERIAL AND METHODS

There were 5 patients with abdominal abscesses associated with infected calculi after previous laparoscopic cholecystectomy at the Sklifosovsky Research Institute for Emergency Care between 2020 and 2023. Mean age of patients was 55±12 years. There were 3 (60%) women and 2 (40%) men. All patients underwent minimally invasive treatment.

RESULTS

Four patients (80%) underwent percutaneous drainage of abscess with subsequent replacement by larger drains and removal of calculi with endoscopic assistance. Event-free period after cholecystectomy was 44±32 months. One patient developed subhepatic abscess in 72 months after laparoscopic cholecystectomy. This patient underwent transluminal removal of calculus through the duodenal wall. There was 1 calculus in 3 (60%) patients, 2 calculi in 1 (20%) patient and 3 calculi in 1 (20%) patient.

CONCLUSION

The above-mentioned cases demonstrate successful minimally invasive interventions for symptomatic abdominal calculi after laparoscopic cholecystectomy. Minimally invasive treatment can reduce surgical aggression and accelerate rehabilitation.

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.

Spilled gallstones after laparoscopic cholecystectomy: a systematic review

&lt;b&gt; Aim: &lt;/b&gt; The study was conducted to analyse the recent peer-reviewed literature related to symptomatic spilled gallstones after Laparoscopic Cholecystectomy (LC). &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Materials and methods:&lt;/b&gt; 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. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; 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. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; 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.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Bile Granuloma Mimicking Peritoneal Seeding: A Case Report

Laparoscopic cholecystectomy is a widely used treatment method for most cholelithiasis and is a relatively safe procedure. Foreign body granulomatous reaction to bile or gallstone spillage during laparoscopic cholecystectomy has rarely been reported. We report a case of bile granuloma after laparoscopic cholecystectomy, which mimicked peritoneal seeding. A 59-year-old Korean man presented with right upper quadrant pain. He underwent laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis. Pathologic examination revealed an incidental adenocarcinoma invading the lamina propria with acute cholecystitis and cholelithiasis. After 3 months, follow-up abdominal computed tomography revealed a subhepatic nodule, which showed hypermetabolism on positron emission tomography–computed tomography. Suspecting localized peritoneal seeding, wedge resection of the liver, wedge resection of the transverse colon, and omentectomy were performed. Pathologic examination of the resected specimens revealed multiple bile granulomas. Awareness of bile granuloma mimicking malignancy is noteworthy for patient management to reduce unnecessary procedure during postoperative surveillance.

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.

Gallstone-related abdominal cystic mass presenting 6 years after laparoscopic cholecystectomy: A case report

INTRODUCTION

Although gallbladder perforation and gallstones spillage are common complications during laparoscopic cholecystectomy (LC), clinically significant complications resulting from stones left in the peritoneum are extremely uncommon. We report a rare case of spilled gallstones complication with a late and uncharacteristic presentation.

PRESENTATION OF THE CASE

A 44-year-old Caucasian female presented with a complaint of a mass in the right upper quadrant associated with a cramping pain for the last 6 months. Her past surgical history included a laparoscopic cholecystectomy performed six years ago. Abdominal computed tomography demonstrated an intra-abdominal cystic mass. On open exploration, a cystic mass adhered to the abdominal wall was excised containing two gallstones. The patient tolerated the procedure well and had uneventful postoperative recovery.

DISCUSSION

Although unretrieved gallstones are considered harmless, serious complications can occur early or late. The most frequent complication is the formation of abscesses in different locations.

CONCLUSION

The diagnosis of gallstone abscess after years of LC is usually a diagnostic challenge. Obtaining a comprehensive past surgical history still plays an important role in the assessment of patients presenting with unusual findings.