Ann Thorac Surg 1995;60:1100-1102
© 1995 The Society of Thoracic Surgeons
Case Reports
Cholelithoptysis and Empyema Formation After Laparoscopic Cholecystectomy
Sion P. Barnard, FRCS,
Ian Pallister, FRCS,
David J. Hendrick, MRCP,
Noel Walter, MRCPath,
Graham N. Morritt, FRCS
Department of Cardiothoracic Surgery, Freeman Road Hospital, Newcastle-Upon-Tyne, United Kingdom
Accepted for publication April 6, 1995.
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Abstract
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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.
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Introduction
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Although atelectasis and pleural effusion are common [1], serious thoracic complications of laparoscopic cholecystectomy are rare. A recent review of more than 77,600 patients who underwent this operation revealed only 10 cases of pneumothorax and 1 of diaphragmatic puncture [2]. However, there are isolated case reports of cholelithoptysis several months after laparoscopic cholecystectomy [3, 4]. A gallstone in the thorax has been described after open cholecystectomy, but this presented as hemoptysis and was discovered as the cause of this only after lobectomy [5]. Pleural gallstones were seen as a complication of ruptured gallbladder at laparoscopic cholecystectomy [6].
A woman of 54 years underwent laparoscopic cholecystectomy for gallstones. During the operation the gallbladder ruptured, releasing gallstones. The postoperative course was marked by right pleuritic chest pain and pleural effusion. Two episodes of right-sided chest infection occurred over the next 6 months, improving with antibiotics. Although her general condition was good there was suspicion of chronic infection, and she underwent abdominal computed tomographic scan 7 months after operation; a right subphrenic abscess was found, associated with calcified bodies. In view of her general improvement we decided to observe this only, rather than formally drain the chronic abscess. One month later she complained only of occasional right chest pain. Six months later a further episode of pneumonia with hemoptysis led to computed tomography of the chest, which demonstrated a gallstone in the right middle lobe (Fig 1
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Fig 1. . Computed tomogram of midthorax showing collapsed middle lobe containing one large and one small gallstone.
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Preliminary right thoracoscopy was quickly converted to thoracotomy because of dense adhesions. There was no free pus, and the middle lobe was collapsed. Middle lobectomy was carried out, and opening the specimen revealed a pigmented gallstone measuring 1.2 cm in diameter (Fig 2). Although there were adhesions onto the diaphragm, no track through to the peritoneal cavity could be demonstrated.
The patient made an uneventful recovery from the operation and was well at follow-up 3 months later.
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Comment
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Laparoscopic cholecystectomy is being carried out with increasing frequency and a low morbidity [7]. Complications peculiar to this operation include trochar site hernias and trochar site abscess from spilled stones [8]. There have been two recent reports of cholelithoptysis after laparoscopic cholecystectomy [3, 4]. Gallstone spillage at operation occurred in both patients described by Lees and associates [4]; subdiaphragmatic or retroperitoneal abscess resulted. Although not proven, spilled gallstones were thought responsible for the only other reported patient with cholelithoptysis [3]; she too had a subdiaphragmatic fluid collection.
The patient described above also had gallstone spillage at operation and subsequent subdiaphragmatic abscess. Her management differed in that she required a thoracotomy to remove a cavity containing the gallstone and the middle lobe.
Gallstone spillage probably occurs quite commonly at laparoscopic cholecystectomy [2] and therefore may not cause any untoward sequelae. Abscess formation is a feature of spillage in the case described here and with other reported cholelithoptysis [3, 4]. It may be that the stones were infected at time of spillage; pigmented stones, as found in this patient, are more likely to be infected than cholesterol stones [9], and this nidus of infection could lead to subdiaphragmatic abscess formation and passage of stones through the diaphragm and into the lung. Gallstone spillage at laparoscopic cholecystectomy occurs relatively frequently [8], and the complication described above might be expected to be seen more often. Two reasons may account for this: the spilled stones may be of the more common cholesterol type and unlikely to be infected, and even if infection does occur it may not progress to subphrenic abscess formation, which appears to be a prerequisite in the cases described to date [3, 4]. Measures to prevent gallstone spillage such as placing the excised gallbladder in a retrieval bag before removal [10] should minimize the incidence of this complication.
In summary, prolonged chest symptoms after laparoscopic cholecystectomy, particularly if the operation was complicated by gallstone spillage or subphrenic abscess, should raise the suspicion of intrathoracic and possibly intrapulmonary gallstone migration.
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Footnotes
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Address reprint requests to Dr Barnard, Freeman Road Hospital, Newcastle-Upon-Tyne, NE7 7DN, UK.
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References
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- McAllister JD, D'Altorio RA, Snyder A. CT findings after uncomplicated laparoscopic cholecystectomy. J Comput Assist Tomogr 1991;15:770–2.[Medline]
- Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and analysis of 77604 cases. Am J Surg 1993;165:9–14.[Medline]
- Downie GH, Robbins MK, Souza JJ, Paradowski LJ. Cholelithoptysis. A complication following laparoscopic cholecystectomy. Chest 1993;103:616–9.[Medline]
- Lee VS, Paulson EK, Libby E, Flannery JE, Meyers WC. Cholelithoptysis and cholelithorrhea: rare complications of laparoscopic cholecystectomy. Gastroenterology 1993;105:1877–81.[Medline]
- Schwegler N, Endrei E. Gallstone in the lung. Radiology 1975;115:541–2.[Abstract]
- Brazinsky SA, Colt HG. Thoracoscopic diagnosis of pleurolithiasis after laparoscopic cholecystectomy. Chest 1993;104:1273–4.[Abstract/Free Full Text]
- The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073–8.[Abstract]
- Dreznik Z, Soper NJ. Trochar site abscess due to spilled gallstones: an unusual late complication of laparoscopic cholecystectomy. Surg Laparosc Endosc 1993;3:223–4.[Medline]
- Cetta F. The role of bacteria in pigment gallstone disease. Ann Surg 1991;213:315–26.[Medline]
- Lingham K, Carter R, Drury JK. Retained gallstones following laparoscopic cholecystectomy. J R Coll Surg Edin 1993;28:353.
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Abstract
Introduction
