Ann Thorac Surg 1999;68:254-255
© 1999 The Society of Thoracic Surgeons
Case Reports
Cholelithoptysis and pleural empyema
Priya Chopra, MDa,
Patrick Killorn, MDc,
Reza John Mehran, MDCMb
a Department of Surgery, University of Ottawa, Ottawa, Canada
b Department of Thoracic Surgery, University of Ottawa, Ottawa, Canada
c Montfort Hospital, Ottawa, Ontario, Canada
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Abstract
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We report a case of delayed cholelithoptysis and pleural empyema caused by gallstone spillage at the time of laparoscopic cholecystecomy. An occult subphrenic abscess developed, and the patient became symptomatic only after trans-diaphragmatic penetration occurred. This resulted in expectoration of bile, gallstones, and pus. Spontaneous decompression of the empyema occurred because of a peritoneo-pleuro-bronchial fistula. This is the first case of such managed nonoperatively and provides support for the importance of intraoperative retrieval of spilled gallstones at the time of laparoscopic cholecystectomy.
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Introduction
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Gallstone spillage occurs commonly after gallbladder surgery performed by laparoscopy. Leaving stones in the abdominal cavity is thought to be harmless. We report the case of a patient in whom the spillage was not so innocuous.
A 64-year-old woman underwent laparoscopic cholecystectomy at another institution for gallstone pancreatitis. The operative note commented on an intraperitoneal spillage of bile and gallstones. She was well until 2 years postcholecystectomy, when she started to experience right upper quadrant and flank pain associated with low-grade fever. These symptoms continued for 3 weeks and resolved spontaneously. Six months afterwards, she developed recurrent pneumonia with expectoration of "greenish fluid" and occasional "stones." There were no abnormal physical findings. Liver function tests were within normal range. Computed tomography (CT) of the thorax and abdomen showed a right sub- and supradiaphragmatic abscess. No liver parenchymal or ductal abnormalities were noted. Because the patient was improving, she was started on broad-spectrum oral antibiotics.
She was referred for opinion to our institution several weeks later and commented that her symptoms had resolved promptly after an episode during which she expectorated approximately 500 cc of green pus. At bronchoscopy, there was no endobronchial abnormality or purulent drainage. Bronchial washings were negative for bilirubin but the amylase content was 104 U/L. No organisms were identified on culture. Crystallographic analysis of expectorated stones was performed, and the compostion of 95% cholesterol and 5% amorphous material was interpreted to be consistent with biliary tract origin. Hepato-iminodiacetic acid (HIDA) scan showed normal bile drainage. We reevaluated the subphrenic space by magnetic resonance imaging, which showed resolution of the subphrenic collection and significant improvement in the supradiaphragmatic abscess. Because we could not find any indication for surgical intervention, we continued the antibiotics orally (trimetroprim sulfametaxazol) for a total of 1 month. She remains well 10 months after her last episode of cholelithoptysis.
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Comment
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We present a case of bilioptysis and cholelithoptysis as a delayed complication of stone spillage at the time of laparoscopic cholecystectomy. Boyd in 1977 [1] described the relationship of subphrenic infection to the formation of broncho-biliary fistulas. Volume and pressure of bile accumulation cause eventual erosion through the diaphragm and secondary pleural infection. If adhesions exist between the lung and diaphragm, perforation into the bronchial system can occur with broncho-biliary fistulization and bilioptysis. Without such adhesions, bilio-pleural fistula with thoracobilia and empyema will occur [2]. We believe that our patient initially developed a delayed subdiaphragmatic infected collection from spillage at cholecystectomy, which fistulized through the diaphragm and into the pleural cavity. This empyema then spontaneously decompressed by fistulizing into the bronchial tree. We do not believe there is active communication between the biliary and bronchial tree.
The differential diagnosis of this patient coughing up pus and stones included spontaneous drainage of a pulmonary abscess, bronchiectasis, and chronic tuberculosis with broncholithiasis. However, the CT appearance and the negative cultures prompted us to send the stones for analysis. A search for the type of amylase isoenzyme in the bronchial washings could have been helpful in establishing the diagnosis if crystallographic analysis was not available.
It has been reported that stones are left after 13%–32% of all laparoscopic cholecystectomies [3]. The incidence of resulting complications is not known, however, case reports have discussed abscess formation, bowel obstruction or perforation, and stone migration into ovaries and pouch of Douglas causing dysmenorrhea [4]. Despite these reports, several series have commented that stone spillage did not increase the complication rate, though duration of follow-up may have been inadequate [5–7].
This case demonstrates the potential for morbidity from stone spillage at the time of laparoscopic cholecystectomy. Typical management includes resolution of distal bile drainage if one exists in the case of a true choledochobronchial fistula. Proper drainage of the subphrenic space either by an open approach with resection of the 11th rib or percutaneously and in the presence of an empyema, empyemectomy, and muscle transposition give very good results.
Aggressive efforts should be made at laparoscopic cholecystectomy to prevent stone spillage and to retrieve stones when it does occur. Prevention is the key to avoid such complications as the one described here.
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References
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Boyd D.P. Bronchobiliary and bronchopleural fistulas. Ann Thorac Surg 1977;24:481-487.[Abstract]
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Adams H.D. Pleurobiliary and bronchobiliary fistulas. J Thorac Surg 1955;30:255-260.
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Soper N.J., Dunnegan D.L. Does intraoperative gallbladder perforation influence the early outcome of laparoscopic cholecystectomy?. Surg Laparosc Endosc 1991;9:344-347.
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Patterson E.J., Nagy A.G. Don’t cry over spilled stones? Complication of gallstones spilled during laparoscopic cholecystectomy. Can J Surg 1997;40:300-304.[Medline]
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Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073-1078.[Abstract]
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Litwin D.E.M., Girotti M.J., Poulin E.C., Mamazza J., Nagy A.G. Laparoscopic cholecystectomy. Can J Surg 1992;35:292-296.
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Cushieri A., Dubois F., Mouiel J., et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161:385-387.[Medline]
Accepted for publication December 29, 1998.
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Y. B. Werber and C. D. Wright
Massive hemoptysis from a lung abscess due to retained gallstones
Ann. Thorac. Surg.,
July 1, 2001;
72(1):
278 - 279.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
