Ann Thorac Surg 2005;79:e26-e27
© 2005 The Society of Thoracic Surgeons
Case report
Lung Abscess Due to Retained Gallstones With an Adenocarcinoma
Scott G. Houghton, MD,
Juan A. Crestanello, MD,
Anh-Quan T. Nguyen, MD,
Claude Deschamps, MD*
Department of Surgery, Division of Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
Accepted for publication October 18, 2004.
* Address reprint requests to Dr Deschamps, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; (E-mail: deschamps.claude{at}mayo.edu).
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Abstract
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We describe a patient who had a right lower lobe mass containing calcifications consistent with gallstones develop 31/2 years after laparoscopic cholecystectomy. Thoracotomy revealed a chronic abscess containing pigmented gallstones and an adjacent area of bronchoalveolar adenocarcinoma involving both N1 and N2 lymph nodes.
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Introduction
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Thoracic complications after spilled gallstones are uncommon after laparoscopic cholecystectomy. Failure to recognize the problem may ultimately result in hemoptysis, empyema, and even broncholithiasis. [1–3] The combination of such complications with a synchronous diagnosis of nonsmall cell carcinoma has not been previously reported.
A 61-year-old woman of Southeastern Asian descent presented in September 2003 with a 31/2 history of cough and a 1-year history of hemoptysis that had worsened during the past 2 weeks. In January 2000, she underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. The gallbladder was perforated during the procedure with spillage of gallstones into the peritoneal cavity. She was dismissed without further complications. A cough started shortly thereafter, productive of white sputum. The patient denied weight loss, fever, chills, night sweats, or shortness of breath. In July of 2000, the patient complained of hemoptysis and underwent a computed tomography of the chest (Fig 1). In late 2002, a thoracentesis demonstrated serous fluid; cytology was negative for malignancy but it did show inflammatory cells. The computed tomography was repeated and it showed right pleural thickening and an irregularity in the costophrenic angle (not shown). Her physician elected to observe her in 2000 and again in 2002.
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Fig 1. Computed tomography of the lower chest demonstrating a mass containing calcification in the right costophrenic angle (arrow).
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In September 2003, she was seen again because of worsening hemoptysis. Another computed tomographic scan of the chest was performed which showed a 3-cm mass in the right lower lobe containing calcifications consistent with gallstones and a separate nodule anteriorly in the costophrenic angle (Fig 2). Hilar and subcarinal lymphadenopathy was now present. Bronchoscopy revealed a large amount of blood in the right lower lobe bronchus; cytology of the washings did not show malignancy. Cultures of the washings grew Stenotrophomonas and Klebsiella pneumonia, whereas stains for acid fast bacilli and fungi were negative. Sputum cultures also grew K. pneumonia. A 2-week course of antibiotics was administered without improvement in symptoms. Based on the patient's history and studies it was felt that conservative therapy would not be effective and thoracotomy with resection was recommended.
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Fig 2. Computed tomography of the lower chest demonstrating a mass in the right lower lobe and a separate nodule in the costophrenic angle anteriorly (arrows).
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In October 2003, the patient was taken to the operating room and a right thoracotomy was performed. A 5-cm mass was noted in the right lower lobe that was adherent to the diaphragm. On mobilization, several pigmented gallstones came out of a defect in the lung mass. A 1-cm defect in the diaphragm was also noted and communicated with the mass. The diaphragmatic defect was debrided and oversewn using a permanent suture. A wedge resection of the mass was performed as well as a wedge resection of the nodule in the costophrenic angle. Examination of a frozen section of the latter revealed an unexpected adenocarcinoma. A formal right lower lobectomy was undertaken with removal of the subcarinal, right paratracheal, and inferior pulmonary ligament lymph nodes. Cultures of the mass grew K. pneumonia, the same bacteria isolated from preoperative sputum cultures and bronchial washings. Final pathology demonstrated chronic inflammation with adjacent, invasive grade 3 of 4 adenocarcinoma with bronchoalveolar features. There was no pleural involvement with 10 of 17 N1 nodes and 1 of 9 N2 nodes containing metastasis. The patient was discharged from the hospital on the postoperative day 5 without complications.
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Comment
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Migration of gallstones into the lung is an uncommon complication after laparoscopic cholecystectomy [1–4]. The risk of gallbladder perforation during laparoscopic cholecystectomy has been reported to range from 11.6% to 36% [5, 6], often with resultant stone spillage. Surgeons are not always able to retrieve all of the spilled stones without increasing the morbidity of the operation. Therefore, stones that are not retrievable laparoscopically are sometimes left in the peritoneal cavity. The rational for this stems from the low rate of complications secondary to unretrieved stones short-term and long-term [5–7].
Several case reports have been published on the thoracic complications of retained gallstones in the peritoneal cavity [1, 2, 4, 8]. These have involved hemoptysis [2], empyema or abscess [1, 2, 4, 8], cholelithoptysis [4], and death. In this article we present a patient who presented with an abscess and hemoptysis and was found to have a synchronous adenocarcinoma at the time of surgery.
This case illustrates important points. While spillage of gallstones during laparoscopic cholecystectomy may not warrant conversion to an open procedure, every reasonable effort should be made to retrieve spilled stones. Gallstones retained within the peritoneal cavity are not without consequence, and patients with intraperitoneal stones need to be followed closely for the development of complications. These patients may benefit from being seen at 1-year follow-ups after cholecystectomy. Complications secondary to retained intraperitoneal gallstones are not limited to the peritoneal cavity. In this particular case, the known right lower lobe mass may have distracted the treating physician and prevented the patient from getting early treatment for a suspicious lung nodule. A delay in the treatment of the thoracic complication resulted in a delay in the diagnosis and treatment of lung cancer. We believe that there have been no reports of asymptomatic pleural or pulmonary masses after spilled gallstones. We believe it is in the patient's best interest to consider surgical removal of a right lower lobe mass in the context of previously spilled gallstones. Any undiagnosed mass should be investigated and resection considered.
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References
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Abstract
Introduction
