Ann Thorac Surg 2007;84:1760-1762. doi:10.1016/j.athoracsur.2007.06.040
© 2007 The Society of Thoracic Surgeons
Case Reports
Dropped Gallstones Causing Transdiaphragmatic Migration and Thoracic Empyema
Eric Bergeron, MD*,
Claude Beaulieu, MD,
Louise Passerini, MD,
Sebastien Ratte, MD
Charles LeMoyne Hospital, Department of Surgery and Cardiothoracic Surgery, University of Sherbrooke, Quebec, Canada
Accepted for publication June 13, 2007.
* Address correspondence to Dr Bergeron, Charles LeMoyne Hospital, 3120 Taschereau Blvd, Greenfield Park, Quebec, J4V 2H1, Canada (Email: eric.bergeron{at}traumaquebec.org).
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Abstract
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We discuss the case of a 72-year-old female, Asiatic patient who had transdiaphramatic migration of stones after laparoscopic cholecystectomy for a gangrenous cholecystitis. The patient presented with a right thoracic empyema and underwent thoracic decortication. The pertinent literature is reviewed. Pathology and clinical presentation are discussed.
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Introduction
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Perforation of the gallblader and dropped gallstones represent frequent complications of laparoscopic cholecystectomy [1]. Abscesses may occur secondary to retained gallstones in a low percentage of cases [2]. Migration of retained gallstones into the thoracic cavity has been described after subphrenic abscess [3].
We present and discuss an interesting and unusual case of thoracic empyema due to retained gallstones after laparoscopic cholecystectomy for acute cholecystitis in an Asiatic woman. The differential diagnosis and the related literature are reviewed.
The patient was a 72-year-old Chinese woman with type II diabetes. She was operated on for acute cholecystitis. A laparoscopic cholecystectomy was performed for a gangrenous gallbladder. During the laparoscopy a few gallstones were dropped into the peritoneal cavity and most of them were retrieved. Profuse lavage was carried out and a closed-suction drain was left in place, which was removed on postoperative day 3 with minimal serous drainage. Intravenous antibiotics (ie, ciprofloxacin and metronidazole) were administered for 7 days. The patient was discharged on postoperative day 9. One week later she was fine and had no complaints.
She presented to the emergency room 6 weeks later with right pleuritic pain. She was started on moxifloxacin (400 mg daily) with a presumptive diagnosis of community-acquired pneumonia. The chest x-ray film showed a right pleural effusion. An unsuccessful attempt to puncture the pleural effusion was done. The following day an ultrasound confirmed the pleural effusion and again several attempts to retrieve the fluid were unsuccessful. On the third day a computed tomographic scan confirmed loculations of the pleural fluid posteriorly (Fig 1). A small fluid collection (3.2 cm by 2.0 cm) was noted behind the liver. Retained stones were demontrated in the Morrison’s pouch. Antibiotics were changed for ceftriaxone and metronidazole to guard against a possible subphrenic abscess. An attempt to drain the thoracic collection was carried out under computed tomographic guidance, but the fluid was found to be too thick to be aspirated.
On day 4 of admission the patient was taken to the operating room for a right thoracotomy. The pleural space was filled with organized gelatinous fluid. The right lower lobe was embedded in a thick membraneous material. There was a severe inflammatory reaction on the dome and the posterior aspect of the diaphragm, and a frank communication through the diaphram could not be demonstrated. Decortication was carried out. Gallstones were retrieved postero-inferiorly from the pleural collection.
Pleural fluid cultures grew enterococcus. The patient was then treated with vancomycin for 3 weeks and was discharged. The patient is still alive and well 3 years later without further complications.
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Comment
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Perforation of the gallbladder is the most common complication of laparoscopic cholecystectomy [1, 2] and occurs in approximately 20% of cases [4]. Spillage of stones often occurs in as much as 50% of these cases [2]. It is estimated that only two thirds of the dropped stones are retrieved [4].
The reported abdominal complication rate after spillage of stones is 1.4% [2]. Abdominal abscess represents the most frequent complication of retained stones [1]. Complications attributable to missed stones are estimated to be less than 1% of all laparoscopic cholecystectomies [4]. Conversion to laparotomy is therefore unjustified [2], but reasonable efforts to remove all dropped stones should be made [1].
In the case presented here, we were facing an acute necrotizing cholecystitis and spillage of stones occurred because of friability of the gallbladder’s wall. As suggested, efforts were made to retrieve all the stones and copious lavage was carried out [5]. Antibiotic therapy was initiated as a tentative to prevent abscess formation [1]. Thoracic complications developed in the patient relatively early in the postoperative period, and not less surprisingly, these complications were without the presence of a frank subphrenic abscess. Although the conversion rate remains higher in cases of gangrenous cholecystitis, laparoscopic approach in these cases remains associated with lower rates of respiratory [6] and abdominal complications [7].
Notwithstanding the differential diagnosis, the severity of the initial abdominal process with the complicated surgery and the time relationship of the right thoracic problem, a surinfection of a reactional right pleural effusion secondary to the abdominal inflammatory process or to a right pneumonia or atelectasis represented the most probable causes [7]. However, this case remains unusual considering the thoracic complication and empyema in the absence of a frank subphrenic abscess. Migration of stones through the diaphragm has been described in case reports [3], but mainly secondary to subphrenic abscesses [4]. The underlying pathophysiologic process involves inflammatory reaction secondary to the presence of retained stones. They may then erode through the diaphragm and cause a bronchopleural fistula with cholelithopthysis, thoracic empyema, or pulmonary abscess [1]. In the case presented here, a computed tomographic scan could miss stones in the pleural cavity, or they may have been mistaken for stones in the abdomen. In the presence of an empyema with suspected stones, a thoracotomy was clearly indicated. As for abdominal abscesses secondary to retained stones [3], only open drainage and removal of the stones can probably achieve a good, long-term result, as recurrence will result after isolated drainage [8].
In conclusion, when a thoracic empyema occurs after an acute cholecystitis and laparoscopic cholecystectomy, more frequent causes, such as infection of a pleural effusion or complication of postoperative pneumonia must be contemplated first. However, even if the occurrence of a thoracic empyema remains certainly low, complications secondary to retained gallstones, even if more infrequent, should be kept in mind for difficult and complicated cases, particularly if a history of spillage of gallstones can be identified.
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References
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- Zehetner J, Shamiyeh A, Wayand W. Lost gallstones in laparoscopic cholecystectomy: all possible complications Am J Surg 2007;193:73-78.
- Schäfer M, Suter C, Klaiber C, Wehrli H, Frei E, Krähenbühl L. Spilled gallstones after laparoscopic cholecystectomy: a relevant problem?A retrospective analysis of 10,174 laparoscopic cholecystectomies. Surg Endosc 1998;12:305-309.
- Barnard SP, Pallister I, Hendrick DJ. Cholelithoptysis and empyema formation after laparoscopic cholecystectomy Ann Thor Surg 1997;60:1100-1102.
- Brockmann JG, Kocher T, Senninger NJ, Schürmann GM. Complications due to gallsotnes lost during laparoscopic cholecystectomy: an analysis of incidence, clinical course, and management Surg Endosc 2002;16:1226-1232.
- Hashimoto M, Matsuda M, Watanabe G. Reduction of the risk of unretrieved stones during laparoscopic cholecystectomy Hepatogastroenterology 2003;50:326-328.
- Suter M, Meyer A. A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe? Surg Endosc 2001;15:1187-1192.
- Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomized trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis Lancet 1998;351:321-325.
- Memon MA, Jenkins Jr HJ, Fitzgibbons Jr RJ. Spontaneous erosion of a lost intra-abdominal gallstone through the back eight months following laparoscopic cholecystectomy JSLS 1997;1:153-157.
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Abstract
Introduction
