Missed gallstones in the bile duct and abdominal cavity: a case report


Irkorucu, O.; Tascilar, O.; Emre, A.Ugur.; Cakmak, Güldeniz.Karadeniz.; Ucan, Bülent.Hamdi.; Comert, M.

Clinics 63(4): 561-564

2008


st
)
CLINICS
2008;64:561-4
LETTER
TO
THE
EDITOR
MISSED
GALLSTONES
IN
THE
BILE
DUCT
AND
ABDOMINAL
CAVITY:
A
CASE
REPORT
doi:
10.1590/S1807-59322008000400027
Oktay
Irkorucu,
Oge
Tascilar,
Ali
Ugur
Emre,
Gilldeniz
Karadeniz
cakmak,
Billent
Hamdi
Ucan,
Mustafa
Comert
INTRODUCTION
Laparoscopic
cholecystectomy
is
considered
the
gold
standard
surgical
intervention
for
the
treatment
of
symptomatic
gallstones.'
Gallbladder
perforation
(10-
40%)
and
stone
spillage
(6-30%)
are
the
two
complications
encountered
most
often
during
the
dissection
and
removal
of
the
gallbladder
in
LC.
2
Gallstone
spillage
was
initially
considered
to
be
a
benign
event
with
no
serious
squeal.
However,
there
have
been
reports
of
serious
complications
due
to
spilled
gallstones
during
LC.
3-6
The
present
report
present
an
extremely
rare
case
of
missed
gallstones
with
an
intra-abdominal
abscess
complicated
by
erosion
and
fistula
of
the
bile
duct
due
to
stones
retained
in
the
abdominal
cavity
during
LC.
50
L
45
CASE
REPORT
Pos
-206.1
A
29
year-old
woman
was
admitted
to
the
hospital
with
a
4-day
history
of
fatigue,
nausea,
vomiting,
and
fever.
Her
physical
examination
was
unremarkable
except
for
mild
abdominal
distention
without
rebound
or
guarding.
The
results
of
standard
laboratory
tests
were
within
normal
ranges,
except
for
the
leukocyte
count
(23
000
cells/UL).
The
computerised
tomography
and
ultrasonographic
examination
of
the
abdomen
revealed
a
complex
infra-hepatic
abscess
(5
x
7
x
9
cm)
with
a
calcified
density
observed
within
the
lateral
margin
(Figure
1).
The
patient's
previous
medical
history
revealed
that
she
had
medication-controlled
diabetes
mellitus
and
had
undergone
LC
in
another
hospital
four
weeks
prior
to
hospitalization
at
our
facility.
According
to
consultation
with
infectious
disease
specialists,
the
patient
was
placed
on
Department
of
Surgery,
Zonguldak
Karaelmas
University,
School
of
Medi-
cine,
Kozlu-Zonguldak,
Turkey.
Email:
oktaytip@yahoo.com
Figure
1-
The
computed
tomography
of
the
abdomen
revealed
a
complex
infra-hepatic
abscess
(5
x
7
x
9
cm)
showing
calcified
density
(gallstones)
within
the
lateral
margin
(arrow)
imipenem
and
examined
by
gastroenterologists.
Since
upper
and
lower
gastrointestinal
endoscopy
revealed
no
significant
findings,
open
drainage
of
the
abscess
was
chosen
as
the
treatment.
Following
a
right
subcostal
mini-laparatomy,
the
abscess
was
drained,
and
16
pigment
gallstones,
each
7-8
mm
in
size,
were
evacuated.
The
abscess
cavity
was
washed
out
and
a
large
drain
was
placed.
An
erosion
area
on
the
common
bile
duct
without
a
leakage
was
observed.
On
the
first
postoperative
day,
bile
drainage
into
the
infra-hepatic
abdominal
drain
was
identified.
Endoscopic
retrograde
cholangiopancreatography
(ERCP)
visualised
a
leakage
near
the
cystic
duct
with
retained
stones
in
the
common
bile
duct
(Figure
2).
The
calculus
was
evacuated
following
sphincterotomy,
and
a
drainage
stent/catheter
was
inserted
into
the
common
bile
duct.
561
Missed
gallstones
in
the
bile
duct
and
abdominal
cavity:
a
case
report
Irkorucu
0
et
al.
CLINICS
2008;64:561-4
ti
..tor
4100'
Figure
2-
The
large
arrow
indicates
the
bile
duct
fistulae,
while
the
thin
arrow
indicates
stones
in
the
common
bile
duct
The
patient
tolerated
the
procedure
well
and
had
an
uneventful
clinical
course.
The
microbiological
evaluation
of
the
drained
material
was
positive
for
Klebsiella
pneumoniae
and
Escherichia
coli.
The
review
of
the
previous
operative
record
confirmed
that
iatrogenic
gallbladder
perforation
and
gallstone
spillage
had
occurred
during
the
procedure.
DISCUSSION
LC
is
currently
regarded
as
the
gold
standard
treatment
for
symptomatic
gallstones.
Gallbladder
perforation
(10-
40%)
and
stone
spillage
(6-30%)
are
the
two
most
common
complications
of
LC
that
arise
during
the
dissection
(75%)
and
removal
(25%)
of
the
gallbladder.
2-5
In
the
majority
of
cases,
these
stones
usually
cause
no
problem
and
remain
benign.
However,
0.08-0.3%
of
patients
develop
complications
as
a
result
of
these
stones,
and
this
percentage
increases
to
7%
in
the
case
of
unretrieved
peritoneal
gallstone.
3-5
In
the
literature,
the
mean
time
between
LC
and
reintervention
is
reported
to
be
10.4
months,
with
a
range
of
10
days
to
20
years.
3-5
In
our
case,
the
duration
between
LC
and
intra-abdominal
abscess
formation
was
one
month.
Various
studies
have
reviewed
the
risk
factors
for
iatrogenic
gallbladder
perforation
in
LC.
These
risk
factors
include
surgeon
experience,
difficulty
of
the
operation
(cholecystitis),
adhesions
in
the
right
upper
quadrant
of
abdominal
cavity,
preoperative
pain
lasting
longer
than
96
hours,
palpable
gallbladder
in
the
preoperative
period,
obesity,
older
age,
and
male
sex.
2,5,7-9
In
the
present
case,
aside
from
the
fact
that
the
patient
was
obese,
we
encountered
adhesions
in
the
right
upper
quadrant,
which
were
probably
due
to
her
previous
operation
for
chronic
cholecystitis.
In
our
opinion,
an
experienced
surgeon
should
be
attentive
to
the
risk
of
perforation,
particularly
in
high-
risk
patients
mentioned
above.
The
significant
risk
factors
for
complications
due
to
peritoneal
gallstones
include
older
age,
male
sex,
acute
cholecystitis,
spillage
of
pigment
stones,
number
(>15)
or
size
(>1.5
cm)
of
the
stones,
and
perihepatic
localization
of
the
spilled
stones.
In
our
case,
16
pigment
gallstones,
all
of
which
were
located
in
the
subhepatic
region
with
a
diameter
of
7-8
mm,
were
removed
from
the
abscess
cavity.
Brockmann
and
Cohen
et
al.
stated
that
gallstones
around
the
liver,
especially
in
cases
where
they
are
"sandwiched"
between
the
liver
surface
and
the
diaphragm,
may
escape
from
the
intra-abdominal
clearing
mechanism
provided
by
the
greater
omentum
and
intestinal
immune
system.
This
may
explain
the
abscess
formation
in
our
case.
2,1
°
In
cases
of
pigment
stones,
83%
show
bacterial
contamination,
which
may
also
be
responsible
for
abscess
formation
in
the
present
case.
2,5,11,12
The
most
common
complication
of
intraperitoneal
gallstones
is
abscess
formation
,1,4-6,12,13
accounting
for
60%
of
complications.
2
The
most
common
pathogen
reported
is
Escherichia
coli,
which
is
consistent
with
our
microbiological
evaluation
of
the
present
case.
1
'
4
'
5
The
other
rare
complications
of
LC
are
as
follows:
ovarian
stone
implantation,
tubalithiasis,
dyspareunia,
chronic
pelvic
pain,
small
bowel
obstruction,
and
enteric
fistulae.
Biliary
complications
including
biliary
obstruction,
cholangitis,
jaundice,
and
biliary-cutaneus
fistulae
may
be
a
result
of
extrinsic
pressure
on
the
biliary
tree.
1,2,4-9
Cavitary
abscess
as
a
result
of
spilled
gallstones
has
previously
been
reported,
nevertheless
little
has
been
noted
about
the
relationship
between
abscess
process
and
fistulae
formation.
Moreover,
potential
role
of
endoscopy
in
the
management
of
these
complications
has
not
been
absolutely
clarified
yet.
In
the
present
case,
the
erosion
of
the
bile
duct
leading
to
a
biliary
fistulae
can
be
attributed
to
the
spilled
gallstones
at
the
time
of
the
LC
and
with
the
resulting
acute
inflammation.
Nevertheless,
occlusion
of
the
site
of
communication
by
either
debris
or
edema
within
the
first
days
following
surgery
may
have
caused
the
delayed
drainage
flow
and
resulting
delay
in
detecting
fistulae.
To
minimize
the
above-mentioned
complications,
proper
dissection
is
absolutely
required.
In
the
case
of
gallbladder
perforation,
the
correct
use
of
suction
devices
and
an
endo-bag
is
necessary
to
minimize
bile
and
gallstone
spillage.
If
possible,
the
hole
in
the
gallbladder
should
be
closed
by
either
grasp
forceps
or
by
an
endoclip
and
endoloop.
The
abdominal
cavity
should
be
thoroughly
irrigated
immediately
to
reduce
the
spillage
of
bile
and
562
CLINICS
2008;64:561-4
Missed
gallstones
in
the
bile
duct
and
abdominal
cavity:
a
case
report
Irkorucu
0
et
al.
gallstones.
1
'
2
The
therapeutic
use
of
antibiotics
in
gallbladder
perforation
without
the
spillage
of
gallstones
is
obligatory.
1
'
5
Whenever
gallstone
spillage
occurs,
stone
collection
can
be
facilitated
by
the
carefull
use
of
an
intra-abdominal
bag
and
a
laparoscopic
grasper
with
a
10-mm
suction
device,
or
a
"shuttle"
stone
collector.
1-5
'
14
Every
effort
should
be
made
to
remove
spilled
gallstones
to
prevent
further
complications;
nevertheless,
conversion
to
open
surgery
is
not
mandatory.
The
appropriate
treatment
is
almost
always
drainage,
which
may require
a
laparatomy
or
laparoscopy.
Although
percutaneous
drainage
is
a
minimally
invasive
procedure
that
is
effective
at
resolving
acute
symptoms,
abscess
recurrence
is
extremely
likely
if
the
gallstones
within
the
cavity
are
not
removed.
1
'
3
A
-6
In
our
patient,
open
drainage
of
the
abscess
and
removal
of
the
retained
gallstones
via
a
mini-laparatomy
was
for
the
chosen
treatment.
In
addition,
the
difference
between
the
drainage
of
an
uncomplicated
abscess
and
an
abscess
with
fistulae
should
be
emphasized.
Since
the
abscess
cavity
itself
may
heal
within
a
few
days
after drainage,
the
fistulae
often
takes
a
longer
time
to
close.
Accordingly,
the
mechanical
principles
influencing
the
healing
process
of
the
fistulae
have
been
clearly
established
by
surgical
experience.
In
general,
the
presence
of
a
distal
obstruction
will
impair
the
healing
of
the
fistulae,
although
such
an
obstruction
can
also
impair
healing.
Thus,
gastrostomy,
jejunostomy,
and
T-tubes
are
often
removed
without
leaks.
Similar
mechanics
are
valid
for
successful
fistulae
drainage
after
the
abscess
is
drained;
the
biliary
tree
preferentially
drains
internally,
leading
eventually
to
the
healing
of
the
iatrogenic
hole
or
tear.
However,
in
case
of
a
stone
in
the
distal
bile duct,
the
pressure
remains
high
in
the
system,
and
the
fistulae
leak
will
continue
to
drain
externally.
In
the
present
case,
the
stones
were
evacuated
by
sphincterotomy,
and
a
drainage
catheter
was
inserted
into
the
common
bile
duct
in
order
to
relieve
intraluminal
pressure.
As
a
result,
the
patient
had
an
uneventful
clinical
course.
The
present
study
is
a
example
of
how
gallbladder
perforation
and
stone
spillage
can
cause
hazardous
complications.
Every
effort
should
be
made
to
avoid
perforation
of
the
gallbladder
during
its
dissection—this
is
the
first
and
most
important
step
in
prevention.
In
the
presence
of
gallbladder
perforation
and
gallstone
spillage,
removing
the
spilled
gallstones
may
prevent
forthcoming
complications.
As
in
the
present
case,
maintaining
and
consulting
detailed
patient
records
can
provide
valuable
guidance
in
treatment
decisions.
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564