Cholelithoptysis: an unusual delayed complication of laparoscopic cholecystectomy

We report the case of a 54-year old woman who presented with a persistent right lower lobe pneumonia followed by cholelithoptysis, 11 months after a laparoscopic cholecystectomy. It is postulated that this was a result of the formation of a subphrenic abscess secondary to intraoperative spillage of gallstones. It is concluded that spillage of gallstones at laparoscopic cholecystectomy is not as benign as previously thought and that efforts to prevent spillage should include scrupulous operative technique, especially in the presence of gallbladder inflammation, and especial care when removing the gallbladder from the abdominal cavity.     

Subhepatic abscess as a late complication of missed intraperitoneal gallstone after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the treatment of choice in symptomatic cholelithiasis. Despite its many advantages over the conventional laparotomic approach, accidental perforation of the gallbladder with spilled stones and bile leakage is frequent during this procedure. Complications from missed gallstones are uncommon, although they can sometimes lead to severe consequences. Great effort must be made to achieve laparoscopic retrieval of all the gallstones missed into the peritoneal cavity and conversion to an open procedure should be used only in selected cases. We report a case of subhepatic abscess as a late complication of a missed gallstone during a previous laparoscopic cholecystectomy.     

Porcelain gallbladder complicated with pancreas divisum

We report a rare case of porcelain gallbladder associated with pancreas divisum (PD). A 60-year-old woman suffered from discomfort in the back of the right side. An abdominal radiograph revealed a calcified spherical mass in the right upper quadrant. Ultrasonography revealed a scattered echo with a posterior acoustic shadow in the gallbladder wall. A plain computed tomography (CT) scan showed flecks of intramural calcification in the wall of the gallbladder. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) showed separate openings for the Santorini and Wirsung ducts. The patient underwent cholecystectomy after porcelain gallbladder and pancreas divisum had been diagnosed. The porcelain gallbladder resulted from a stone impacted in the neck of the gallbladder. Patients with PD should be followed carefully, because gallstones often accompany PD, and porcelain gallbladder may result, as in this patient.     

Spilled gallstones mimicking a retroperitoneal sarcoma following laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become a standard treatment of symptomatic gallstone disease. Although spilled gallstones are considered harmless, unretrieved gallstones can result in intra-abdominal abscess. We report a case of abscess formation due to spilled gallstones after laparoscopic cholecystectomy mimicking a retroperitoneal sarcoma on radiologic imaging. A 59-year-old male with a surgical history of a laparoscopic cholecystectomy complicated by gallstones spillage presented with a 1 mo history of constant right-sided abdominal pain and tenderness. Computed tomography and magnetic resonance imaging demonstrated a retroperitoneal sarcoma at the sub-hepatic space. On open exploration a 5 cm × 5 cm retroperitoneal mass was excised. The mass contained purulent material and gallstones. Final pathology revealed abscess formation and foreign body granuloma. Vigilance concerning the possibility of lost gallstones during laparoscopic cholecystectomy is important. If possible, every spilled gallstone during surgery should be retrieved to prevent this rare complication.     

Omental abscess due to a spilled gallstone after laparoscopic cholecystectomy

Omental abscess due to a spilled gallstone is extremely rare after laparoscopic cholecystectomy. Herein, we report a 68-year-old man who presented with left upper abdominal pain after laparoscopic cholecystectomy for gangrenous cholecystitis. Seven months prior to admission, gallbladder perforation with spillage of pigment gallstones and bile occurred during laparoscopic cholecystectomy. The spilled gallstones were retrieved through vigorous peritoneal lavage. Abdominal computed tomography showed a 3?×?2.5 cm intra-abdominal heterogeneous mass, suspected to be an omental abscess, and ascites around the spleen. Exploratory laparoscopy revealed an inflammatory mass within the greater omentum. Laparoscopic partial omentectomy and abscess drainage were performed, and a small black pigment gallstone was unexpectedly found in the whitish abscess fluid. Abscess fluid culture results were positive for extended-spectrum β-lactamase-producing Escherichia coli and Streptococcus salivarius, which were previously detected in the gangrenous gallbladder abscess. The histopathological diagnosis was abscess in the greater omentum. Postoperative course was uneventful, and the patient was discharged 13 days later. In conclusion, we report a successful case of laparoscopic management of an omental abscess due to a spilled gallstone after LC. It is important to attempt to retrieve spilled gallstones during LC because they may occasionally result in serious complications.     

Laparoscopic cholecystectomy in patients with porcelain gallbladder based on the preoperative ultrasound findings

BACKGROUND/AIMS: Porcelain gallbladder is considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer or gastrointestinal cancer. We examined the management of laparoscopic cholecystectomy in patients with porcelain gallbladder. METHODOLOGY: 1,608 patients underwent cholecystectomy and 13 (0.81%) patients had porcelain gallbladder. All patients underwent preoperative spiral computed tomography after intravenous infusion cholangiography and intraoperative cholangiography. Patients with porcelain gallbladder were classified as Type I to III according to preoperative ultrasound findings. The Type I porcelain gallbladder was indicated for laparoscopic cholecystectomy and Type II porcelain gallbladder was selected for open cholecystectomy. RESULTS: The laparoscopic cholecystectomy was completed in 10 patients with Type I porcelain gallbladder and the microscopie diagnosis demonstrated no cancer in the calcified wall of the gallbladder. In one patient with a non-transected injury to the right hepatic duct, a T-drainage tube was inserted at the site of the injury using the laparoscopic technique. Three patients with Type II porcelain gallbladder underwent open cholecystectomy and one patient had gallbladder cancer, therefore additional hepatectomy and lymphadenectomy was performed. CONCLUSIONS: We conclude that patients with a Type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.     

Methicillin-resistant Staphylococcus aureus hepatic abscess in a patient with sickle-cell disease

We report a case of a 16-year-old female patient with sickle-cell disease with a liver abscess secondary to methicillin-resistant Staphylococcus aureus (MRSA). She had initially presented with jaundice and abdominal pain and subsequently underwent endoscopic retrograde cholangio-pancreaticography followed by laparoscopic cholecystectomy for removal of gallstones. However, post-cholecystectomy she presented with generalized abdominal pain and computed tomography scan of the abdomen revealed a liver abscess. A pigtail catheter was inserted into the abscess and culture of the aspirate yielded MRSA (susceptibility pattern of the organism was compatible with community-acquired MRSA). She was treated with intravenous clindamycin for 6 weeks with complete resolution of the abscess.     

Small gallstones, preserved gallbladder motility, and fast crystallization are associated with pancreatitis

Acute pancreatitis is a severe complication of gallstones with considerable mortality. We sought to explore the potential risk factors for biliary pancreatitis. We compared postprandial gallbladder motility (via ultrasonography) and, after subsequent cholecystectomy, numbers, sizes, and types of gallstones; gallbladder bile composition; and cholesterol crystallization in 21 gallstone patients with previous pancreatitis and 30 patients with uncomplicated symptomatic gallstones. Gallbladder motility was stronger in pancreatitis patients than in patients with uncomplicated symptomatic gallstones (minimum postprandial gallbladder volumes: 5.8 +/- 1.0 vs. 8.1 +/- 0.7 mL; P = .005). Pancreatitis patients had more often sludge (41% vs. 13%; P = .03) and smaller and more gallstones than patients with symptomatic gallstones (smallest stone diameters: 2 +/- 1 vs. 8 +/- 2 mm; P = .001). Also, crystallization occurred much faster in the bile of pancreatitis patients (1.0 +/- 0.0 vs. 2.5 +/- 0.4 days; P < .001), possibly because of higher mucin concentrations (3.3 +/- 1.9 vs. 0.8 +/- 0.2 mg/mL; P = .04). No significant differences were found in types of gallstones, relative biliary lipid contents, cholesterol saturation indexes, bile salt species composition, phospholipid classes, total protein or immunoglobulin (G, M, and A), haptoglobin, and alpha-1 acid glycoprotein concentrations. In conclusion, patients with small gallbladder stones and/or preserved gallbladder motility are at increased risk of pancreatitis. The potential benefit of prophylactic cholecystectomy in this patient category has yet to be explored.     

Amyloidosis of the gallbladder mimicking gallbladder cancer

We report a rare case of amyloidosis of the gallbladder in a 63-year-old woman with a history of primary amyloidosis. The patient was asymptomatic. Blood chemistry and hematologic laboratory levels, as well as values for tumor markers, were unremarkable. Ultrasonography (US) of the abdomen showed a focal echogenic lesion (22 × 15 mm) in the body of the gallbladder, and moderate enhancement was noted on contrast-enhanced US. Abdominal computed tomography revealed nodular wall thickening in the body of the gallbladder that was enhanced by contrast material. Although this patient was asymptomatic, the existence of gallbladder cancer could not be totally denied. Therefore, laparoscopic cholecystectomy was performed for total biopsy of the gallbladder. An intraoperative frozen-section examination revealed evidence of mild chronic cholecystitis with the appearance of hyalinal stroma. There was no malignant lesion. The final diagnosis, amyloidosis of the gallbladder, was obtained by alkaline alcoholic Congo red staining. Amyloid depositions were found in the walls of the vessels in the submucosa and the lamina propria mucosae, consistent with an elevated nodular lesion in the body of the gallbladder. To our knowledge, this is the first case of amyloidosis of the gallbladder mimicking gallbladder cancer that was diagnosed after laparoscopic cholecystectomy.     

Laparoscopic cholecystectomy in a patient with situs inversus totalis

INtroDUCtIoNSitus inversus totalis (SIT) is a very uncommon entity. It was first reported by Fabricius in 1600[1]. The incidenceis thought to be in the range of 1:10 000 to 1:20 000[2]. Transposition of the organs may also affect thoracic organs, besides …     

Two cases of ectopic liver attached to the gallbladder wall

BackgroundEctopic liver tissue is occasionally found either attached to the gallbladder or elswhere in the upper abdomen.Case OutlinesA 49-year-old man and a 39-year-old woman were found to have a tongue of liver tissue attached to the serosa of the gallbladder (but separate from the liver) during laparoscopic cholecystectomy for gallstones. The ectopic liver was removed with the gallbladder and was histologically normal in each case.DiscussionSeveral embryological hypotheses have been advanced to explain the development of ectopic liver. The anomaly is usually discovered incidentally at operation. Although the tissue is histologically normal.it can develop the same conditions as orthotopic liver.     

Laparoscopic cholecystectomy for left-sided gallbladder: report of two cases

We report two cases in which patients, who had different junctions of the cystic duct with the common bile duct (CBD), with left-sided gallbladders were treated with laparoscopic cholecystectomy. The first patient, a 69-year-old man, could be diagnosed intraoperatively, and his cystic duct joined the CBD from the right side. The gallbladder of the second patient, a 52-year-old woman, was located on the left side of the CBD, and the cystic duct entered the left hepatic duct directly. In both instances, successful laparoscopic cholecystectomy was performed, and the patients recovered uneventfully. We describe these cases and discuss the key procedures for safe laparoscopic cholecystectomy for a left-sided gallbladder from our experience and a review of the relevant literature.     

Reduction of the risk of unretrieved stones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy entails the risk of gallbladder rupture and consequent loss of stones within the abdominal cavity, which is not an uncommon complication. The development of intraperitoneal abscesses due to the spilled gallstones is one of its major complications. When gallbladder was injured during laparoscopic cholecystectomy, gallbladder was dissected on the medial and lateral side, or from the fundus of the gallbladder in the original position to reduce the spillage of stones. After putting the removed gallbladder into the endoscopic bags, hepatorenal fossa and right subphrenic space was thoroughly examined using retractor and oblique view scope. We performed these procedures in 30 consecutive patients with gallbladder ruptured during operation. Dropped stones were noted in 5 patients and were retrieved successfully. Reduction of stone spillage and the retrieval of spilled stones were essential. It is advisable to retrieve as many gallstones as possible after gallbladder perforation during laparoscopic cholecystectomy.     

Gallbladder agenesis with no other biliary tract abnormality: report of a case and review of the literature

We report a rare adult case of gallbladder agenesis with no other biliary tract abnormality. The patient was a 29‐year‐old man with pain in the right upper‐quadrant of the abdomen, and vomiting. The gallbladder was not visualized by ultrasonography, computed tomography, or endoscopic retrograde cholangiography. The common bile duct was slightly dilated. No other abnormalities, including anomalous choledochopancreatic duct junction, were found. Based on these imaging findings and the patient's right hypochondrial pain, there was a high index of suspicion of chronic cholecystitis caused by incarcerated gallstones in the neck of the gallbladder. At operation, we carefully observed the gallbladder fossa, using laparoscopy, and found gallbladder to be absent. Although the operation involved only observation via a laparoscope, the patient has since remained well and asymptomatic. It is difficult to make a correct diagnosis of gallbladder agenesis preoperatively. We believe that, if the gallbladder is not visualized by imaging techniques, it may be better to perform laparoscopy for observation before performing laparotomy, in order to reduce surgical stress.     

Axillary lymph node metastasis following resection of abdominal wall laparoscopic port site recurrence of gallbladder cancer

Abdominal wall port site recurrence of gallbladder cancer is well described in the literature in patients that have undergone laparoscopic cholecystectomy with the incidental finding of a gallbladder cancer. The etiology and consequences of this type of metastatic recurrence are unclear. This report describes two cases with the unique sequelae of the interval development of nodal metastases to the axillary lymph nodes following resection of an abdominal wall laparoscopic port site recurrence of gallbladder cancer. The first case involves a patient who developed an isolated left axillary lymph node metastasis approximately 10 months after undergoing resection of a left-sided abdominal wall port site recurrence for a T2 gallbladder cancer. The original tumor had been found at laparoscopic cholecystectomy and definitively treated surgically approximately 3 years earlier. The second case involves a patient who developed isolated nodal metastases to the right axillary lymph nodes approximately 4 months after undergoing resection of right-sided abdominal wall port site recurrence, segment 4/5 hepatic resection, and portal lymphadenectomy for a T2 gallbladder cancer. This tumor had originally been found at laparoscopic cholecystectomy approximately 1 year earlier. These unique sequelae of the interval development of nodal metastases to the axillary lymph nodes demonstrated in both cases has not been previously reported.     

New strategies for the treatment of gallstone disease

BACKGROUND: Symptomatic gallstones are generally accepted as being the indication for cholecystectomy. Generally, severe abdominal pain in epigastrium and in the right upper abdominal quadrant, and lasting for more than 15 min, is thought to be caused by gallstones. However, many patients with other abdominal complaints undergo cholecystectomy and are satisfied with the outcome of surgery. Possible ways to improve the results of cholecystectomy are discussed. METHODS: Review of previous work by the authors. RESULTS: The introduction of laparoscopic cholecystectomy has even led to an increase in cholecystectomies; in a higher complication rate; and in increased costs of the treatment of gallstone disease. Because of faster recovery, 70% of symptomatic gallstone patients are able and willing to undergo laparoscopic cholecystectomy in day care. Cholecystectomy after sphincterotomy and stone extraction in patients who have stones in the gallbladder was demonstrated to prevent gallstone-related symptoms in at least 40% of patients. If the gallbladder had to be removed later for symptomatic disease, however, this did not result in a higher rate of conversions and complications. Because of shortage in operation capacity in The Netherlands, there is a considerable delay between the diagnosis of symptomatic stones and cholecystectomy. Better selection of patients for cholecystectomy will not only improve the results of cholecystectomy, it will also reduce the number of cholecystectomies and patients on waiting lists. Delay of cholecystectomy is associated with more complications, longer operative times, higher conversion rates to open cholecystectomy and prolonged hospitalization. The efficacy of the bile salt ursodeoxycholic acid in preventing gallstone-related pain attacks and complications in patients with contraindications for operation or waiting to undergo cholecystectomy should be investigated further, since two retrospective studies have demonstrated favourable outcomes for this strategy. CONCLUSION: The results of cholecystectomy are likely to be improved by better selection of patients, prevention of delay of the procedure and possibly treatment with ursodeoxycholic acid.     

Port site and distant metastases of gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography

We report port site and distant metastases of unsuspected gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography （PET） in two patients. Patient 1, a 72-yearold woman was diagnosed as cholelithiasis and cholecystitis and received laparoscopic cholecystectomy. Unsuspected gallbladder cancer was discovered with histological result of well-differentiated squamous cell carcinoma of the gallbladder infiltrating the entire wall. A PET scan using F-18-fluorodeoxyglucose （FDG- PET） before radical resection revealed residual tumor in the gallbladder fossa and recurrence at port site and metastases in bilateral hilar lymph nodes. Patient 2, a 69-year-old woman underwent laparoscopic cholecystectomy more than one year ago with pathologically confirmed unsuspected adenosquamous carcinoma of stage pTlb. At 7-mo follow-up after surgery, the patient presented with nodules in the periumbilical incision. Excisional biopsy of the nodule revealed adenosquamous carcinoma. The patient was examined by FDG-PET, demonstrating increased FDG uptake in the right lobe of the liver and mediastinal lymph nodes consistent with metastatic disease. This report is followed by a discussion about the utility of FDG-PET in the gallbladder cancer.     

Percutaneous techniques for the management of symptomatic gallbladder stones.

Several non-operative treatments for the management of patients with symptomatic gallstones have been developed with the purpose of avoiding the considerable morbidity associated with open cholecystectomy. Minimally invasive techniques utilizing direct percutaneous puncture of the gallbladder are being increasingly used for the diagnosis and treatment of gallbladder disease and are the subject of this review. With the emergence of laparoscopic cholecystectomy the role of these techniques is less certain but they are likely to continue to be important in the management of high risk, elderly or medically unfit patients.     

Gallstone disease: Current therapeutic practice

Opinion statement Most asymptomatic gallstone carriers require no therapy. Laparoscopic cholecystectomy is the best definitive therapy for symptomatic gallstone disease. Selective laparoscopic cholecystectomy can provide secondary prevention of symptoms and complications in certain instances (in a complex clinical setting such as sickle cell disease or to prevent gallbladder carcinoma from developing in those at risk with large [> 3 cm] gallstones or with a calcified gallbladder). Primary prevention is unproven but focuses on early identification and risk alteration to decrease the possibility of developing gallstones. Ursodeoxycholic acid has a limited role for stone dissolution but can prevent stone development in severe obesity during rapid weight reduction with diet or after bariatric surgery. Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy represents the therapeutic cornerstone for managing severe pancreatitis and cholangitis.     

Relation of gallbladder function and Helicobacter pylori infection to gastric mucosa inflammation in patients with symptomatic cholecystolithiasis

BACKGROUND: Inflammatory alterations of the gastric mucosa are commonly caused by Helicobacter pylori (Hp) infection in patients with symptomatic gallstone disease. However, the additional pathogenetic role of an impaired gallbladder function leading to an increased alkaline duodenogastric reflux is controversially discussed. AIM: To investigate the relation of gallbladder function and Hp infection to gastric mucosa inflammation in patients with symptomatic gallstones prior to cholecystectomy. PATIENTS: Seventy-three patients with symptomatic gallstones were studied by endoscopy and Hp testing. Methods: Gastritis classification was performed according to the updated Sydney System and gallbladder function was determined by total lipid concentration of gallbladder bile collected during mainly laparoscopic cholecystectomy. RESULTS: Fifteen patients revealed no, 39 patients mild, and 19 moderate to marked gastritis. No significant differences for bile salts, phospholipids, cholesterol, or total lipids in gallbladder bile were found between these three groups of patients. However, while only 1 out of 54 (<2%) patients with mild or no gastritis was found histologically positive for Hp, this infection could be detected in 14 (74%) out of 19 patients with moderate to marked gastritis. CONCLUSION: Moderate to marked gastric mucosa inflammation in gallstone patients is mainly caused by Hp infection, whereas gallbladder function is not related to the degree of gastritis. Thus, an increased alkaline duodenogastric reflux in gallstone patients seems to be of limited pathophysiological relevance.