Digestive complications of biliary gallstone lost during laparoscopic cholecystectomy

A patient was admitted because of an intestinal obstruction. Eight years before, he underwent a laparoscopic cholecystectomy. Abdominal ultrasonography and small bowel series showed a gallstone in the small bowel that computed tomography scan failed to identify. Laparotomy showed a Meckel's diverticula and a biliary stone in the terminal ileum. In the literature, it has been shown that gallstone lost during laparoscopic cholecystectomy may be responsible for intraperitoneal abscess. In the contact of intestine, the stone may induce an obstructive abscess, a communicating abscess, a digestive fistula or a biliary ileus. During the postoperative course of laparoscopic cholecystectomy, these patients suffer from abdominal pain and fever lasting from few days to several months. Imaging shows the biliary gallstone mechanical complications induced by the stone. To avoid such complications, biliary gallstone that falls into the peritoneum during laparoscopic cholecystectomy should be removed under laparoscopy.     

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.     

Intususcepción ileocólica en un adulto causado por divertículo de Meckel invertido

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. It is found in 2.00% of the population and is more frequent in children. Invagination is an unusual complication that can cause secondary intestinal intussusception. This event is extremely rare and only a few cases have been reported. We present the case of a 19-year-old male who presented with chronic abdominal pain and weight loss of 23 Kg 6 months prior to hospital admittance. The last episode manifested as intense abdominal pain, nausea, vomiting, and diarrhea with a 6-hour progression. Imaging studies established the diagnosis of bowel obstruction and ileocolic intussusception. Laparotomy with ileocolic resection was performed without reducing the intussusception. The histopathologic study reported inverted Meckel's diverticulum at the base of the ileocolic intussusception. Intestinal intussusception in adults, secondary to inverted Meckel's diverticulum is rare and should be considered in the differential diagnosis of patients presenting with abdominal pain and bowel obstruction.     

Meckel＇s diverticulum manifested by a subcutaneous abscess

This case report describes an extremely rare complication of a Meckel's diverticulum: enterocutaneous fistula of the diverticulum. The presence of Meckel's diverticulum is a well known entity, but subcutaneous perforation of the diverticulum is very rare. Here we report the case of a patient with the complaint of a right lower quadrant abscess, preoperatively diagnosed as enterocutaneous fistula, which was determined intraoperatively to be a fistula resulting from Meckel's diverticulum.     

Meckel's Diverticulum��Revisited

Meckel''s diverticulum is a true intestinal diverticulum that results from the failure of the vitelline duct to obliterate during the fifth week of fetal development. In about 50% cases, it contains ectopic or heterotopic tissue which can be the cause of complications. A systematic review of literature was undertaken to study the history, incidence, embryoanatomy, clinical presentation, complication and management of Meckel''s diverticulum. Although Meckel''s diverticulum is the most common congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. It may remain asymptomatic or it may mimic disorders such as Crohn''s disease, appendicitis and peptic ulcer disease.     

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.     

Rescue Radioguided Laparoscopy Surgery for Meckel's Diverticulum: Technical Notes

The extirpation of Meckel''s diverticulum (MD) via conventional or laparoscopic surgery is the definitive treatment. However, certain circumstances may modify or alter this situation and require the application of exceptional measures.We report a case under our observation who previously had an exploratory abdominal laparotomy for a suspected MD; however, the findings were negative. At that time, the diagnosis was established based on low-level gastrointestinal bleeding and isotopic tests that confirmed the existence of the diverticulum. Given the findings of gamma-graphic exploration and the previous negative surgical exploration, a decision was made to remove the lesion by laparoscopic radioguided surgery.The patient underwent bilateral laparoscopic radioguided surgery using a gamma radiation detection probe. The exploration of the abdominal cavity noted the existence of the diverticulum about 60 to 70 cm from the ileocecal valve. In this way, it was possible to proceed with the resection of the bowel loop and perform an intracorporeal anastomosis termino lateral. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day.We believe that the combination of radioguided surgery and single photon emission computed tomography/computed tomography could be useful for treating lesions in locations that are surgically difficult because of the characteristics of the lesion itself or the peculiarities of an individual patient.     

Gallstone ileus one quarter of a century post cholecystectomy

Gallstone ileus is a rare but potentially serious complication of cholelithiasis. It is usually preceded by history of biliary symptoms. It usually occurs as a result of a large gallstone creating and passing through a cholecysto-enteric fistula. Most of the time, the stone will pass the GI tract without any problems, but large enough stones can cause obstruction. The two most common locations of impaction are the terminal ileum and the ileocaecal valve because of the anatomical small diameter and less active peristalsis. We present an unusual case of small bowel obstruction secondary to gallstone ileus 24 years after an open cholecystectomy.     

A case of malignant gastrointestinal stromal tumor of ileum with liver abscess]

Gastrointestinal stromal tumor (GIST) is an uncommon mesenchymal tumor of the gastrointestinal tract and is generally located in the stomach and small intestine. They usually present with abdominal pain, gastrointestinal bleeding, and palpable mass. Some patients present with rare symptoms that are more common in malignant GIST. Malignant GIST combined with a liver abscess has not been reported yet in the literatures. We report a case of 67-year-old woman who suffered from liver abscess combined by malignant GIST with central necrosis and fistula in the ileum. She complained of fever, chills, and abdominal pain. Abdominal CT scan showed huge liver abscess and ileal mass with air pocket. Small bowel series showed contrast material filling into the ileal GIST mass. An operation was performed and the final diagnosis was malignant GIST of the ileum with invasion into the sigmoid colon and urinary bladder.     

HETEROTOPIC GASTRIC MUCOSA IN MECKEL'S DIVERTICULUM INCIDENTALLY FOUND BY DOUBLE BALLOON ENTEROSCOPY

A 45‐year‐old Japanese man who had been suffering from intestinal‐type Behcet's disease was referred to Yamagata University Hospital for enteroscopic examination. Double balloon enteroscopy was performed via the anal route. We identified ulceration of the terminal ileum that was detected previously. In addition, we incidentally recognized a Meckel's diverticulum coexisting with a heterotopic mucosal island nearly 100 cm on the oral side from the ileocecal valve. Meckel's diverticulum did not accompany ulcers and there was no history of bleeding. The heterotopic mucosal island was confirmed as gastric mucosa from biopsy specimens. High‐resolution endoscopic features of heterotopic gastric mucosa in Meckel's diverticulum using a double balloon enteroscopy are considered informative images.     

A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis

Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed. The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected.     

A case of jejunal perforation in gallstone ileus

Gallstone ileus is a rare but important cause of small bowel obstruction in the geriatric population. A 65-year-old man with a twenty year history of cholecystolithiasis was admitted to our hospital with abdominal pain and vomiting. Physical exams showed abdominal defence and rebound tenderness. A plain abdominal X-ray suggested a small bowel obstruction and pneumobilia. CT scan revealed a 2.5-cm gallstone at the jejunum and air in the biliary tree. The patient underwent a emergency laparotomy based on a diagnosis of panperitonitis with a perforation associated with gallstone ileus. Operative findings revealed a jejunal perforation and a impacted stone on the anal side of perforation. Enterolithotomy and jejunal resection were performed with cholecystectomy and repairment of the cholecystoduodenal fistula.     

Klebsiella and E. coli liver abscess associated with aerobilia: a case report

Pyogenic liver abscesses are commonly caused by biliary tract infections. We report here a case of liver abscess developed secondary to a biliary-enteric fistula. A 83 year old diabetic woman was admitted because of sepsis due to Klebsiella pneumoniae and E. Coli and with upper right quadrant pain. Six months before admission, a laparoscopic cholecystectomy was performed. The abdominal sonography showed a liver abscess associated with an important aerobilia. The Magnetic Resonance Cholangiography showed a choledocho-colic fistula with an important inflammatory background. There was no evidence of neoplasia or inflammatory bowel disease. The evolution was marked by the development of urinary and bronchial tract infection due to Klebsiella. Septic metastasis are characteristics of Klebsiella liver abscesses. Percutaneous drainage associated with a intravenous antibiotherapy was performed.     

Meckel's diverticulum causing intestinal obstruction

Meckel's diverticulum is an uncommon cause of acute abdominal pain and small bowel obstruction in adults. We present a case of a 31-yr-old man with recurrent vomiting and abdominal pain in whom the diagnosis of Meckel's diverticulum was not suspected until CT of the abdomen revealed multiple fluid-filled, dilated loops of ileum with distal collapse after normal abdominal radiographs. We suggest that CT may be helpful when the diagnosis of Meckel's diverticulum is suspected.     

Divertículo de Meckel y enterolitos como complicación de la enfermedad de Crohn

We describe the case of a 43-year-old man recently diagnosed with ileal Crohn's disease complicated by a free peritoneal perforation of a Meckel's diverticulum and the presence of enteroliths in the intestinal lumen. The coexistence of Crohńs disease, Meckel's diverticulum and enteroliths has rarely been reported. Meckel's diverticulum can hamper the management of Crohn's disease.     

Tubeless, drainless, short-stay cholecystectomy.

Of 340 patients undergoing elective cholecystectomy for gallstone disease, 41 (12%) required an abdominal drain and 22 (65%) required a nasogastric tube postoperatively to control vomiting. Eighty six percent patients were discharged on the third post-operative day; 53% were satisfied with the early discharge. In our opinion, routine use of nasogastric tube and abdominal drain is not necessary and patients can be safely discharged on the third postoperative day after an uncomplicated cholecystectomy.     

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.     

Acute biliary conditions

Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.     

腹腔镜胆囊切除术后支气管-胆管瘘

目的提高对腹腔镜胆囊切除术（LC）后支气管-胆管瘘的认识.方法对1例肝硬化伴支气管-胆管瘘患者的临床资料进行分析,并结合文献复习.结果LC可致胆囊破裂,胆汁、胆石漏入腹腔,引起腹腔感染、肝脓肿等,并可致膈肌穿孔、支气管-胆管瘘形成而持续由肺排出新鲜胆汁.结论支气管-胆管瘘实属罕见,痰液中含有高浓度胆红素为其主要临床表现.对LC术后腹腔内残留结石者应想尽一切办法取净结石.再次腹腔镜手术或开腹手术取出“丢失”于腹腔内的结石是治疗腹腔脓肿等并发症的有效方法.     

The consequences of lost gallstones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the preferred surgical technique for symptomatic gallstone disease. The technique generally is safe. probably one of the most common intra-operative complications is gallbladder perforation with stones spreading into the peritoneal cavity. In this paper the sequelae of lost gallstones after laparoscopic cholecystectomy and the diagnostic problems facing the clinician are reviewed. Abscesses and fistula formation in the abdominal wall occur. A long delay can be present between the initial operation and the complications of the lost stones. Although rupture of the gallbladder is usually noticed during preparation and retrieval, the surgeon may not be aware of losing stones. due to the long delay, the occurrence of intra-abdominal abscesses and fistula is often not linked to the prior procedure.