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.     

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.     

Gallstone expectoration following laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the treatment of choice for uncomplicated gallstone disease. Laparoscopic cholecystectomy may result in lost (spilled) gallstones. Such stones may precipitate various infective intra-abdominal complications. An unusual case of spilled gallstones eroding the diaphragm and eventually being expectorated out 12 months after laparoscopic cholecystectomy is reported.     

Digestive complications of gallstones lost during laparoscopic cholecystectomy

IntroductionSerious complications can ensue if a gallstone is dropped into the peritoneal cavity during laparoscopic cholecystectomy and not retrieved.Case outlineA 75-year-old-man was admitted with intestinal obstruction 8 years after laparoscopic cholecystectomy. Ultrasound scan and a contrast x-ray of the small bowel showed a gallstone within the small bowel lumen that CT scan had failed to identify. Laparotomy showed a Meckel''s diverticulum plus a 4×6-cm gallstone in the terminal ileum. The gallstone had penetrated into the Meckel''s diverticulum before migrating into the ileum and obstructing it.DiscussionGallstones lost during laparoscopic cholecystectomy can cause an intraperitoneal abscess. In addition, they can migrate through the anterior or posterior abdominal wall or the diaphragm and into the urinary tract or bronchus. The resulting abscess can obstruct the digestive tract or drain into the digestive tract to cause a communicating abscess. It can also drain through the abdominal wall and the digestive tract to cause an enterocutaneous fistula. Lastly, the stone can migrate into the intestine and cause gallstone ileus. Following laparoscopic cholecystectomy, patients with a lost gallstone may suffer from abdominal pain and fever within days or months. Thus, all dropped gallstones should be removed during laparoscopy.     

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.     

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.     

Recurrent staphylococcal bacteraemia and subhepatic abscess associated with gallstones spilled during laparoscopic cholecystectomy two years earlier

This is the first report of Staphylococcus aureus bacteraemia and subhepatic abscess in association with intraperitoneal gallstones spilled during laparoscopic cholecystectomy two years earlier. Spilled gallstones can lead to abscess formation in the late postoperative period by acting as foreign bodies that can become infected during bacteraemia and then become a source of recurrent bacteraemia.     

Abdominal wall abscess due to spilled gallstone presenting 11 years after laparoscopic cholecystectomy

Gallstone spillage during laparoscopic cholecystectomy may be a source of significant morbidity. In this report, we describe the clinical course of a patient who presented with a tender right subcostal swelling. She had had a laparoscopic cholecystectomy 11 years earlier. Imaging revealed a dumbbell-shaped abscess in the perihepatic area with communication into the subcutaneous tissue with a stone inside the cavity. The patient underwent abscess drainage and the stone was retrieved. During laparoscopic cholecystectomy, every effort should be made to remove spilled gallstones to prevent further complications but conversion is not mandatory.     

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.     

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.     

A Pediatric Case with Gallstones Treated with Laparoscopic Cholecystectomy

Abstract: We report herein a case of a 13-year-old Japanese boy with symptomatic cholelithiasis. The patient was admitted to our hospital for investigation of right hypochondrial pain. An abdominal plain X-ray film showed calcifications at the right upper quadrant of the abdomen. Ultrasonography and computed tomography of the abdomen revealed several stones in the gallbladder. He underwent laparoscopic cholecystectomy under a diagnosis of idiopathic and radiopaque gallstones. Twelve calcium bilirubinate stones were found in the gallbladder. Reports of laparoscopic cholecystectomy in children are rare, and only 29 cases of 15 years of age or younger have been reported in Japan. This paper presents an additional case report of laparoscopic cholecystectomy in a pediatric patient, body weight 32 kg, with symptomatic and pigment gallstones. We believe that laparoscopic cholecystectomy should be the procedure of choice for removal of the gallbladder even in children.     

Hilar cholangioplasty using omentum for ductal defect in biliobiliary fistula

Background/purpose

A non-circumferential defect of the biliary system is occasionally faced at surgery for biliobiliary fistula. The condition represents an uncommon but important complication of gallstone disease. Although direct closure and patch repair using the gallbladder cuff are recommended as first-line treatments, these procedures are sometimes technically difficult in the presence of severe inflammation. The authors, herein, present a novel procedure denoted as hilar cholangioplasty, which utilizes the pedicled omentum.

Methods

An 80-year-old man was referred to our hospital because of cholangitis. Endoscopic retrograde cholangiography demonstrated a large gallstone astride the common hepatic duct with upstream biliary dilation, indicating biliobiliary fistula. Upon laparotomy, a 2 × 3 cm ductal defect was found just under the hepatic bifurcation, after removal of the gallstones and the gallbladder. The surrounding tissue, as well as the bile duct, was extensively inflamed with dense fibrosis, such that first-line repair methods could not be performed. As an alternative method, the pedicled omentum was used for cholangioplasty.

Results

Postoperative cholangioscopy showed a yellow polypoid mass without constriction. Histologically, ordinary biliary epithelium overlaid the surface of the grafted omentum. The patient has remained well at 3-year follow-up.

Conclusion

The present method is simple and could be a promising option when standard repair methods cannot be applied.     

Relation between the risk of gallstone pancreatitis and characteristics of gallstone in Korea

BACKGROUND/AIMS: Pancreatitis is a serious complication of patients with gallstones. However, risk factors of gallstone pancreatitis were unpredictable until recently. In Korea, characteristics of gallstones are different from Western countries. The present study was designed to determine differences in the risk of gallstone pancreatitis and characteristics of gallstones in Korean patients. METHODOLOGY: Clinical data were collected on patients undergoing laparoscopic cholecystectomy. The physical characteristics of gallstones recovered at surgery were also recorded. Patients with gallstone pancreatitis were compared with patients who had uncomplicated biliary pain. RESULTS: In a logistic regression model, acute gallstone pancreatitis was associated with a stone diameter of less than 5 mm (odds ratio: 3.3695; P = 0.0352) and with stone number of more than 20 (odds ratio: 3.8686; P = 0.0361). No other variable, including pigment stone, age, and sex, remained statistically significant in the adjusted analysis (P > 0.05). CONCLUSIONS: Patients with at least 1 gallstone smaller than 5 mm in diameter and stone number more than 20 each have a more than 3-fold increased risk of presenting with acute gallstone pancreatitis. The composition of gallstones, especially pigment stones, was not an important risk factor in gallstone pancreatitis in Korean patients with stones having a different composition than those from Western countries.     

胆囊结石患者胆囊壁CCK-AR mRNA表达及血浆CCK-8水平与胆囊排空功能的关系

目的探讨胆囊结石患者胆囊收缩素(CCK)-A受体(AR)mRNA表达及血浆CCK-8水平与胆囊排空功能的关系。方法60例胆囊结石患者(结石组)和30例无胆囊结石而行上腹部手术者(对照组),术前用B超测定胆囊排空功能,RT-PCR技术检测胆囊壁CCK-ARmRNA,放射免疫法检测血浆CCK-8。结果结石组CCK-ARmRNA为0.59±0.11,与对照组的0.91±0.06相比,P<0.01;结石组中,胆囊收缩减弱者的CCK-ARmRNA为0.52±0.06,与收缩正常者的0.70±0.07相比,P<0.01;结石组血浆CCK-8为(42.91±2.88)pmol/L,与对照组的(31.50±1.62)pmol/L相比,P<0.05;结石组术前血浆CCK-8为(42.91±2.88)pmol/L,与术后的(34.21±2.56)pmol/L相比,P<0.05。结论CCK-AR、CCK-8在胆囊运动调节中发挥重要作用。     

Occult gallbladder perforation: an unusual complication of gallstone lithotripsy.

Three days following extracorporeal shock-wave lithotripsy of a solitary, calcified gallstone, a 69-year-old white male patient was re-admitted with E. coli sepsis and fever of up to 39.4 degrees C. Ultrasound and CT both revealed a smooth-rimmed hypodense paravasate in the middle portion of the left liver lobe adjacent to the gallbladder, with a density identical to gallbladder fluid. The evidence for perforation was based on CT scanning, and a diagnosis of occult gallbladder perforation was made. Conservative treatment was performed successfully. Following elective cholecystectomy two months thereafter, gallbladder histology showed signs of chronic cholecystitis and E. coli was isolated in bile cultures. The paravasate had granulated and finally cicatrized. By combining ESWL and chemical dissolution, treatment of multiple, calcified and pigment gallstones is possible and this approach has become an attractive alternative therapy modality for a selected group of gallstone patients. Further assessments of the efficacy and safety of this technique are necessary. Conservative treatment of occult gallbladder perforation is possible and should be performed in high-risk patients.     

High vesicular cholesterol and protein in bile are associated with formation of cholesterol but not pigment gallstones

To examine the differentiating parameters between cholesterol and pigment gallstones, we compared the nucleation times, concentrations of biliary lipid and protein, and the distribution of vesicular cholesterol in gallbladder bile of 16 patients with cholesterol, eight patients with black pigment gallstones, and nine gallstone-free control patients. Cholesterol monohydrate crystals were present in the fresh bile of only the cholesterol gallstone group. The nucleation time was significantly faster in the cholesterol stone group (3.3±3.2 days) than in the other two groups (pigment stone: 15.8±6.6, control: 16.9±5.7). The cholesterol saturation indices and the distribution of vesicular cholesterol were significantly higher in the cholesterol gallstone group than those in the other two groups. The total biliary protein concentration was significantly (P<0.01) higher in the cholesterol gallstone group [2.57±1.91 (sd) mg/ml] than that in the black pigment stone group (1.09±0.59). All parameters in patients with black pigment gallstone were essentially similar to the controls. We conclude that the presence of cholesterol crystals, rapid nucleation time, high vesicular cholesterol distribution, elevated cholesterol saturation index, and high protein concentration are associated with cholesterol gallstones but not with black pigment gallstones.     

L-型钙通道α-1c亚型mRNA在结石胆囊组织的表达

目的研究不同类别结石胆囊组织L-型钙通道（Car1．2）mRNA的表达,探讨胆囊结石形成的可能分子机制及意义。方法应用RT-PCR半定量法分析胆色素结石、胆固醇结石、胆囊息肉的胆囊组织Car1．2mRNA的表达量。结果Cav1．2mRNA的表达在胆色素结石组和胆囊息肉组明显高于胆固醇结石组（P〈0．05）,但在胆色素结石组和息肉胆囊组之间差异无统计学意义（P〉0．05）。结论Cav1．2mRNA在胆色素结石、胆固醇结石、胆囊息肉三组胆囊组织中均有表达,并且在不同组别中的表达存在明显的差异,这种差异可能是钙离子通道在各类胆囊上分布差异的分子基础,在胆囊结石形成过程中起着重要作用。     

Gallbladder contractility and volume characteristics in gallstone dyspepsia

AIM:It is difficult to differentiate gallstone dyspepsia and functional dyspepsia by clinical symptoms and signs. We hypothesized that gallstone dyspepsia was related to abnormal gallbladder motility. We aimed to differentiate gallstone dyspepsia from functional dyspepsia by measuring gallbladder motility.METHODS: We measured gallbladder volume changes in response to gastric distension (saline 500mL) and fatty meal in 10normal volunteers (controls) and 62 patients with gallstones and dyspepsia before cholecystectomy. Forty cholecystectomized patients were symptom free or had improvement (group I), while the remaining 22 patients had persistent dyspepsia (group Ⅱ). Gallbladder volume change and ejection fraction were analyzed and compared among the three groups.RESULTS:In group I, there were significant decreases in gallbladder volumes 5-25 rain after gastric distension,compared to fasting volumes. Compared to normal volunteers and group Ⅱ, group I had significantly decreased gallbladder volumes 10-20min after drinking 500mL of normal saline and 10 to 50min after eating fatty meal.CONCLUSION:Our results support the hypothesis that increased gallbladder contraction after gastric distension or fatty meal may be related to dyspeptic symptoms in uncomplicated gallstone disease. These findings may be useful in differentiating functional dyspepsia from gallstone dyspepsia, patients with the latter disease may benefit from laparoscopic cholecystectomy.     

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.     

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.