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Eur J Cardiothorac Surg 1998;13:107-108
© 1998 Elsevier Science NL

Case report

Empyema due to spilled stones during laparoscopic cholecystectomy

Department of Cardiothoracic Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK

Received 6 May 1997; received in revised form 25 August 1997; accepted 16 September 1997.

Corresponding author. Tel.: +44 114 2434343; fax: +44 114 2560472.

	Abstract

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We describe a patient who suffered right pleuritic chest pain and an exudative pleural effusion, leading to empyema formation. Thoracotomy revealed this to be due to a subphrenic abscess around spilled gall stones.

Key Words: Cholecystectomy • Laparoscopic • Empyema • Gall stones

	Introduction

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Empyema is a rare but documented complication of laparoscopic cholecystectomy. It is usually attributed to spread from a subphrenic collection around lost gallstones [1] [2] [4]. It has been suggested that spilled stones are of no consequence [3], but we present a case where an empyema due to spilled stones resulted in significant morbidity.

	Case report

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A 73-year old female underwent laparoscopic cholecystectomy for symptomatic gall stone disease and initially recovered well. She presented 5 weeks later complaining of right pleuritic chest pain and dyspnoea. Examination revealed decreased air entry at the right base. A chest X-Ray showed consolidation of the right lower lobe and a moderate sized effusion ( Fig. 1 ). A diagnosis of Pneumonia with reactive effusion was made and treated with oral antibiotics. There was no resolution after 1 month so aspiration was performed. Cultures grew Enterobacter and Eschericia Coli. This was treated with further oral antibiotics and intercostal drainage. She settled clinically but relapsed. Ultrasound examination revealed a `thick walled effusion', in keeping with a chronic empyema. She was referred to the thoracic surgeons and a decortication of empyema carried out.

View larger version (123K): [in this window] [in a new window]   Fig. 1. Chest X-Ray showing right lower lobe consolidation and pleural effusion.

View larger version (148K): [in this window] [in a new window]   Fig. 2. Gallstones recovered from the thorax at operation.

	Discussion

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Laparoscopic cholecystectomy is a technique now widely accepted in the treatment of symptomatic gallstone disease and is associated with few complications and low morbidity [3] [9]. Retained intraperitoneal stones are uncommon in traditional open cholecystectomy as they can be removed and the peritoneal cavity irrigated. However, when this occurs in laparoscopic cholecystectomy clearance can be laborious and is thus often avoided. Complications of laparoscopic cholecystectomy have been extensively studied and rupture of the gallbladder with subsequent stone spillage occurs quite frequently. Figures of 30% have been reported [5] [8], and a review of more than 77 600 patients acknowledged that it happened sufficiently often that many surgeons do not report it, nor convert to open cholecystectomy to recover them [3]. Despite this, the incidence of abscesses is low, as the presence of stones does not always progress to abscess formation. It is thus unlikely to be of major medico-legal significance.

Intrathoracic gallstones have been described in a number of cases and have been attributed to gallbladder rupture and stone spillage [1] [2] [4]. The proposed pathogenesis is that the retained pocket of stones induces an inflammatory reaction which in the presence of infection leads to abscess formation. This localised reaction may allow passage of stones into the thorax by eroding through the right hemidiaphragm forming a fistula. Fistula formation is low, occuring in approximately 10% of subphrenic abscesses [7]. It has been suggested that gallstones may passively migrate into the thorax via the fistula [2]. In this patient the fistula persisted thus the empyema could be attributed to spread from the subphrenic abscess. The diagnosis was delayed due to vague symptoms and complications such as simple effusion and atelectasis are common after uncomplicated laparoscopic cholecystectomy [6].

In summary, it is worthwhile documenting in operation notes that gallbladder rupture and stone spillage has occured so that prolonged chest symptoms raise a high index of suspicion. This will speed diagnosis and referral to a thoracic unit for treatment.

	References

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1. Barnard S.P., Pallister I., Hendrick D.J., Walter N., Morritt G.N. Cholelithoptysis and empyema formation after laparoscopic cholecystectomy. Ann Thorac Surg 1995;60:1100-1102.[Abstract/Free Full Text]
2. Cunningham L.W., Grobman M., Paz H.L., Hanlon C.A., Promisloff R.A. Cholecystopleural fistula with cholelithiasis presenting as a right pleural effusion. Chest 1990;97:751-752.[Abstract/Free Full Text]
3. Deziel D.J., Millikan K.W., Economou S.G., Doolas A., Ko S.T., Airan M.C. Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and analysis of 77 604 cases. Am J Surg 1993;165:9-14.[Medline]
4. Downie G.H., Robbins M.K., Souza J.J., Paradowski L.J. Cholelithoptysis. A complication following laparoscopic cholecytectomy. Chest 1993;103:616-6174.
5. Fitzgibbons R.J., Annibali R., Litke B.S. Gallbladder and gallstone removal, open versus closed laparoscopy and pneumoperitoneum. Am J Surg 1993;165:497-504.[Medline]
6. McAllister J.D., D'Altorio R.A., Snyder A. CT findings after uncomplicated laparoscopic cholecystectomy. J Comput Assisted Tomogr 1991;15:770-772.[Medline]
7. Oschner A., DeBakey M. Subphrenic abscess, collected review and analysis of 3608 collected and personal cases. Int Abstr Surg 1938;66:426-438.
8. Soper N.J. Laparoscopic cholecystectomy. Curr Probl Surg 1991;27:583-655.
9. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073–1078.

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