Original Report. Radiologic Features of Complications Arising from Dropped Gallstones in Laparoscopic Cholecystectomy Patients

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1 M. M. Morrin 1 J.. Kruskal M. G. Hochman 1 P. F. Saldinger 2 R.. Kane 1 Received September 2, 1999; accepted after revision October 27, Department of Radiology, eth Israel Deaconess Medical Center, Harvard Medical School, 330 rookline ve., oston, M ddress correspondence to M. M. Morrin. 2 Department of Surgery, eth Israel Deaconess Medical Center, Harvard Medical School, oston, M JR 2000;174: X/00/ merican Roentgen Ray Society Original Report Radiologic Features of Complications rising from Dropped Gallstones in Laparoscopic Cholecystectomy Patients OJECTIVE. ecause laparoscopic cholecystectomy has become the accepted treatment for symptomatic cholelithiasis, radiologists frequently encounter patients who have had this surgery. lthough the radiologic features of postoperative bile duct injury are well documented, the imaging features of less well-known complications remain poorly described. One such unusual complication is abscess formation caused by dropped gallstones. CONCLUSION. lthough the incidence of dropped gallstones is an uncommon complication of laparoscopic cholecystectomy, it should be recognized as a potential source of both intraabdominal and intrathoracic abscess formation in any patient presenting months to years after undergoing laparoscopic cholecystectomy. These abscesses are not neccessarily confined to the right upper quadrant. L aparoscopic cholecystectomy has become the treatment of choice for symptomatic gallstones, offering improved patient satisfaction and decreased hospital stays [1]. lthough the overall complication rate is less for laparoscopic cholecystectomy than for the traditional open approach, there are at least two operative complications that occur with increased frequency with the laparoscopic technique. One is an increased incidence of bile duct injury or leakage, and the other is late infection caused by dropped gallstones [1]. The reported incidence of bile duct injury with laparoscopic cholecystectomy is % compared with % for open cholecystectomy [1, 2]. Late abscess formation as a result of dropped gallstones after open cholecystectomy is exceptionally rare [3]. The estimated incidence of abscess formation caused by dropped stones after the laparoscopic approach is approximately 0.3% [4]. Dropped stones are rarely encountered with open cholecystectomy because the entire intraabdominal field remains well visualized during the surgery so that any spillage can be immediately addressed intraoperatively. Subsequent abscesses and inflammatory masses containing gallstones or stone fragments are generally confined to the subhepatic space or the retroperitoneum below the subhepatic space. However, unusual locations have been described, including the right thorax, the subphrenic space, the abdominal wall at trocar sites, and the sites of incisional hernias [4]. In this article, we present the largest series in the radiology literature (to our knowledge) to date of abscesses arising from gallstones dropped during laparoscopic cholecystectomy, and we describe the clinical and imaging features of this often-overlooked complication. JR:174, May

2 Morrin et al. Materials and Methods Five patients were identified who developed visceral abscesses as a result of gallstones dropped during laparoscopic cholecystectomy. The cholecystectomies were performed between 1990 and 1997 at either eth Israel Deaconess Medical Center ( n = 2) or affiliated community hospitals (n = 3). These cases were found during a retrospective review of laparoscopic cholecystectomies performed at eth Israel Deaconess Medical Center and the affiliated hospitals since 1990, and include one previously published case [5]. The clinical and radiologic features of these cases are presented. Surgical notes from the original laparoscopic cholecystectomies were reviewed to assess whether dropped stones were noted at the time of surgery and whether conversion to open cholecystectomy was performed. The duration from the laparoscopic cholecystectomy to the first onset of symptoms and the duration from the onset of symptoms to the diagnosis of gallstone-related abscess were noted. s part of the imaging workup, all five patients had undergone sonographic examinations of the right upper quadrant, three of these patients had also undergone CT, and three patients had also undergone MR imaging. Sonographic examinations were performed with 3.5- or 5-MHz transducers on either an HDI 3000 (dvanced Technology Laboratories, othell, W), an Elegra (Siemens Medical Systems, Issaquah, W), or a 128XPIO (cuson, Mountain View, C) sonographic machine. CT scans were performed using either a General Electric CT scanner (General Electric Medical Systems, Milwaukee, WI) or a Somatom Plus 4 helical CT scanner (Siemens, Iselin, NJ). ll MR imaging was performed using a 1.5-T MR system (Magnetom Vision; Siemens, Erlangen, Germany) with a phased array body coil. Results Five patients (three men, two women; age range, years; mean, 74.2 years) developed abscesses 4 72 months after laparoscopic cholecystectomy. ll five patients underwent laparoscopic cholecystectomy for symptomatic cholelithiasis. Dropped stones were noted during cholecystectomy in three patients, and minimal biliary debris was noted to have spilled from the cystic duct stump in another patient. The mean duration between laparoscopic cholecystectomy and onset of symptoms was 2.1 ± 0.6 years, ranging from 4 months to 4 years, whereas the duration from onset of symptoms to the diagnosis of abscess caused by dropped gallstones was 2.9 ± 1.0 years, ranging from 4 months to 6 years. ll five patients presented with multifocal abscesses. Four abscess collections were subhepatic, two of which had eroded through the posterolateral abdominal wall (Fig. 1). Three of these four patients had right subphrenic collections, two of whom developed right-sided empyemas caused by erosion of calculi through the right hemidiaphragm. The other patient had an isolated subphrenic abscess without significant diaphragmatic involvement. On gross inspection at surgery, four of the five patients had bilirubinate pigment stones, and one had a mixture of cholesterol and pigment stones. In only two of the five patients, the diagnosis of abscess formation as a result of dropped stones was prospectively made on the basis of Fig year-old man who presented 4 months after laparoscopic cholecystectomy with night sweats, dyspnea, and leucocytosis., Sonogram of right upper quadrant shows two echogenic calculi within diaphragm (arrows), with third calculus (arrowhead) inferior to right hepatic lobe. Right-sided pleural effusion of moderate size and small amount of free fluid within Morison s pouch are also seen., Unenhanced axial abdominal CT scan shows right-sided pleural effusion (short arrow) and thickened diaphragm containing calcified gallstones (arrowheads). Laparoscopic surgical clips can be seen anteriorly in gallbladder fossa (long arrow). C, xial short tau inversion recovery T1-weighted MR image shows right-sided pleural effusion (long arrow), small amount of perihepatic fluid (short arrow), and thickened diaphragm containing low-signal-intensity calculi (arrowheads) as seen in. C 1442 JR:174, May 2000

3 Radiology of Complications in Laparoscopic Cholecystectomy imaging findings. The first patient, a 90-year-old man who had undergone a laparoscopic cholecystectomy more than 4 months earlier, underwent a right upper quadrant sonographic examination for a 1-week history of abdominal pain and fever, which revealed a pleural effusion, a subphrenic and perihepatic collection, and a thickened diaphragm that clearly contained two calculi smaller than 1 cm in diameter seen as small echogenic foci within the substance of the thickened diaphragm. smaller calculus was also seen floating in the subphrenic collection. Subsequent CT and MR imaging confirmed the effusion and the subphrenic collection and identified the calculi embedded in the substance of the thickened diaphragm (Fig. 1). The second patient was a 76-year-old man who presented with fever, chills, and abdominal pain 4 years after a complicated laparoscopic cholecystectomy that was converted to an open procedure because of spillage of gallstones. t that time, CT revealed a complex subhepatic abscess; however, no calculi were found and the subhepatic collection was successfully drained on CT. He presented 2 years later with a recurrence of the subhepatic abscess, at which time a sonogram revealed multiple echogenic shadowing foci within a multiloculated subhepatic collection (Fig. 2). large number of calculi were removed using sonographically guided basket retrieval. However, because of its multiloculated nature, surgical débridement was required. In retrospect, a 1-cm calculus was identified on the contemporaneous CT performed with IV contrast mate- rial within a loculation of the complex abscess inferoposterior to the right lobe of the liver. t surgery, a gallstone was identified embedded within the wall of the transverse colon, the presumed source of the recurrent abscesses. diagnosis of abscess formation caused by dropped stones was not entertained at the time of imaging in three patients, but subsequent review identified calculi on at least one imaging technique in all three patients. One of these patients, an 85-year-old woman, presented with a painful right-flank mass. She had undergone a laparoscopic cholecystectomy more than 4 years earlier, during which minimal spillage of debris from the cystic duct stump was noted (Fig. 3). nother patient, a 50-year-old woman, had noticed a painless swelling of her right flank 1 year before diagnosis, which was initially attributed to a hematoma after a motor vehicle accident. Two years before presentation; she had undergone a laparoscopic cholecystectomy complicated by spillage of stones that required conversion to an open procedure (Fig. 4). Initial interpretations of the abdominal MR images in these two patients failed to identify calculi but identified multiloculated perihepatic and abdominal wall collections exhibiting heterogeneous signal intensity with half-fourier acquistion single-shot turbo spin-echo (HSTE) T2-weighted and short tau inversion recovery (STIR) T1-weighted sequences. In both these patients, a contiguous area of similarly heterogeneous signal characteristics extended through the right posterolateral abdominal wall musculature. However, subsequent review of MR images identified calculi as low-signal-intensity foci smaller than 1 cm on T1-weighted gradient-echo sequences. The last patient was a 70-year-old man who presented with fever, cough, and an elevatedwc. He had undergone a laparoscopic cholecystectomy 2 years earlier. Initial review of the CT scan revealed a right-sided empyema in addition to a perihepatic collection, but failed to identify two calculi in a collection posterior to the liver that were discovered at drainage. The empyema and perihepatic collections were drained followed by subsequent decortication of the right pleural space and débridement of the perihepatic abscess. Of the four patients who had undergone sonography, all had findings that included echogenic shadowing foci typical of stones in the abscess collection ( n = 3) or in the diaphragm ( n = 1), in retrospect. The conditions of only two of these patients were diagnosed prospectively on the basis of the sonographic findings. Of the three patients who had CT, definite high-density calculi could be identified in the abscess in all three patients; the conditions of two of these patients were diagnosed prospectively and of one patient only in retrospect. In one of these patients who had undergone CT, dense calcified calculi could be identified in the diaphragm. In the three patients who had undergone MR imaging, calculi could be correctly identified on retrospective review as foci of low signal intensity on gradient-echo T1-weighted images. However, the abscess formation was correctly diagnosed in Fig year-old man who presented 4 years after laparoscopic cholecystectomy with low-grade pyrexia., Right upper quadrant sonogram shows multiloculated extrahepatic fluid collection related to inferoposterior aspect of right lobe of liver, which contained innumerable shadowing echogenic gallstones (arrows)., Contrast-enhanced axial abdominal CT scan shows multiloculated fluid as seen in, which contained 1-cm high-density focus, representing gallstone (long arrow). Cholecystectomy surgical clips can be seen in gallbladder fossa anteriorly (short arrow). JR:174, May

4 Morrin et al. Fig year-old woman who presented 4 years after laparoscopic cholecystectomy with painful right-flank mass. During laparoscopic cholecystectomy, minimal spillage of debris from cystic duct stump was noted. xial gradient-echo T1-weighted MR image shows several low-signal-intensity foci representing calculi (arrows) within collection inferoposterior to right hepatic lobe. Fig year-old woman who presented 2 years after laparoscopic cholecystectomy with persistent painless right-flank swelling, which she initially attributed to trauma after motor vehicle accident., Sonogram shows hypoechoic fluid collection inferior to liver, with two echogenic shadowing foci (arrows). In addition, large heterogeneous collection within abdominal wall was seen (not shown)., Coronal fast low-angle shot two-dimensional T1-weighted abdominal MR image shows 4 4 cm, low-signal-intensity lesion involving inferior aspect of right hepatic lobe with two internal low-signal-intensity foci representing gallstones (arrows). C, xial short tau inversion recovery T1-weighted MR image shows 5 3 cm heterogeneous high-signal-intensity collection (arrows) within posterior abdominal wall, which represents intraabdominal abscess caused by dropped gallstones, which had extended through abdominal wall. C 1444 JR:174, May 2000

5 Radiology of Complications in Laparoscopic Cholecystectomy only one of these patients preoperatively and in the other two patients only in retrospect. Discussion More than 30 cases of abscesses that developed as a result of dropped stones after laparoscopic cholecystectomy have been described in the literature since 1990 [4, 6]. Ours is the largest series in the radiology literature of abscesses developing as a result of dropped gallstones. To our knowledge, this report is the first description of the MR imaging findings in patients with dropped stones after laparoscopic cholecystectomy. One of the most frequent complications occurring during laparoscopic cholecystectomy is gallbladder perforation with leakage of bile or stones, so-called dropped stones [7, 8]. The incidence of gallbladder perforation has been estimated to occur during 15 30% of laparoscopic cholecystectomies [1, 9]. Gallbladder perforation may occur during dissection of the gallbladder from the liver bed or more commonly during extraction of the gallbladder through a relatively narrow umbilical incision. Gallbladder retrieval bags have been designed to reduce this complication [10], but retrieval of dropped stones at surgery remains the most important means of minimizing the incidence of subsequent abscess formation. Rice et al. [6] studied more than 1000 patients undergoing consecutive laparoscopic cholecystectomies, with a median follow-up period of approximately 3 years. No intraabdominal abscesses occurred in patients in whom the gallbladder was removed intact, whereas intraabdominal abscesses occurred in 0.6% of patients who had bile spillage and 2.9% of patients who had both bile and gallstone spillage [6]. Spillage of gallstones as a result of perforation of the gallbladder is a well-known complication of laparoscopic cholecystectomy, but subsequent abscess formation is unusual. However, when abscesses form, the delay between laparoscopic cholecystectomy and abscess presentation is often considerable, probably because of a combination of the indolent nature of these inflammatory processes and the fact that the site of eventual abscess formation may be unusual [4]. Cross-sectional imaging techniques (sonography, CT, and MR imaging) show the presence of gallstones or stone fragments within abscesses. Complications, including abscess formation, are related to the spillage of infected bile and stones. Infectious complications are more likely to occur with bilirubinate stones because these stones often contain viable bacteria [11]. This was the case in our series; four of the five patients had bilirubinate pigment stones, and one had a mixed stone containing cholesterol and bile pigment. The experience of the five patients in our series shows that dropped stones or stone fragments can lodge in virtually any crevice of the abdominal cavity. The combination of pneumoperitoneum and peritoneal irrigation performed at the time of laparoscopic cholecystectomy may disperse the calculi within the peritoneal cavity. Stones can migrate into the right pleural space, as was the case in two of our patients. nother patient in our series had a calculus erode into the wall of the transverse colon. lthough the diagnosis of an abscess associated with dropped opaque gallstones can easily be made, the abscess can be misdiagnosed as a simple abscess or tumor when the gallstones are nonopaque, leading to inadequate or delayed treatment. In addition, a history of laparoscopic cholecystectomy several years before the development of symptoms may not alert the radiologist to the possibility of dropped stones as a delayed complication of laparoscopic cholecystectomy. This was the case in our series; the mean duration from the time of dropped stones to the development of symptoms was 2 years, and the mean duration from the dropped stones to the correct diagnosis was almost 3 years. The long duration between laparoscopic cholecystectomy and the development of symptoms may relate to the indolent nature of the inflammatory process that occurs. Though preoperative imaging only diagnosed calculi in two out of the five patients, retrospective review of all imaging studies clearly identified calculi on at least one imaging technique in the remaining three patients. On the basis of our experience, for reasons of both cost and effectiveness, we recommend sonography or CT before MR imaging in patients who develop abscesses after laparoscopic cholecystectomy. Our experience highlights an infrequent late postoperative complication after laparoscopic cholecystectomy that is rarely encountered with open cholecystectomy. The occurrence of dropped stones with associated abscess formation can mimic other causes, such as a simple abscess and an unusual infective process including actinomycosis or softtissue sarcoma. Often patients with abscess formation can be afebrile and have a normal WC, and the unusual sites of abscess formation coupled with the lack of awareness of a previous laparoscopic cholecystectomy can lead to an inaccurate or delayed diagnosis. The fact that all calculi could be identified at imaging on retrospective review highlights the importance of looking for calculi in abscesses in all patients who have a history, however remote, of laparoscopic cholecystectomy. Suspicion should be heightened by a surgical history of conversion to open cholecystectomy or gallbladder perforation and spillage of gallstones into the peritoneal cavity. Radiologists should consider dropped stones as a potential source of recurrent intraabdominal and intrathoracic abscesses in any patient presenting months to years after laparoscopic cholecystectomy because simple drainage without removing the calculi either percutaneously or by surgery will be inadequate. The presence of calculi identified using sonography, CT, or MR imaging within the collection is virtually diagnostic of dropped stones complicated by abscess formation. Such abscesses are usually best treated by surgical removal as opposed to imaging-guided percutaneous drainage to ensure complete removal of all gallstone fragments. References 1. Strasberg SM. Laparoscopic biliary surgery. Gastroenterol Clin North m 1999;28: MacFadyen V Jr, Vecchio R, Ricardo E, Mathis CR. ile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 1998;12: Jacob H, Rubin KP, Cohen MC, Kahn IJ, Kan P. 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