Lost gallstones in laparoscopic cholecystectomy: all possible complications

The American Journal of Surgery 193 (2007) 73–78

Review

Lost gallstones in laparoscopic cholecystectomy: all possible complications Jörg Zehetner, M.D.*, Andreas Shamiyeh, M.D., Wolfgang Wayand, M.D., F.A.C.S. Department of Surgery, Ludwig Boltzmann Institute for Operative Laparoscopy, AKH Linz, Krankenhausstrasse 9, 4020 Linz, Austria Manuscript received January 9, 2006; revised manuscript May 1, 2006

Abstract Background: Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gallstones for 15 years. During that time, several studies and case reports have been published which outline the possible complications of lost gallstones. The aim of this review is to categorize these complications and to evaluate the frequency and management of lost gallstones. Data Sources: A Medline search from 1987 to 2005 was performed. A total of 111 case reports and studies were found, and all reported complications were listed alphabetically. Eight studies with more than 500 LCs that reported lost gallstones and perforated gallbladder were analyzed for frequency and management of lost gallstones. Conclusion: Lost gallstones have a low incidence of causing complications but have a large variety of possible postoperative problems. Every effort should be made to remove spilled gallstones to prevent further complications, but conversion is not mandatory. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Laparoscopy; Cholecystectomy; Lost gallstones

Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gallstones for 15 years. However, there are 2 problems that are more frequent in LC than in open cholecystectomy: (1) injury to the common bile duct and (2) complications from lost gallstones. Over the last 15 years, the rate of common bile duct injuries in LC has declined as laparoscopic surgeons have become more experienced; unfortunately, the incidence of lost gallstones has been unchanged. Initially, lost gallstones were considered to be harmless, but with the shift from open cholecystectomy to LC, a wide variety of complications has been seen. Several case reports, prospective studies, and reviews have been published since 1987 about the incidence, complications, and management of the lost gallstones. The aim of this review is to categorize these complications through a systematic literature search to show the variety of complications and to assess the frequency and management of lost gallstones in LC.

* Corresponding author. Tel.: ⫹43-732-780-673-289; fax: ⫹43-732780-62198. E-mail address: [email protected]

Methods A systematic literature search in the NCBI National Library of Medicine (Pub Med; January 1987–January 2005) was conducted by the senior author (J.Z.). As mentioned in Brockmann et al [1], a systemic review according to the Cochrane recommendations is not possible because of the limitations of the primary literature. A search strategy was set up using the following text words and combinations (Boolean operators): abscess, bile, fistula, lost gallstones, spilled gallstones, spilt gallstone, gallstone retrieval, gallbladder perforation, and laparoscopic cholecystectomy. Out of 412 listed references, titles, abstracts, and full text articles were screened to compile a selection of relevant studies. All reviews and case reports concerning lost gallstones in LC were then screened for the reported complications. These complications were categorized alphabetically with their references. Also, the reference lists of the retrieved literature were manually crosssearched for additional publications. No unpublished data or data from abstracts were used; no language restrictions were applied. All studies with more than 500 LCs that reported the incidence of lost peritoneal gallstones and/or perforated gallbladder were analyzed in this review for incidence and importance of lost gallstones. Guidelines for surgical man-

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agement were created from these studies as well as from published reviews. Results List of possible complications A total of 111 case reports and studies were found with documented complications after gallstone spillage or lost gallstones after LC. A list of possible complications categorized alphabetically with the references as mentioned in MEDLINE was created (Table 1). The most frequently reported complication was an abscess in the abdominal wall as a consequence of lost gallstones, which was mentioned in 16 case reports or studies. Intra-abdominal abscess was mentioned in 15 publications. Also, subhepatic and subphrenic abscesses were reported with a high frequency in 10

Complications of Lost Gallstones in LC

septic

general

thoracic

fever

stone expectoration

peritonitis

liver abscess

abdominal wall

portsite

pleural emphyema

umbilical

broncholithiasis

jaundice

abdominal (abscess)

pneumonia

pleural fluid collections

biliary

fistulas

intraabdominal

to the umbilicus

to the urinary bladder to the skin

subhepatic colovesical subphrenic

Table 1 List of possible complications of lost gallstones in LC categorized alphabetically with references Abscess in the abdominal wall [5,23–27] Broncholithiasis, stone expectoration [38–42] Cellulites [5] Dyspareunia [43] Erosion to the back [44–46] Fat necrosis posterior of the rectus muscle [47] Fever [5,33,48–50] Fistula formation [25,28,48,51–56] Gallstone granuloma [57,58] Gluteal abscess [59] Granulomatous peritonitis mimicking endometriosis [60] Ileus, intestinal obstruction [7,61–63] Implantation malignancy [64] Incarcerated hernia [23,65] Intraabdominal abscess [6,7,24,27,34,37,66–74] Jaundice [68,75,76] Liver abscess mimicking malignancy [77] Middle colic artery thrombosis [78] Mimicking acute appendicitis [45] Paracolic abscess [43,59,79] Paraumbilical tumor [7] Peritoneal abscess formation [80–82] Pelvic abscess [83] Pelvic stones [43,84–86] Peritonitis [87] Pleural empyema, fluid collections [41,88–91] Pneumonia [48,92] Port site stones [7,34,93] Port site abscess [7,94] Recurrent staphylococcal bacteraemia [95] Retrohepatic abscess [46] Retroperitoneal abscess [49,96–98] Retroperitoneal actinomycosis [99] Right flank abscess [26,100] Small bowel obstruction [101,102] Stones in gastrocolic omentum [68] Stones in hernia sac [103,104] Stones of the ovary, tubalithiasis [84,85,105] Subhepatic abscess [8,48,59,92,95,106–110] Subphrenic abscess [5,88–90,111–115] Thoracoabdominal mycosis [38] Transdiaphragmatic abscess [116] Umbilical wound abscess [5,7,117] Vesical granuloma [118]

rare stone locations

colocutaneous retrohepatic

pelvic pelvic

gluteolumbar

ovary paracolic

intestinal

hernia sac peritoneal ileus retroperitoneal

others

gluteal

right flank

intestinal obstruction small bowel obstruction incarcerated hernia

Fig. 1. Diagram of possible complications.

and 9 studies, respectively. In several case reports, fistula formation of all different kinds is mentioned. This ranges from fistulas of the skin to fistulas of the gluteolumbar region (Fig. 1). Stone expectoration is a very rare complication but was reported in 4 case reports. Other rare complications were published with stones in the hernia sac, stones in the ovary, and also a case report of tubalithiasis. Studies with more than 500 LCs Eight studies [2–9] with more than 500 LCs were found and analyzed (Table 2). Woodfield et al [10] analyzed 6 of these studies with a total of 18,280 operations in their publication in 2004. The incidence of gallbladder perforation was 18.3% (3356/18280) with an estimation that in 40% of gallbladder perforation cases gallstones fall out of the gallbladder [2,5], resulting in a 7.3% incidence of gallstone spillage. The incidence of lost gallstones (unretrieved peritoneal gallstones) was reported only in 2 studies. Sarli et al [4] reported that 50% of the 52 spilt gallstones were not retrieved, whereas Diez et al [7] reported that 16% were lost. Woodfield et al [10] estimated the incidence of unretrieved gallstones at 33%. Experimental studies assessing the consequences of lost gallstones in LC In 1991, following studies using a rabbit model and a postal questionnaire of patients in whom gallstones were

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Table 2 Summary of studies with more than 500 LC reviewing complications of lost gallstones in LC Diez [7]

Hawasli [8]

Horton [9]

LC Conversion LC in study 3,686 5526 1130 PGB 17% SG 6.9% LS 1.1% Documented complications caused by lost gallstones: 40 LS 2 LS 1130 LC Complications 12 2 3 Abscess (i) 4 1 2 Abscess (o) 8 1 1

Hui [6]

1412 36%

Memon [5]

Rice [3]

Sarli [4]

Schäfer [2]

856

1139 80 1059 29% 10.9%

1239 112 1127 11.6%

10,174 34 10,140

19%

5.4% 2.3%

623 LC 0

106 LC 2 1 1

306 PGB 7 5 2

110 PGB 0

547 SG 8 6 2

Summary 3–9% 24,936 11.6–36% 5.4–19% 1.1–2.3%

1.7/1000 LC

LS ⫽ lost gallstones, LC ⫽ laparoscopic cholecystectomies, PGB ⫽ perforated gallbladder, SG ⫽ spilled gallstones (i) intraperitoneal; (o) others.

lost, Welch et al [11] concluded that there was no indication for a laparotomy to retrieve “escaped” gallstones. In an experimental study, Johnston et al [12] showed that bile, in combination with gallstones in the peritoneal cavity, was associated with an increased risk of intra-abdominal adhesion formation and possible abscess formation. Hornof et al [13] concluded from studies with implanted human gallstones in the peritoneal cavity of rats that cholesterol stones only caused abscess formations in association with gram-negative bowel germs. Zisman et al [14] showed in a rat model that no systemic deleterious outcome could be attributed to the presence of the implanted gallstones except for mild local effects. An experimental study with a mouse model published in 1997 by Yerdel et al [15] showed that intraperitoneally retained cholesterol gallstones remained inert and did not cause serious peritoneal reactions unless they were crushed into fragments or were caused by an acutely inflamed gallbladder. Agalar et al [16] showed in a mouse model that free gallstones within the peritoneal cavity with or without Escherichia coli, sterile bile, or both increased the rate of formation of both abscesses and adhesions. Also, Aytekin et al [17] concluded from experimental studies with a rat model that spilled gallstones and bile, whether infected or not, caused postoperative adhesions.

we can calculate that 8.5% of these lost gallstones will lead to a complication. In this systemic search of the literature, we found several factors that lead to the development of severe septic complications. As shown in several studies [12–17], bile and gallstones are at an increased risk for abscess formation and formation of adhesions, whether the bile is infected or not. One factor is the type of stones; in pigment stones (black, brown or mixed), the bacterial contamination is higher than in cholesterol calculi, which is shown in the collected case reports, as well as in experimental studies. Another factor is the size and number of spilled gallstones. In the systemic review of Brockmann et al [1], a total of 91 patients had 555 stones in different locations ranging from the abdominal wall to all possible intraabdominal sites. Of these patients, 40% were found to have 15 or more stones at the time of reoperation. Their study concluded, as summarized by Woodfield et al [10], that the risk factors for complications because of lost gallstones are acute cholecystitis with infected bile, spillage of pigment stones, multiple stones (⬎15 stones), stone size (⬎1.5cm), and age. From the published case reports and studies as well as the experimental studies, we can conclude that spilled stones are no indication for laparotomy if the following therapeutic guidelines are followed.

Comments The aim of the study was to perform a systemic literature search in order to alphabetically categorize complications of lost gallstones from LC. We found that the most published complications, like intra-abdominal abscesses and abscesses of the abdominal wall, followed by subhepatic and subphrenic abscesses, are likely the most frequent ones. Another common complication is fistula formation, which occurs across a broad spectrum, ranging from fistulas of the skin or umbilicus to colocutaneous or colovesical fistulas. In general, the complications because of lost gallstones in LC are infrequent, occurring in approximately 1.7 per 1000 LCs [10], which makes diagnosis difficult if the complication occurs late. Out of the 8 studies with more than 500 LCs, we can summarize that the incidence of lost gallstones in LC is approximately 2%. From this estimation,

Management of gallbladder perforation In the recent published reviews [1,10], the incidence of these complications was analyzed and the management discussed. Incidence of gallbladder perforation during laparoscopy is 13% to 40% [18], with a mean of 18.3% out of those 8 studies with more than 500 LCs. The reason for gallbladder perforation is often correlated with the surgeon’s skill and experience [19]; however, the incidence is higher in acute cholecystitis, especially when hydropic gallbladder was the most accurate predictor of rupture [20]. To minimize this complication, proper dissection is required. If a perforation occurs, the use of suction devices to minimize the spilled bile and spilled gallstones as well as the use of an endo-bag is mandatory. If possible, the hole in the gallbladder should be closed by the grasp forceps or by an endoclip or endoloop. The abdominal cavity should be

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intensively irrigated immediately to reduce the spillage of bile and gallstones. Therapeutic use of antibiotics in gallbladder perforation without spillage of gallstones is not obligatory. Management of spilled gallstones If gallstones are spilled in the abdominal cavity, either through gallbladder perforation during dissection or extirpation of the gallbladder, careful removal of as many stones as possible should be performed immediately [21]. Intense irrigation and suction should be performed after collecting the visible stones in order to minimize the number of lost gallstones. This should be done carefully without spreading the gallstones into difficult accessible sites. Stone collection might be facilitated by the use of an intra-abdominal bag and a laparoscopic grasper, a 10-mm suction device, or a “shuttle” stone collector [22]. The use of therapeutic antibiotics in cases of spilled gallstones is only necessary, in our opinion, in cases of acute cholecystitis with visibly infected bile or in patients with a high probability for lost gallstones. In these cases, bile and stone samples should be sent for microbiological examination before the first dose of drug is administrated. The intraoperative management of spilt gallstones is based on the conclusions of several publications without any comparative studies. Most authors do not advise conversion to open surgery. In 2 reviews [1,10], the important issue of documentation and patient information is discussed. The clear documentation of the intraoperative gallstone spillage in the medical report is recommended for alerting the clinician in the future to the possibility of stones causing any subsequent problems that might lead to earlier diagnosis. In addition, informing the patient may reduce the medicolegal risk for further prolonged diagnosis if late complications occur but might also provoke unnecessary repeated examinations. Management of late complications Months or even years after laparoscopic cholecystectomy, complications of lost gallstones can occur. The diagnosis is mostly made by abdominal ultrasound or abdominal computed tomography scan. The retrieval of lost gallstones, as well as drainage or rinsage of abcess cavities, can be done interventionally, laparoscopically, thoracoscopically, or by open approach. The indication for either interventional techniques, operative laparoscopic or open removal of lost gallstones, or abscess drainage has to be discussed carefully according to the patient’s medical history and location of the abscess and lost gallstones. The use of minimally invasive techniques, like interventional abscess puncture without stone removal, should be avoided because these often result in ongoing clinical problems, such as abscess formation. Summary Lost gallstones have a low incidence of causing complications but have a large variety of different postoperative problems. Every effort should be made to remove spilled gallstones to prevent further complications, but conversion is not mandatory. Open or laparoscopic removal of lost

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