Peritoneal chronic inflammatory mass formation due to gallstones lost during laparoscopic cholecystectomy

    Peritoneal chronic inflammatory mass formation due to gallstones lost during laparoscopic cholecystectomy Yoshifumi Noda, Masayuki Kanematsu, Satoshi Goshima, Hiroshi Kondo, Haruo Watanabe, Hiroshi Kawada, Nobuyuki Kawai, Yukichi Tanahashi PII: DOI: Reference:

S0899-7071(14)00076-X doi: 10.1016/j.clinimag.2014.03.011 JCT 7597

To appear in:

Journal of Clinical Imaging

Received date: Revised date: Accepted date:

24 December 2013 26 February 2014 20 March 2014

Please cite this article as: Noda Yoshifumi, Kanematsu Masayuki, Goshima Satoshi, Kondo Hiroshi, Watanabe Haruo, Kawada Hiroshi, Kawai Nobuyuki, Tanahashi Yukichi, Peritoneal chronic inflammatory mass formation due to gallstones lost during laparoscopic cholecystectomy, Journal of Clinical Imaging (2014), doi: 10.1016/j.clinimag.2014.03.011

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Case Report

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lost during laparoscopic cholecystectomy

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Peritoneal chronic inflammatory mass formation due to gallstones

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Yoshifumi Noda, M.D., Masayuki Kanematsu, M.D., Satoshi Goshima, M.D, Ph.D., Hiroshi Kondo, M.D., Haruo Watanabe, M.D., Hiroshi Kawada, M.D., Nobuyuki Kawai, M.D., Yukichi Tanahashi, M.D. Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu

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501-1194, Japan Corresponding author: Masayuki Kanematsu, M.D.

Department of Radiology, and Radiology Services Gifu University Hospital

1-1 Yanagido, Gifu 501-1193, Japan Phone: (58) 230-6439

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Fax: (58) 230-6440

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E-mail: [email protected]

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Case Report

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lost during laparoscopic cholecystectomy

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Peritoneal chronic inflammatory mass formation due to gallstones

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Abstract

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We here describe the radiologic findings of peritoneal chronic abscess formation due to gallstones lost within the peritoneum during laparoscopic cholecystectomy (LC). A

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radiologic workup 7 months after LC revealed a soft-tissue mass with contrast

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enhancement, harboring internal necrosis and punctate calcium located in the Morrison's pouch. The mass exhibited restricted water molecule diffusion, absence of fat deposition, and increased F-18 fluorodeoxy-D-glucose uptake, thus mimicking a malignant tumor.

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The biopsy revealed an inflammatory granuloma. Another patient with similar findings

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was treated with percutaneous abscess drainage. Thus, radiologists should be aware of

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this disease condition and its imaging findings.

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Keywords: peritoneal chronic abscess formation; lost gallstone; laparoscopic cholecystectomy

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1. Introduction

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Laparoscopic cholecystectomy (LC) has become the gold standard treatment for symptomatic gallstones, as it offer improved patient satisfaction and reduced hospital

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stays [1]. Although the overall complication rate associated with the LC procedure is less

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than that with open cholecystectomy, two major LC-associated complications have been frequently described in the literature including bile duct injury or leakage and delayed abscess formation due to lost gallstones [1]. Although the incidence of bile duct injury

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with LC ranges from 0.1% to 0.5% and has decreased as surgeons have accumulated

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more experience during the past 2 decades [1], the incidence of complications due to lost

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gallstones has been unaffected. The estimated incidence of post-LC abscess formation due to lost gallstones is approximately 0.3% [2]. Previous reports described that

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abscesses or inflammatory masses that contained gallstones or stone fragments were generally located in the abdominal wall, subhepatic space, or retroperitoneum below the subhepatic space, but such masses could occur anywhere in the abdomen or in unusual locations, including the right thorax or the site of incisional hernias [3]. Our literature search did not find any previous reports that precisely describe the radiologic features of this disease condition. Therefore, we describe these findings in this report.

2. Case reports 4

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Case 1

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A 52-year-old woman, an asymptomatic subhepatic mass was identified using ultrasonography during a medical checkup and was referred to our hospital for further

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examination. She underwent LC for a symptomatic gallstone 7 months before. Blood

protein (CRP) level (0.25 mg/dL).

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biochemical findings revealed normal levels, except for a slightly elevated C-reactive

Unenhanced computed tomography (CT; Discovery CT750 HD; GE Healthcare,

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Milwaukee, WI, USA) demonstrated a soft-tissue-density mass at the Morrison’s pouch

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that measured 3 cm in diameter and had ill-defined margins and internal punctate calcium

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(Fig. 1A). Contrast-enhanced dynamic CT demonstrated delayed, peripheral enhancement with central necrosis in the mass during the arterial and equilibrium phases

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(Fig. 1B, C). Magnetic resonance (MR) imaging was performed on a 1.5-T system (Intera Achieva 1.5-T Pulsar; Philips Medical Systems, Netherlands). In-phase (TR/TE, 292/2.3 msec) and out-of-phase (TR/TE, 292/1.1 msec) T1-weighted gradient-recalled-echo images showed the mass as an isointense area in comparison with the right kidney (Fig. 1D, 1E). Respiratory-triggered T2-weighted turbo spin-echo axial images (TR/TE, 1,600/80 msec) showed the mass as a hypointense area in comparison with the right kidney (Fig. 1F). Diffusion-weighted imaging (DWI; TR/TE, 2,291/46 msec; b factors, 0

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and 500 sec/mm2) showed obvious diffusion restriction within the mass (Fig. 1G), with a

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reduced apparent diffusion coefficient value (ADC) of 0.87 × 10−3 mm2/sec. The F-18 fluorodeoxy-D-glucose (FDG) positron emission tomography (PET)/CT scanning

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(Biograph Sensation 16; Siemens Medical Solutions, Malvern, PA, USA) demonstrated

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intense and homogeneous FDG uptake in the mass, with a maximum standardized uptake value of 9.99 (Fig. 1H). A percutaneous biopsy specimen, obtained under sonographic guidance, revealed that the mass included rich fibrous connective tissue and plasma cell

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chronic inflammation.

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infiltration; these findings were compatible with a granulated tissue resulting from

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Case 2

A 41-year-old man was referred to our hospital with right upper quadrant pain.

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He underwent LC for a symptomatic gallstone 13 months before. A clinical inspection determined that he had mild tenderness in the right upper abdominal quadrant. Blood biochemical findings revealed normal levels, except for a slightly elevated white blood cell count (9,500/μL) and CRP level (0.59 mg/dL). Axial and coronal reformatted unenhanced CT images demonstrated a rounded mass in the subhepatic space, with ill-defined margins and internal punctate calcium (Fig. 2A, B). The mass was successfully removed by an open drainage procedure. The cytological examination

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revealed Streptococcus anginosus mixed with pus cells. A pigment gallstone was found in

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the abscess cavity. 3. Discussion

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In the United States, more than 700,000 LC procedures are performed each year,

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and this number continues to increase [4]. The advantages of LC, compared with open cholecystectomy, include smaller incisions, reduced postoperative pain, and a shorter recovery time. However, limited visualization and the technical challenges of

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laparoscopy increase the risk of bile duct injury and lost gallstones. The incidence of lost

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gallstones after LC is reported ranges from 5.4% to 19%, and 8.5% of these lost

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gallstones will lead to some complications [3]. Although rare, the complications associated with lost gallstones after LC can include localized or systemic infection,

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inflammation, fibrosis, adhesion, fistula formation, ileus, and abscess formation [2, 4]. The most frequently reported complication was abscess formation, as noted in our cases [3]. The local inflammatory response induced by peritoneal lost gallstones is greater in the presence of acute cholecystitis [5], stone fragmentation [5], and pigment stones [6]. Pigment stones are more likely to be infected than cholesterol stones [7]. According to a previous report, up to 80%–90% of pigment stones contained bacteria such as

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formation after LC ranges from 4 months to 10 years [8].

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Escherichia coli, Klebsiella pneumonia, and Enterococcus [2]. The mean time to abscess

A diagnosis of lost gallstones should be considered when a peritoneal abscess or

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fistula formation occurs months to years after LC. The abscess formation associated with

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lost gallstones can mimic other causes, such as soft tissue sarcoma or malignant lymphoma. Such a patient may still undergo an otherwise avoidable biopsy for the diagnosis in many centers. In our series, CT showed punctate calcium suspicious of lost

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calculi in the soft tissue masses in both patients, and these findings led to the correct

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diagnosis. Radiologists should be aware that abscess formation after LC is not limited to

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the perioperative period, but can also occur rather later. Sonography and CT are helpful to identify gallstones or stone fragments within abscesses, and such findings are crucial to

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make a correct diagnosis [9]. We might be able to avoid an unnecessary biopsy, should we have knowledge of the imaging features. Abscess formation secondary due to lost gallstones requires the drainage or rinsing of abscess cavities, stone removal by an open or laparoscopic approach [3], and interventional approaches [10]. In conclusion, we presented two cases of peritoneal chronic inflammatory mass formation after LC due to lost gallstones. Complications of lost gallstones are infrequent, but can cause various postoperative problems. The presence of calculi identified using

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sonography or CT within mass lesions provides a valuable clue to the correct diagnosis of

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a chronic inflammatory mass or abscess formation in the peritoneum after LC.

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References [1] Strasberg, S.M. Laparoscopic biliary surgery. Gastroenterol Clin North Am 1999; Horton, M. and M.G. Florence. Unusual abscess patterns following dropped

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[2]

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28(1): 117-32. gallstones during laparoscopic cholecystectomy. Am J Surg,1998; 175(5): 375-9. [3]

Zehetner, J., A. Shamiyeh, and W. Wayand. Lost gallstones in laparoscopic

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Lohan, D., et al. Imaging of the complications of laparoscopic cholecystectomy. European Radiology 2005; 15(5): 904-12.

Yerdel, M.A., et al. The fate of intraperitoneally retained gallstones with different

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[5]

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cholecystectomy: all possible complications. Am J Surg 2007; 193(1): 73-78.

morphologic and microbiologic characteristics: an experimental study. J Laparoendosc Adv Surg Tech A 1997; 7(2): 87-94. [6]

Gurleyik, E., et al. Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat? Surgical Laparoscopy & Endoscopy 1998; 8(2): 113-116.

Woodfield, J.C. M. Rodgers, and J.A. Windsor, Peritoneal gallstones following

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[7]

laparoscopic cholecystectomy: incidence, complications, and management. Surg [8]

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Endosc 2004; 18(8): 1200-7.

Van Brunt, P.H. and R.J. Lanzafame. Subhepatic inflammatory mass after laparoscopic cholecystectomy. A delayed complication of spilled gallstones. Arch Surg

[9]

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1994;129(8): 882-3.

Morrin, M.M., et al. Radiologic features of complications arising from dropped

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gallstones in laparoscopic cholecystectomy patients. AJR Am J Roentgenol 2000; 174(5): 1441-5. [10]

Whiting, J., N.T. Welch, and M.T. Hallissey. Subphrenic abscess caused by gallstones "lost" at laparoscopic cholecystectomy one year previously: management by minimally invasive techniques. Surgical Laparoscopy & Endoscopy 1997; 7(1): 77-8.

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Figure legends

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Fig. 1. A 52-year-old woman with asymptomatic subhepatic mass who had undergone LC

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7 months before. (A) Unenhanced CT demonstrates a soft-tissue-density mass (arrow) at

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the Morrison’s pouch that measured 3 cm in diameter and had ill-defined margins and

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internal punctate calcium. Contrast-enhanced CT demonstrates delayed peripheral enhancement in the mass during the arterial (B) and equilibrium (C) phases. In-phase (D) and out-of-phase (E) T1-weighted gradient-recalled-echo images show the mass as an

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isointense area, compared with the right kidney. Respiratory-triggered T2-weighted turbo spin-echo axial image (F) shows the mass as a hypointense area, compared with the right

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kidney. Diffusion-weighted image (G) shows obvious diffusion restriction corresponding

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to the mass. The F18-FDG-PET/CT scan (H) demonstrates intense and homogeneous

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FDG uptake in the mass, with a maximum standardized uptake value of 9.99. Fig. 2. A 41-year-old man who underwent LC 13 months before presented with symptomatic subhepatic mass. Axial (A) and coronal-reformatted (B) unenhanced CT images demonstrate a rounded mass in the subhepatic space. The mass has ill-defined margins and contains punctate calcium corresponding to the lost calculus (arrow).

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Fig. 1a

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Fig. 1e

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Fig. 1g

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Fig. 2b

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