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Postoperative fistula of the abdominal wall after laparascopic cholecystectomy due to lost gallstones
European Journal of Ultrasound 15 (2002) 61 – 63 www.elsevier.com/locate/ejultrasou
Postoperative fistula of the abdominal wall after laparascopic cholecystectomy due to lost gallstones H. Weiler *, A. Grandel Clinic of Ludwigsburg, Department of Gastroenterology/Hepatology, Posilipostreet 4, D 71640 Ludwigsburg, Germany
Abstract Abdominal fistula caused by cholesterol gallstones, which remained in the abdominal wall after laparascopic cholecystectomy: a laparascopic cholecystectomy was performed in a 60-years-old man who was diagnosed as acute necrosing cholecystitis due to cholecystolithiasis. After removal of the gallbladder using an Endocath some gallstones remained in the excision channel of the abdominal wall. Therefore, a fistula developed in the excision channel postoperatively. As the wound healing was disturbed an investigation of the abdominal wall was performed by ultrasound. In the former excision channel several small, oval, formations with high echogenicity and faint ultrasound shadows were detected, corresponding to additional gallstones. After excision of granulation tissue and removal of the cholesterol stones, complete healing of the fistula in the abdominal wall was achieved. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cholecystectomy; Ultrasound; Fistula; Gallstones
1. Introduction Laparascopic cholecystectomy is established as a less invasive and effective method of treatment of symptomatic cholecystolithiasis with a fatality rate in the range from 0.09 to 0.2%, an intraoperative rate of complications of 1.0% and a postoperative rate of complications from 4.4 to 5.0% Siewert et al., 1993; Shea et al., 1996; Scha¨fer et al., 1998; Kraas et al., 2001. The intraoperative complications are mainly injuries to the small intestine, the bile ducts and the aorta Siewert et al., 1993; Scho¨nleben et al., 1993. Postoperative
* Corresponding author.
complications are diverse e.g. haematomas, wound infection, postoperative bleeding, leakage of the cystic bile duct, persisting fistulas of bile ducts, intraabdominal abscesses, lost gallstones, stenosis or perforation of the common bile duct, incisional hernias, deep venous thrombosis of the legs, pulmonary embolism and cardiopulmonary problems. As an example of such a complication we report a case of lost gallstones in the former excision channel with consecutive development of a fistula in the abdominal wall.
2. Case report A laparascopic cholecystectomy for necrosing cholecystitis due to cholecystolithiasis was per-
0929-8266/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 9 2 9 - 8 2 6 6 ( 0 2 ) 0 0 0 0 7 - 1
62
H. Weiler, A. Grandel / European Journal of Ultrasound 15 (2002) 61–63
formed in a 60-years-old man. The resected gall bladder was extracted through the middle of three excision channels by means of an Endocath. A painless fistula of the abdominal wall developed postoperatively. On clinical examination the patient was in good general health (166 cm, 92 kg). The liver and spleen were not palpable due to the adipose abdominal wall. A 1.5 cm long and non-tender incision wound with serous secretion was found in the left upper quadrant of the abdominal wall. Using B-mode sonography (ATL HDI 5000)and a 2–5 MHz curved array probe, the upper abdomen appeared normal. Using the 5– 12 MHz linear probe a 7– 8 mm wide, inhomogenous duct with low echogenicity, a few stones (5– 6 mm long) with an inner structure of high echogenity and a discrete shadow in the left upper quadrant of the abdominal wall (Fig. 1) was demonstrated. An excision of the scar tissue was performed on this patient. The histological examination revealed a chronic granulating, partly phlegmonic, partly abscess forming inflammation with a foreign body granuloma of cholesterol concretions.
wall. Even with this technique concretions can get lost and remain in the adipose abdominal wall. These lost cholesterol concretions can lead to a discrete tissue reaction with formation of small fistulas and foreign body granulomas. There are reports in the medical literature which show that cholesterol gallstones, which are lost in the abdominal cavity, cause no relevant complications Wetscher et al., 1994; Gallinaro et al., 1994; Chanson et al., 1997; Patterson et al., 1997. On the other hand reports of lost pigment
3. Discussion For approximately 10 years laparascopic cholecystectomy has become the accepted technique to remove the gall bladder, especially in cases of non-complicated symptomatic gallstones or other diseases of the gall bladder Siewert et al., 1993; Shea et al., 1996; Scha¨ fer et al., 1998; Kraas et al., 2001; Scho¨ nleben et al., 1993. In most cases a removal of the gall bladder is successful with this minimal invasive procedure after preparation of the gall bladder through the trochar. However, in up to 10%, loss of concretions into the abdominal cavity has been reported (Zamir et al., 1999; Wetscher et al., 1994; Gallinaro et al., 1994; Chanson et al., 1997; Patterson et al., 1997). If there are a lot of gallstones or the stones are too big to be removed through the trochar or in the case of a purulent cholecystitis, gall bladder empyema or a suspected malignancy, the gall bladder can be removed by using an Endocath after extension of the incision in the abdominal
Fig. 1. B-mode sonography of the abdominal wall with fistula and gallstones. Sloping position (1a) and transverse position (1b) in the epigastric area.
H. Weiler, A. Grandel / European Journal of Ultrasound 15 (2002) 61–63
stones can cause complications such as local adhesions, abscess formation, necrosis of adipose tissue or of omental tissue, which can appear months or even years after the laparascopic cholecystectomy Wetscher et al., 1994; Gallinaro et al., 1994; Chanson et al., 1997. In this situation a re-laparascopy is usually necessary for a curative treatment. In the literature only one case has been found, which concerns lost pigment gallstones after laparascopic cholecystectomy. These were detected by ultrasound- and CT of the abdominal wall and which caused necrosis of adipose tissue Walch et al., 2000. In our patient the B-modesonography revealed a few lost gallstones in the former excision channel in the abdominal wall after laparascopic cholecystectomy. Contrary to the above-mentioned case report where the lost pigment gallstones led to pain in the upper abdomen, our patient had no pain due to the lost cholesterol concretions. In cases of abdominal complications after laparascopic cholecystectomy like local tenderness, insufficient wound healing and the development of a mass in the abdominal wall in the area of the former operation channels, lost gallstones should be considered as a possible complication. Therefore, an ultrasound examination of the abdominal wall should be performed in addition to ultrasound examination of the abdominal organs.
63
References Chanson C, Nassiopoulos K, Petropoulos P. Les complications de la lithiase biliaire intra-peritoneale. Schweiz Med Wschr 1997;127:1323 – 8. Gallinaro RN, Miller FB. The lost Gallstone. Surg Endosc 1994;8:913 – 4. Kraas E, Frauenschuh D. Chirurgie der Gallenblase und Gallenwege durch MIC. Der Chirurg 2001;72:378 – 88. Patterson EG, Nagy AG. Do not cry over spilled stones? Complications of the gallstones spille during laparoscopic cholecystectomy: case report and literature review. CJS 1997;4:40. Schafer M, Suter C, Klaiber C, Wehrli H, et al. Spilled gallstones after laparascopic cholecystectomy. A relevant problem? A retrospective analysis of 10 174 laparascopic cholecystectomies. Surg Endosc 1998;2:305. Scho¨ nleben K, Brune JB, Zender FJ. In: Brune JB, Schbnleben K, editors. Laparoskopische Cholezystektomie. Mu¨ nchen: Hans Marseille Verlag, 1993:89 –108. Shea JA, Healey MJ, Berlin JA, Clarke JR, et al. Mortality and complications associated with laparascopic cholecystectomy: a meta-analysis. Am Surg 1996;224:609. Siewert JR, Feussner MA, Brune JR. Fehler und Gefahren der laparoskopischen Cholezystektomie. Chirurg 1993;64:221 – 9. Walch C, Bodner G, Hufler K. Zum, schicksal der verlorenen gallensteine. Ultraschall in Med 2000;21:189 – 92. Wetscher G, Schwab G, Fend F, Glaser K, Ladurner D, Bodner E. Subcutaneous abscess due to gallstones lost during laparoscopic cholecystectomy. Endoscopy 1994;26:26 – 7. Zamir G, Lyass S, Pertsemlinidis D, Katz B. The fate of the dropped gallstones during laparascopic cholecystectomy. Surg Endosc 1999;13:68 – 70.
Postoperative fistula of the abdominal wall after laparascopic cholecystectomy due to lost gallstones H. Weiler *, A. Grandel Clinic of Ludwigsburg, Department of Gastroenterology/Hepatology, Posilipostreet 4, D 71640 Ludwigsburg, Germany
Abstract Abdominal fistula caused by cholesterol gallstones, which remained in the abdominal wall after laparascopic cholecystectomy: a laparascopic cholecystectomy was performed in a 60-years-old man who was diagnosed as acute necrosing cholecystitis due to cholecystolithiasis. After removal of the gallbladder using an Endocath some gallstones remained in the excision channel of the abdominal wall. Therefore, a fistula developed in the excision channel postoperatively. As the wound healing was disturbed an investigation of the abdominal wall was performed by ultrasound. In the former excision channel several small, oval, formations with high echogenicity and faint ultrasound shadows were detected, corresponding to additional gallstones. After excision of granulation tissue and removal of the cholesterol stones, complete healing of the fistula in the abdominal wall was achieved. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Cholecystectomy; Ultrasound; Fistula; Gallstones
1. Introduction Laparascopic cholecystectomy is established as a less invasive and effective method of treatment of symptomatic cholecystolithiasis with a fatality rate in the range from 0.09 to 0.2%, an intraoperative rate of complications of 1.0% and a postoperative rate of complications from 4.4 to 5.0% Siewert et al., 1993; Shea et al., 1996; Scha¨fer et al., 1998; Kraas et al., 2001. The intraoperative complications are mainly injuries to the small intestine, the bile ducts and the aorta Siewert et al., 1993; Scho¨nleben et al., 1993. Postoperative
* Corresponding author.
complications are diverse e.g. haematomas, wound infection, postoperative bleeding, leakage of the cystic bile duct, persisting fistulas of bile ducts, intraabdominal abscesses, lost gallstones, stenosis or perforation of the common bile duct, incisional hernias, deep venous thrombosis of the legs, pulmonary embolism and cardiopulmonary problems. As an example of such a complication we report a case of lost gallstones in the former excision channel with consecutive development of a fistula in the abdominal wall.
2. Case report A laparascopic cholecystectomy for necrosing cholecystitis due to cholecystolithiasis was per-
0929-8266/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 9 2 9 - 8 2 6 6 ( 0 2 ) 0 0 0 0 7 - 1
62
H. Weiler, A. Grandel / European Journal of Ultrasound 15 (2002) 61–63
formed in a 60-years-old man. The resected gall bladder was extracted through the middle of three excision channels by means of an Endocath. A painless fistula of the abdominal wall developed postoperatively. On clinical examination the patient was in good general health (166 cm, 92 kg). The liver and spleen were not palpable due to the adipose abdominal wall. A 1.5 cm long and non-tender incision wound with serous secretion was found in the left upper quadrant of the abdominal wall. Using B-mode sonography (ATL HDI 5000)and a 2–5 MHz curved array probe, the upper abdomen appeared normal. Using the 5– 12 MHz linear probe a 7– 8 mm wide, inhomogenous duct with low echogenicity, a few stones (5– 6 mm long) with an inner structure of high echogenity and a discrete shadow in the left upper quadrant of the abdominal wall (Fig. 1) was demonstrated. An excision of the scar tissue was performed on this patient. The histological examination revealed a chronic granulating, partly phlegmonic, partly abscess forming inflammation with a foreign body granuloma of cholesterol concretions.
wall. Even with this technique concretions can get lost and remain in the adipose abdominal wall. These lost cholesterol concretions can lead to a discrete tissue reaction with formation of small fistulas and foreign body granulomas. There are reports in the medical literature which show that cholesterol gallstones, which are lost in the abdominal cavity, cause no relevant complications Wetscher et al., 1994; Gallinaro et al., 1994; Chanson et al., 1997; Patterson et al., 1997. On the other hand reports of lost pigment
3. Discussion For approximately 10 years laparascopic cholecystectomy has become the accepted technique to remove the gall bladder, especially in cases of non-complicated symptomatic gallstones or other diseases of the gall bladder Siewert et al., 1993; Shea et al., 1996; Scha¨ fer et al., 1998; Kraas et al., 2001; Scho¨ nleben et al., 1993. In most cases a removal of the gall bladder is successful with this minimal invasive procedure after preparation of the gall bladder through the trochar. However, in up to 10%, loss of concretions into the abdominal cavity has been reported (Zamir et al., 1999; Wetscher et al., 1994; Gallinaro et al., 1994; Chanson et al., 1997; Patterson et al., 1997). If there are a lot of gallstones or the stones are too big to be removed through the trochar or in the case of a purulent cholecystitis, gall bladder empyema or a suspected malignancy, the gall bladder can be removed by using an Endocath after extension of the incision in the abdominal
Fig. 1. B-mode sonography of the abdominal wall with fistula and gallstones. Sloping position (1a) and transverse position (1b) in the epigastric area.
H. Weiler, A. Grandel / European Journal of Ultrasound 15 (2002) 61–63
stones can cause complications such as local adhesions, abscess formation, necrosis of adipose tissue or of omental tissue, which can appear months or even years after the laparascopic cholecystectomy Wetscher et al., 1994; Gallinaro et al., 1994; Chanson et al., 1997. In this situation a re-laparascopy is usually necessary for a curative treatment. In the literature only one case has been found, which concerns lost pigment gallstones after laparascopic cholecystectomy. These were detected by ultrasound- and CT of the abdominal wall and which caused necrosis of adipose tissue Walch et al., 2000. In our patient the B-modesonography revealed a few lost gallstones in the former excision channel in the abdominal wall after laparascopic cholecystectomy. Contrary to the above-mentioned case report where the lost pigment gallstones led to pain in the upper abdomen, our patient had no pain due to the lost cholesterol concretions. In cases of abdominal complications after laparascopic cholecystectomy like local tenderness, insufficient wound healing and the development of a mass in the abdominal wall in the area of the former operation channels, lost gallstones should be considered as a possible complication. Therefore, an ultrasound examination of the abdominal wall should be performed in addition to ultrasound examination of the abdominal organs.
63
References Chanson C, Nassiopoulos K, Petropoulos P. Les complications de la lithiase biliaire intra-peritoneale. Schweiz Med Wschr 1997;127:1323 – 8. Gallinaro RN, Miller FB. The lost Gallstone. Surg Endosc 1994;8:913 – 4. Kraas E, Frauenschuh D. Chirurgie der Gallenblase und Gallenwege durch MIC. Der Chirurg 2001;72:378 – 88. Patterson EG, Nagy AG. Do not cry over spilled stones? Complications of the gallstones spille during laparoscopic cholecystectomy: case report and literature review. CJS 1997;4:40. Schafer M, Suter C, Klaiber C, Wehrli H, et al. Spilled gallstones after laparascopic cholecystectomy. A relevant problem? A retrospective analysis of 10 174 laparascopic cholecystectomies. Surg Endosc 1998;2:305. Scho¨ nleben K, Brune JB, Zender FJ. In: Brune JB, Schbnleben K, editors. Laparoskopische Cholezystektomie. Mu¨ nchen: Hans Marseille Verlag, 1993:89 –108. Shea JA, Healey MJ, Berlin JA, Clarke JR, et al. Mortality and complications associated with laparascopic cholecystectomy: a meta-analysis. Am Surg 1996;224:609. Siewert JR, Feussner MA, Brune JR. Fehler und Gefahren der laparoskopischen Cholezystektomie. Chirurg 1993;64:221 – 9. Walch C, Bodner G, Hufler K. Zum, schicksal der verlorenen gallensteine. Ultraschall in Med 2000;21:189 – 92. Wetscher G, Schwab G, Fend F, Glaser K, Ladurner D, Bodner E. Subcutaneous abscess due to gallstones lost during laparoscopic cholecystectomy. Endoscopy 1994;26:26 – 7. Zamir G, Lyass S, Pertsemlinidis D, Katz B. The fate of the dropped gallstones during laparascopic cholecystectomy. Surg Endosc 1999;13:68 – 70.