Combined percutaneous and endoscopic approach in management of dropped gallstones following laparoscopic cholecystectomy

摘要

Dropped gallstones due to accidental perforation of gallbladder wall during laparoscopic cholecystectomy are often encountered. However, dropped gallstones as nidus of infection with subsequent abscess formation is a rare complication of laparoscopic cholecystectomy (0.3%). Most of the reported cases of complicated dropped stones required open surgical drainage. Minimally invasive measures were less frequently employed. We report a case of dropped gallstones that were removed endoscopically through a percutaneous drainage tract. Keywords. Dropped gallstone, laparoscopic cholecystectomy, percutaneous endoscopic stone extractionCASE REPORTA 53-year-old man presented to the emergency department of our institution with fever and right upper quadrant pain. Urgent ultrasonogram (USG) of the upper abdomen demonstrated the presence of multiple stones in gallbladder and thickened gallbladder wall. Common bile duct (CBD) stones were also seen. Overall features were compatible with acute calculous cholecystitis and cholangitis. Endoscopic retrograde chlangiopancreatography (ERCP) placement of common bile duct stent was performed. The patient was discharged with appointment for elective laparoscopic cholecystectomy 3 weeks later in 1998. The CBD stones were eventually removed by ERCP.Two years later in 2000, this patient was admitted for jaundice, tea color urine, epigastric pain and vomiting. Contrast computed tomography (CT) scan of the abdomen demonstrated a large irregular rim-enhancing subhepatic collection. In the presence of leukocytosis, an abscess was diagnosed in the subhepatic region. The patient was referred to the interventional radiology unit for percutaneous ultrasonographic guided drainage of the abscess. He had prompt resolution of his symptoms following abscess drainage.Thereafter, this patient had multiple hospital admissions due to recurrent infection with subhepatic abscess requiring repeated percutaneous drainage by interventional radiologists in 2001, 2002 and 2007. The drained pus grew pseudomonas. Contrast fistulogram in 2001 showed no definite communication of the abscess cavity with bowel or biliary tract.He was last admitted in 2007 again for right sided abdominal pain and pus oozing from previous drainage tract skin wound. CT scan confirmed a cutaneous fistula connected to the subhepatic collection (Figure 1a). Multiple tiny hyperdense presumptive dropped gallstones were seen within the inferior part of the collection. Majority of the dropped gallstones were less than 5mm in size (Figure 1a, b). A 6.7Fr Grollman catheter was inserted for percutaneous abscess drainage (Figure 2). Open in a separate windowFigure 1 52-year-old male patient with dropped gallstones. A, B. Axial contrast enhanced (IV) CT image of the upper abdomen showed subhepatic rim-enhancing collection extending to right anterior abdominal wall. The right kidney was anteriorly displaced. Tiny hyperdense foci (arrow) were noted within the inferior portion of the collection suggestive of dropped gallstones related to prior laparoscopic cholecystectomy. (Technique. KVp=120; mA=240; Slice Thickness=5.00 mm; Dose of intravenous contrast. Iopamiro 370, 70ml).