Need brooks no delay. Peritoneo-cutaneous fistula formation secondary to gallstone dropped at laparoscopic cholecystectomy 20 years previously: a case report

Need brooks no delay. Peritoneo-cutaneous fistula formation secondary to gallstone dropped at... Dropped gallstones, in addition to inadvertent damage to the biliary tree, is a complication seen in laparoscopic cholecystec- tomy (LC) far more frequently than the open procedure. It can result in symptomatic abscess formation, and given its rela- tive rarity, can present a diagnostic challenge. We present the case of a lady whose dropped gallstone resulted in a peritoneo-cutaneous fistula, over 20 years on from her LC. We present the case of a lady whose dropped gallstone INTRODUCTION resulted in a peritoneo-cutaneous fistula, over 20 years on from The benefits of the laparoscopic approach to cholecystectomy her LC. are well documented and this is reflected in its adoption as the standard of care for symptomatic gallstone disease [1]. Despite its advantages, its increasing prevalence has resulted CASE in so-called ‘diseases of medical progress’; complications sin- gular to the laparoscopic approach which were not encoun- A 73-year-old lady presented to her GP with a 3-month history tered prior to the advent of laparoscopy in the 1980s. A notable of pain present in the lower back and right buttock on walking. example being the spillage of stones from the gallbladder, Additionally, she had noted a swelling over the right flank which can occur as a result of direct trauma during trocar which was intermittently painful. Her background included insertion, or mechanically as the gallbladder is manipulated well controlled hypertension, three normal vaginal deliveries, laparoscopically or with compressive force as the specimen is and an elective LC carried out for biliary colic in a DGH in North pulled through a port site. West England 20 years previously. She had never smoked, was Literature review suggests that even when such a spillage is a trivial drinker, and lived independently. noted and acted on intra-operatively (with retrieval and washout), Her GP examined her and noted an indurated, non-tender retention of a dropped stone within the peritoneal cavity or port lump, 6 cm in diameter, immediately postero-lateral the crest site tract can result in a symptomatic abscess in as many as 1% of the right ilium. Weight-bearing and rotational movements of of patients receiving laparoscopic cholecystectomy (LC) [2]. the hip were pain-free, however, extension and flexion at the Received: November 9, 2017. Accepted: January 27, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy013/4857396 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 L. Nugent and P. Chandran right hip would reproduce her symptoms. Plain films of the pel- Upon completion of the laparoscopy the patient was turned to vis and both hips demonstrated mild bilateral degenerative the left lateral position for incision and drainage of the abscess. A change only. A sarcoma of the posterior abdominal wall was peritoneo-cutaneous fistula had indeed formed, ~8 cm in suspected and so an urgent outpatient MR scan of the abdomen diameter at its mouth. This was drained, washed-out, packed, and pelvis was arranged (Fig. 1). and left to heal by secondary intention. Swabs from the abscess The study showed an abscess in the superficial tissuesofthe cavity grew Escherichia coli and Bacteroides species. right lower back, communicating with a partially calcified mass The patient received a short course of oral antibiotic (1 week in theright para-colic gutter. Thepresenceof the mass as alikely cefaclor and metronidazole) therapy at discharge. She was fol- infectious focus precluded percutaneous drainage and so the lowed up as an outpatient 4 weeks later. The sinus had reduced patient was referred to a general surgeon. She remained system- in diameter to ~4 cm and intermittently discharged serous ically well, and baseline investigations showed a normal white fluid, but the surrounding skin was free of erythema, and there −3 cell count, andonlymodestlyelevated CRPlevelsat53mgdm . was no clinical evidence of ongoing infection. Her pain on hip Abscess formation secondary to a dropped gallstone from her his- flexion/extension was significantly diminished and she was torical procedure was diagnosed, and she was listed for laparo- pleased with her outcome. She was discharged to the care of scopic retrieval of the calculus with drainage of the abscess. the community nursing team who will continue to pack the By the time of operation, the mass on her right flank had sinus until it has closed satisfactorily. become inflamed, and purulent discharge from a central punc- tum was noted. DISCUSSION Intra-operatively multiple adhesions were lysed, and the cae- cum was found to be adherent to the posterior wall. It was freed This lady’s case is unusual given the length of time between up andinvertedtorevealan inflammatory mass in the right para- when the stone was (presumably) dropped and the onset of her colic gutter underlying the ascending colon. Dissection of the symptoms (the median onset for such cases being ~5 months overlying inflamed tissue revealed a walled-off gallstone (Fig. 2). [3]). Literature review suggests spillage of gallstones at LC is The stone was retrieved (Fig. 4) and the cavity debrided and reported in as many as 40% of procedures [4], however, fewer washed-out. Figure 3 shows the same cavity following excision of the offending stone. Figure 2: Laparoscopic view of the dropped stone in the right para-colic gutter (caecum inverted top right). Figure 1: Subsequent axial MR sections of the pelvis. In the first image a large superficial collection can be seen in the soft tissues of the right lower back with surrounding fat stranding. A partially calcified, roughly spherical mass (3 cm in diameter) can be seen, walled-off within the abdominal cavity (red arrow). The second, more inferior section demonstrates communication (blue arrow) between the abscess cavity, through the belly of quadratus lumborum, and the calcified mass. Figure 3: Post-excision laparoscopic view of the posterior abdominal wall cavity. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy013/4857396 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Need brooks no delay 3 abscess as it elevated the ilium during the swing phase of gait, but the delay in abscess formation and presentation remains unaccounted for. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), 2010 https://www.sages.org/ publications/guidelines 2. Reiter S, French B, Holzmer S, Phillips BJ, Martinez RJ. Dropped gallstones: a case of persistent right flank abscess Figure 4: A 3 cm mixed pigment cholelith excised from the abdominal cavity, requiring surgical management. Scientific Pages Emerg Med presumably dropped at laparoscopic cholecystectomy over 20 years previously. 2017;1:11–4. 3. Horton M, Florence MG. Unusual abscess patterns following than 1% of these cases prove symptomatic, and washout at the dropped gallstones during laparoscopic cholecystectomy. time of LC is considered a sufficient management technique Am J Surg 1998;175:375–3. (i.e. conversion to open is not indicated given our current evi- 4. Sathesh-Kumar T, Saklani AP, Vinayagam R, Blackett RL. dence base) [2]. Calculi that are left behind however, can Spilled gall stones during laparoscopic cholecystectomy: a migrate to a plethora of unusual locations [5, 6], and may pre- review of the literature. Postgrad Med J 2004;80:77–9. sent radiologists with diagnostic challenges, particularly when 5. Anteby E, Hurwitz A, Palti Z, Amir G, Yagel S, Lavy Y, et al. the calculus itself is not radio-opaque, the surrounding inflam- Gallstones in an ovarian dermoid cyst. N Engl J Med 1992;327: matory change may be mistaken for an intra-abdominal neo- 129–30. plastic process [7]. 6. Jabbari Nooghabi A, Hassanpour M, Jangjoo A. Consequences This case adds to the multitude of potential presenting pat- of lost gallstones during laparoscopic cholecystectomy: a ternsfor abscessessecondary to dropped gallstones, and the van- review article. Surg Laparosc Endosc Percutan Tech 2016;26: ishingly rare incidence of cases of peritoneo-cutaneous fistulae 183–92. secondary to dropped gallstones (cf cholecysto-cutaneous fistulae 7. Ramamurthy NK, Rudralingam V, Martin DF, Galloway SG, seen in active cholecystitis) Sukumar SA. Out of sight but kept in mind: complications The authors speculate that this lady’s pain on walking may and imitations of dropped gallstones. Am J Roentgenol 2013; be explained by contraction of quadratus lumborum about the 200:1244–53. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy013/4857396 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Need brooks no delay. Peritoneo-cutaneous fistula formation secondary to gallstone dropped at laparoscopic cholecystectomy 20 years previously: a case report

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Dropped gallstones, in addition to inadvertent damage to the biliary tree, is a complication seen in laparoscopic cholecystec- tomy (LC) far more frequently than the open procedure. It can result in symptomatic abscess formation, and given its rela- tive rarity, can present a diagnostic challenge. We present the case of a lady whose dropped gallstone resulted in a peritoneo-cutaneous fistula, over 20 years on from her LC. We present the case of a lady whose dropped gallstone INTRODUCTION resulted in a peritoneo-cutaneous fistula, over 20 years on from The benefits of the laparoscopic approach to cholecystectomy her LC. are well documented and this is reflected in its adoption as the standard of care for symptomatic gallstone disease [1]. Despite its advantages, its increasing prevalence has resulted CASE in so-called ‘diseases of medical progress’; complications sin- gular to the laparoscopic approach which were not encoun- A 73-year-old lady presented to her GP with a 3-month history tered prior to the advent of laparoscopy in the 1980s. A notable of pain present in the lower back and right buttock on walking. example being the spillage of stones from the gallbladder, Additionally, she had noted a swelling over the right flank which can occur as a result of direct trauma during trocar which was intermittently painful. Her background included insertion, or mechanically as the gallbladder is manipulated well controlled hypertension, three normal vaginal deliveries, laparoscopically or with compressive force as the specimen is and an elective LC carried out for biliary colic in a DGH in North pulled through a port site. West England 20 years previously. She had never smoked, was Literature review suggests that even when such a spillage is a trivial drinker, and lived independently. noted and acted on intra-operatively (with retrieval and washout), Her GP examined her and noted an indurated, non-tender retention of a dropped stone within the peritoneal cavity or port lump, 6 cm in diameter, immediately postero-lateral the crest site tract can result in a symptomatic abscess in as many as 1% of the right ilium. Weight-bearing and rotational movements of of patients receiving laparoscopic cholecystectomy (LC) [2]. the hip were pain-free, however, extension and flexion at the Received: November 9, 2017. Accepted: January 27, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy013/4857396 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 L. Nugent and P. Chandran right hip would reproduce her symptoms. Plain films of the pel- Upon completion of the laparoscopy the patient was turned to vis and both hips demonstrated mild bilateral degenerative the left lateral position for incision and drainage of the abscess. A change only. A sarcoma of the posterior abdominal wall was peritoneo-cutaneous fistula had indeed formed, ~8 cm in suspected and so an urgent outpatient MR scan of the abdomen diameter at its mouth. This was drained, washed-out, packed, and pelvis was arranged (Fig. 1). and left to heal by secondary intention. Swabs from the abscess The study showed an abscess in the superficial tissuesofthe cavity grew Escherichia coli and Bacteroides species. right lower back, communicating with a partially calcified mass The patient received a short course of oral antibiotic (1 week in theright para-colic gutter. Thepresenceof the mass as alikely cefaclor and metronidazole) therapy at discharge. She was fol- infectious focus precluded percutaneous drainage and so the lowed up as an outpatient 4 weeks later. The sinus had reduced patient was referred to a general surgeon. She remained system- in diameter to ~4 cm and intermittently discharged serous ically well, and baseline investigations showed a normal white fluid, but the surrounding skin was free of erythema, and there −3 cell count, andonlymodestlyelevated CRPlevelsat53mgdm . was no clinical evidence of ongoing infection. Her pain on hip Abscess formation secondary to a dropped gallstone from her his- flexion/extension was significantly diminished and she was torical procedure was diagnosed, and she was listed for laparo- pleased with her outcome. She was discharged to the care of scopic retrieval of the calculus with drainage of the abscess. the community nursing team who will continue to pack the By the time of operation, the mass on her right flank had sinus until it has closed satisfactorily. become inflamed, and purulent discharge from a central punc- tum was noted. DISCUSSION Intra-operatively multiple adhesions were lysed, and the cae- cum was found to be adherent to the posterior wall. It was freed This lady’s case is unusual given the length of time between up andinvertedtorevealan inflammatory mass in the right para- when the stone was (presumably) dropped and the onset of her colic gutter underlying the ascending colon. Dissection of the symptoms (the median onset for such cases being ~5 months overlying inflamed tissue revealed a walled-off gallstone (Fig. 2). [3]). Literature review suggests spillage of gallstones at LC is The stone was retrieved (Fig. 4) and the cavity debrided and reported in as many as 40% of procedures [4], however, fewer washed-out. Figure 3 shows the same cavity following excision of the offending stone. Figure 2: Laparoscopic view of the dropped stone in the right para-colic gutter (caecum inverted top right). Figure 1: Subsequent axial MR sections of the pelvis. In the first image a large superficial collection can be seen in the soft tissues of the right lower back with surrounding fat stranding. A partially calcified, roughly spherical mass (3 cm in diameter) can be seen, walled-off within the abdominal cavity (red arrow). The second, more inferior section demonstrates communication (blue arrow) between the abscess cavity, through the belly of quadratus lumborum, and the calcified mass. Figure 3: Post-excision laparoscopic view of the posterior abdominal wall cavity. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy013/4857396 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Need brooks no delay 3 abscess as it elevated the ilium during the swing phase of gait, but the delay in abscess formation and presentation remains unaccounted for. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), 2010 https://www.sages.org/ publications/guidelines 2. Reiter S, French B, Holzmer S, Phillips BJ, Martinez RJ. Dropped gallstones: a case of persistent right flank abscess Figure 4: A 3 cm mixed pigment cholelith excised from the abdominal cavity, requiring surgical management. Scientific Pages Emerg Med presumably dropped at laparoscopic cholecystectomy over 20 years previously. 2017;1:11–4. 3. Horton M, Florence MG. Unusual abscess patterns following than 1% of these cases prove symptomatic, and washout at the dropped gallstones during laparoscopic cholecystectomy. time of LC is considered a sufficient management technique Am J Surg 1998;175:375–3. (i.e. conversion to open is not indicated given our current evi- 4. Sathesh-Kumar T, Saklani AP, Vinayagam R, Blackett RL. dence base) [2]. Calculi that are left behind however, can Spilled gall stones during laparoscopic cholecystectomy: a migrate to a plethora of unusual locations [5, 6], and may pre- review of the literature. Postgrad Med J 2004;80:77–9. sent radiologists with diagnostic challenges, particularly when 5. Anteby E, Hurwitz A, Palti Z, Amir G, Yagel S, Lavy Y, et al. the calculus itself is not radio-opaque, the surrounding inflam- Gallstones in an ovarian dermoid cyst. N Engl J Med 1992;327: matory change may be mistaken for an intra-abdominal neo- 129–30. plastic process [7]. 6. Jabbari Nooghabi A, Hassanpour M, Jangjoo A. Consequences This case adds to the multitude of potential presenting pat- of lost gallstones during laparoscopic cholecystectomy: a ternsfor abscessessecondary to dropped gallstones, and the van- review article. Surg Laparosc Endosc Percutan Tech 2016;26: ishingly rare incidence of cases of peritoneo-cutaneous fistulae 183–92. secondary to dropped gallstones (cf cholecysto-cutaneous fistulae 7. Ramamurthy NK, Rudralingam V, Martin DF, Galloway SG, seen in active cholecystitis) Sukumar SA. Out of sight but kept in mind: complications The authors speculate that this lady’s pain on walking may and imitations of dropped gallstones. Am J Roentgenol 2013; be explained by contraction of quadratus lumborum about the 200:1244–53. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy013/4857396 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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