Skip to main content

Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report

Abstract

Background

Dropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC.

Case presentation

We present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up.

Conclusions

We report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC.

Background

Laparoscopic cholecystectomy (LC) is the gold standard for cholelithiasis owing to shorter postoperative stay and fewer complications [1,2,3]. Furthermore, LC is the first treatment option for acute cholecystitis [4]. However, intraoperative gallbladder perforation and gallstone spillage sometimes occur during LC [5, 6].

Dropped gallstones during LC sometimes induce postoperative infectious complications, such as abdominal abscesses [7]. However, pleural empyema rarely occurs as a complication of LC. This study aimed to highlight the potential risk of dropped gallstones in the patients’ postoperative course and to provide a review of literature on pleural empyema caused by dropped gallstones during LC.

Case presentation

A 66-year-old woman was referred to our hospital because of right upper abdominal pain, right chest pain, and dyspnea. Her past medical history included hypertension, primary biliary cirrhosis, and rheumatoid arthritis (RA), treated with a steroid agent and interleukin-6 (IL-6) inhibitor. In addition, LC was performed for acute gangrenous cholecystitis 11 months earlier (Fig. 1). The operative report revealed iatrogenic gallbladder perforation and stone spillage due to severe regional inflammation. The bacterial culture of the gallbladder bile tested positive for Escherichia coli. Tazobactam/piperacillin was administered from the time of surgery to postoperative day 7. Although the inflammatory markers such as white blood cell counts and C-reactive protein were improved, she had persistent fever. Computed tomography (CT) was performed and multiple dropped stones were found. However, abdominal abscess was not found on CT. Upon receiving the culture results, meropenem was administered for the next 10 days. She was discharged from the hospital on postoperative day 21.

Fig. 1
figure 1

CT scan and gallbladder of initial surgery. Abdominal CT performed at the time of diagnosis of cholecystitis shows marked gallbladder swelling and intramural abscess, with gallstones (arrowhead): a axial and b coronal views. c Laparoscopic cholecystectomy for acute cholecystitis. Iatrogenic perforation of the gallbladder due to the pus drainage. d Gallstones and gallbladder with wall thickening and mucosal necrosis

Chest radiography revealed a right pleural effusion (Fig. 2a). Chest CT revealed a right pleural effusion with passive atelectasis (Fig. 2b). Furthermore, abdominal CT showed perihepatic fluid collection and multiple small radiopaque density masses (Fig. 2c). The patient was treated with an antimicrobial agent (meropenem), and ultrasound-guided transthoracic drainage was performed. The bacterial culture of pleural effusion was positive for Escherichia coli, which was consistent with the culture result of the gallbladder bile in acute cholecystitis. However, the drainage was incomplete, and the prescribed treatments did not alleviate the inflammatory reaction. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed. In laparotomy, the abscess in the Morrison’s fossa was opened and drained, and dropped stones around the liver were removed (Fig. 3a–c). The thoracic cavity was covered with membranous necrotic tissue, and a multilocular abscess was observed. However, there was no communication between the thoracic cavity and the abdominal cavity and there were no stones in the thoracic cavity (Fig. 3d). The patient’s symptoms, pleural effusion, and perihepatic fluid collection completely resolved after surgery. The patient has remained well without complications after 14 months of follow-up.

Fig. 2
figure 2

Chest radiography and CT at the time of pleural empyema diagnosis. a Chest radiography reveals a large amount of right pleural effusion. b Chest CT shows a large amount of right pleural effusion with passive atelectasis. c, d Abdominal CT shows perihepatic fluid collection (arrowhead) and multiple small radiopaque density masses (arrow)

Fig. 3
figure 3

Thoracotomy and laparotomy for drainage. a, b The abscess in the Morrison's fossa was opened (arrowhead). c Retrieved gallstones. d Decortication via video-assisted thoracoscopy. No fistula connecting to the abdominal cavity was found

Discussion

This study highlighted two significant findings. First, pleural empyema occurred owing to delayed-onset gallstone formation after LC for acute cholecystitis. Second, complete removal of dropped gallstones was the only curative treatment for pleural empyema.

LC has become the gold standard treatment for cholelithiasis [1,2,3]. The application of LC for acute cholecystitis has increased owing to improvements in the procedure and reduced postoperative hospital stay. However, difficult LC cases, such as necrotic cholecystitis, have been encountered [8]. Iatrogenic gallbladder perforation reportedly occurred in 10–30% of LC procedures [5]. Moreover, the incidence of dropped gallstones was reportedly 5.4–19%, and 1.1–2.3% of dropped gallstones persisted [6].

The incidence of abdominal abscess formation after LC is reportedly low at 0.08%. However, this increases to 1.46% when dropped gallstones are not retrieved [7]. Therefore, 76.8% of surgeons have followed up their patients with dropped gallstones two years after LC owing to concerns regarding abdominal infections [9]. The development of pleural empyema after LC has rarely been reported, with only 13 previous cases [10,11,12,13,14,15,16,17,18,19,20,21,22]. The clinical features of pleural empyema, caused by dropped gallstones after LC, are summarized in Table 1. The median age of the patients was 68 years (range, 53–83 years). The etiologic agents were Escherichia coli in five cases, Klebsiella spp. in four cases, Enterococcus spp. in two cases, and Salmonella spp. in one case. The median period from LC to abscess formation was 17 months (range, 1.5–63 months).

Table 1 Literature review of pleural empyema caused by dropped gallstones during laparoscopic cholecystectomy

The mechanisms that the abdominal infection causes the pleural empyema were reported as follows [23, 24]: first, a port of laparoscopic surgery or a drainage tube may be placed via the thoracic cavity. Second, the diaphragm has congenital defect, such as the esophageal hiatus and the aortic hiatus. Third, inflammation may have destroyed the diaphragm and formed a fistula. Finally, bacteria may have entered the thoracic cavity through the lymphatic network that is abundant in the diaphragm. In any case, there is negative pressure in the thoracic cavity, and infection in the abdominal cavity may transfer into the thoracic cavity through the diaphragm. However, in our case, cholecystitis was not previously treated with percutaneous transhepatic gallbladder drainage and there was no transthoracic port in laparoscopic cholecystectomy. In the previous reports, the fistula which was caused by abdominal inflammation was identified in the diaphragm [11, 20, 22]. In contrast, the fistula could not be found in the diaphragm by the visual inspection and palpation in our case. Furthermore, there were no stones in the thoracic cavity on CT. However, it is difficult to identify the micro fistula intraoperatively. Therefore, we suspected that there was the micro fistula between the abdominal abscess and thoracic cavity. Furthermore, ultrasound-guided transthoracic drainage and antimicrobial agent were not effective enough because the abscess cavity was multilocular. In these aspects, we needed a thoracotomy with laparotomy for complete drainage.

Complete retrieval of dropped gallstones is necessary for the complete recovery of patients with pleural empyema or an abdominal abscess caused by dropped gallstones. The pathogenic bacteriologic profile of pleural empyema, caused by intra-abdominal infection, suggested an abdominal origin [23]. Escherichia coli, Klebsiella spp., and Enterococcus spp. have been commonly isolated in acute cholecystitis [25]. In our case, the bacteriological profile of pleural empyema was similar to that of the bile at the time of acute cholecystitis. However, the pleural empyema and abdominal abscess were not completely resolved despite abscess drainage and administration of the appropriate antimicrobials, as shown in Table 1. However, the pleural empyema and abdominal abscess were treated entirely with complete retrieval of the dropped gallstones. Therefore, dropped gallstones should always be retrieved. Furthermore, abscess formation, caused by dropped gallstones, requires a long time to develop. In these cases, a physician aside from the surgeon can detect the development of pleural empyema or an abdominal abscess. Therefore, all physicians should be informed that the treatment of an abscess, due to dropped gallstones, requires prompt and complete retrieval of the dropped gallstones.

In our case, IL-6 inhibitor is considered one of causes diagnosed after reaching pleural empyema. She started IL-6 inhibitor 2 months before the onset of empyema because her rheumatism worsened. While IL-6 inhibitors are highly effective biological drugs for RA, their anti-inflammatory effects masked the signs and symptoms of infection [26, 27]. She also had no fever even at the onset of empyema. Thus, exacerbation of the patient’s condition may have been avoided by recognizing the dropped stones as a source of infection and IL-6 inhibitors as a risk factor for severe infection.

Conclusion

We report a case of pleural empyema, caused by dropped gallstones after LC for acute cholecystitis. Physicians should keep in mind that dropped gallstones during LC can cause pleural empyema, even after several years. Complete retrieval of the dropped gallstones is necessary to cure pleural empyema and abdominal abscess.

Availability of data and materials

Data sharing is not applicable as no datasets were generated analyzed during the current study.

Abbreviations

LC:

Laparoscopic cholecystectomy

RA:

Rheumatoid arthritis

IL-6:

Interleukin-6

References

  1. Yamashita Y, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, et al. TG13 surgical management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20:89–96.

    Article  Google Scholar 

  2. Maehira H, Kawasaki M, Itoh A, Ogawa M, Mizumura N, Toyoda S, et al. Prediction of difficult laparoscopic cholecystectomy for acute cholecystitis. J Surg Res. 2017;216:143–8.

    Article  Google Scholar 

  3. Iida H, Maehira H, Mori H, Kodama H, Tokuda A, Takebayashi K, et al. Attenuation around the gallbladder on plain abdominal computed tomography as a predictor of surgical difficulty in laparoscopic cholecystectomy. Asian J Endosc Surg. 2021;14:724–31.

    Article  Google Scholar 

  4. Mayumi T, Okamoto K, Takada T, Strasberg SM, Solomkin JS, Schlossberg D, et al. Tokyo guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:96–100.

    Article  Google Scholar 

  5. Duca S, Bãlã O, Al-Hajjar N, Lancu C, Puia IC, Munteanu D, et al. Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford). 2003;5:152–8.

    CAS  Article  Google Scholar 

  6. Zehetner J, Shamiyeh A, Wayand W. Lost gallstones in laparoscopic cholecystectomy: all possible complications. Am J Surg. 2007;193:73–8.

    Article  Google Scholar 

  7. Schäfer M, Suter C, Klaiber C, Wehrli H, Frei E, Krähenbühl L. Spilled gallstones after laparoscopic cholecystectomy. A relevant problem? A retrospective analysis of 10,174 laparoscopic cholecystectomies. Surg Endosc. 1998;12:305–9.

    Article  Google Scholar 

  8. Maehira H, Itoh A, Kawasaki M, Ogawa M, Imagawa A, Mizumura N, et al. Use of dynamic CT attenuation value for diagnosis of acute gangrenous cholecystitis. Am J Emerg Med. 2016;34:2306–9.

    Article  Google Scholar 

  9. Yethadka R, Shetty S, Vijayakumar A. Attitudes and practices of surgeons towards spilled gallstones during laparoscopic cholecystectomy: an observational study. Int Sch Res Notices. 2014;2014: 381514.

    PubMed  PubMed Central  Google Scholar 

  10. Leslie KA, Rankin RN, Duff JH. Lost gallstones during laparoscopic cholecystectomy: are they really benign? Can J Surg. 1994;37:240–2.

    CAS  PubMed  Google Scholar 

  11. Barnard SP, Pallister I, Hendrick DJ, Walter N, Morritt GN. Cholelithoptysis and empyema formation after laparoscopic cholecystectomy. Ann Thorac Surg. 1995;60:1100–2.

    CAS  Article  Google Scholar 

  12. Willekes CL, Widmann WD. Empyema from lost gallstones: a thoracic complication of laparoscopic cholecystectomy. J Laparoendosc Surg. 1996;6:123–6.

    CAS  Article  Google Scholar 

  13. Chopra P, Killorn P, Mehran RJ. Cholelithoptysis and pleural empyema. Ann Thorac Surg. 1999;68:254–5.

    CAS  Article  Google Scholar 

  14. Preciado A, Matthews BD, Scarborough TK, Marti JL, Reardon PR, Weinstein GS, et al. Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A. 1999;9:517–21.

    CAS  Article  Google Scholar 

  15. Roberts DJ, Chun HM. Dropped gallstone as a nidus of intra-abdominal abscess complicated by empyema. Clin Infect Dis. 2005;41:e64–6.

    Article  Google Scholar 

  16. Bergeron E, Beaulieu C, Passerini L, Ratte S. Dropped gallstones causing transdiaphragmatic migration and thoracic empyema. Ann Thorac Surg. 2007;84:1760–2.

    Article  Google Scholar 

  17. Cheah YL, Ng T, Shah K, Patrozou E, Fischer S. Video-assisted thoracoscopic surgery (VATS) drainage of salmonella enteritidis empyema and needle-localization for retrieval of a dropped gallstone. Surg Laparosc Endosc Percutan Tech. 2010;20:265–8.

    Article  Google Scholar 

  18. Quail JF, Soballe PW, Gramins DL. Thoracic gallstones: a delayed complication of laparoscopic cholecystectomy. Surg Infect (Larchmt). 2014;15:69–71.

    Article  Google Scholar 

  19. Gaster RS, Berger AJ, Ahmadi-Kashani M, Shrager JB, Lee GK. Chronic cutaneous chest wall fistula and gallstone empyema due to retained gallstones. BMJ Case Rep. 2014;2014: bcr2013010159.

    Article  Google Scholar 

  20. Robinson JR, Wright JK, Geevarghese SK. Dropped gallstones causing a perihepatic abscess and empyema. Case Rep Surg. 2015;2015: 629704.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. McPherson I, McSorley ST, Cannings E, Cannings E, Shearer CJ, Crumley AB. Dropped gallstones causing abdominal wall abscess and pleural empyema: a case series. Scott Med J. 2019;64:67–70.

    Article  Google Scholar 

  22. Tchercansky AN, Fernandez Alberti J, Panzardi N, Auvieux R, Buero A. Thoracic empyema after gallstone spillage in times of Covid. Int J Surg Case Rep. 2020;76:221–6.

    Article  Google Scholar 

  23. Ballantyne KC, Sethia B, Reece IJ, Davidson KG. Empyema following intra-abdominal sepsis. Br J Surg. 1984;71:723–5.

    CAS  Article  Google Scholar 

  24. Panicek DM, Benson CB, Gottlieb RH, Heitzman ER. The diaphragm: anatomic, pathologic, and radiologic considerations. Radiographics. 1988;8:385–425.

    CAS  Article  Google Scholar 

  25. Maehira H, Kawasaki M, Ogawa M, Imagawa A, Itoh A, Mizumura N, et al. Optimizing perioperative antimicrobial therapy for acute cholecystitis using bile Gram stain results. Int Surg. 2019;104:364–70.

    Article  Google Scholar 

  26. Vajdić ID, Štimac G, Pezelj I, Mustapić M, Grazio S. Psoas abscess during treatment with intravenous tocilizumab in a patient with rheumatoid arthritis: a case-based review. Rheumatol Int. 2021;41:819–25.

    Article  Google Scholar 

  27. Maruya Y, Taniguchi K, Koga N, Azuma T, Matsuo S, Hayashi T, et al. Acute appendicitis in a rheumatoid arthritis patient treated with tocilizumab: report of a case. Acta Med Nagasaki. 2015;60:29–31.

    Google Scholar 

Download references

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Funding

The authors received no specific funding for this work.

Author information

Authors and Affiliations

Authors

Contributions

AT and HM described and designed the manuscript. MT revised the manuscript. RK and HY performed the initial medical care and transthoracic ultrasound-guided drainage. HI, HM, NN, TM, KT, SK, TM performed surgery and postoperative management. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hiromitsu Maehira.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Tokuda, A., Maehira, H., Iida, H. et al. Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report. surg case rep 8, 62 (2022). https://doi.org/10.1186/s40792-022-01419-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40792-022-01419-4

Keywords

  • Pleural empyema
  • Dropped gallstone
  • Acute cholecystitis
  • Laparoscopic cholecystectomy