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Special Feature |

Image of the Month—Diagnosis FREE

[+] Author Affiliations

SECTION EDITOR: CARL E. BREDENBERG, MD

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JAMA Surg. 2013;148(1):100. doi:10.1001/jamasurgery.2013.410b.
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ANSWER: ABSCESS DUE TO A “LOST” STONE DURING THE PREVIOUS CHOLECYSTECTOMY

The surgical exploration confirmed the hypothesis of an abscess due to a spilled gallstone. The stone was removed, the area washed, and the patient fully recovered. Although the positron emission tomographic/computed tomographic imaging was performed owing to the patient's history of cancer, a recurrent vulvar cancer was unlikely because the peritoneum is a rare primary site of vulvar cancer metastasis.

Gallbladder perforation with or without bile and stone spillage is a relatively common event (reported in up to 40% of laparoscopic cholecystectomies).1 It occurs more frequently during laparoscopic procedures than open laparoscopic procedures, performed by junior surgeons, in male and/or elderly patients, and in the presence of a severely inflamed gallbladder and intra-abdominal adhesions.2

Although most spilled stones can be found and extracted during the same cholecystectomy procedure, some 0.8% to 1% of patients secondarily present with a stone-related complication.3 They often appear late after the cholecystectomy (up to several years) with abdominal pain and signs of infection, due to a local abscess.4 The mechanism by which gallstones induce the abscess is not completely understood, but pigmented and large (>1.5 cm) stones appear to be more often involved.5,6 Other potential stone-related complications include the occurrence of adhesions, fistula, obstruction, intestinal perforation, and pleural empyema.7 In case of a stone spillage during a cholecystectomy, the abdominal cavity should be carefully explored with the removal of as many stones as possible and with intense irrigation.6

In summary, the present case illustrates the risk of an abscess linked to lost stones, which can appear years after cholecystectomy (10 years in the present case). Such a diagnosis should be considered in case of inflammation/abscess at the surface of the lower part of the right lobe of the liver for patients who had a cholecystectomy. Every effort should be made to find and remove lost stones during cholecystectomy.

Return to Quiz Case.

Submissions

Due to the overwhelmingly positive response to the Image of the Month, the JAMA Surgery has temporarily discontinued accepting submissions for this feature. Requests for submissions will resume in April 2013. Thank you.

Correspondence: Théodoros Thomopoulos, MD, Department of Surgery, Abdominal and Transplant Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, Switzerland (teothomopoulos@yahoo.com).

Accepted for Publication: December 16, 2011.

Author Contributions:Study concept and design: Mentha and Toso. Acquisition of data: Mentha and Toso. Analysis and interpretation of data: Thomopoulos, Mentha, and Toso. Drafting of the manuscript: Toso. Critical revision of the manuscript for important intellectual content: Thomopoulos and Mentha. Administrative, technical, and material support: Thomopoulos. Study supervision: Mentha and Toso.

Conflict of Interest Disclosures: None reported.

Gerlinzani S, Tos M, Gornati R, Molteni B, Poliziani D, Taschieri AM. Is the loss of gallstones during laparoscopic cholecystectomy an underestimated complication?  Surg Endosc. 2000;14(4):373-374
PubMed
Hawasli A, Schroder D, Rizzo J,  et al.  Remote complications of spilled gallstones during laparoscopic cholecystectomy: causes, prevention, and management.  J Laparoendosc Adv Surg Tech A. 2002;12(2):123-128
PubMed   |  Link to Article
Woodfield JC, Rodgers M, Windsor JA. Peritoneal gallstones following laparoscopic cholecystectomy: incidence, complications, and management.  Surg Endosc. 2004;18(8):1200-1207
PubMed   |  Link to Article
Habib E, Khoury R, Elhadad A, Jarno F, Diallo T. Digestive complications of biliary gallstone lost during laparoscopic cholecystectomy [in French].  Gastroenterol Clin Biol. 2002;26(10):930-934
PubMed
Gürleyik E, Gürleyik G, Yücel O, Unalmiŝer S. Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat?  Surg Laparosc Endosc. 1998;8(2):113-116
PubMed   |  Link to Article
Brockmann JG, Kocher T, Senninger NJ, Schürmann GM. Complications due to gallstones lost during laparoscopic cholecystectomy.  Surg Endosc. 2002;16(8):1226-1232
PubMed   |  Link to Article
Sathesh-Kumar T, Saklani AP, Vinayagam R, Blackett RL. Spilled gall stones during laparoscopic cholecystectomy: a review of the literature.  Postgrad Med J. 2004;80(940):77-79
PubMed   |  Link to Article

Figures

Tables

References

Gerlinzani S, Tos M, Gornati R, Molteni B, Poliziani D, Taschieri AM. Is the loss of gallstones during laparoscopic cholecystectomy an underestimated complication?  Surg Endosc. 2000;14(4):373-374
PubMed
Hawasli A, Schroder D, Rizzo J,  et al.  Remote complications of spilled gallstones during laparoscopic cholecystectomy: causes, prevention, and management.  J Laparoendosc Adv Surg Tech A. 2002;12(2):123-128
PubMed   |  Link to Article
Woodfield JC, Rodgers M, Windsor JA. Peritoneal gallstones following laparoscopic cholecystectomy: incidence, complications, and management.  Surg Endosc. 2004;18(8):1200-1207
PubMed   |  Link to Article
Habib E, Khoury R, Elhadad A, Jarno F, Diallo T. Digestive complications of biliary gallstone lost during laparoscopic cholecystectomy [in French].  Gastroenterol Clin Biol. 2002;26(10):930-934
PubMed
Gürleyik E, Gürleyik G, Yücel O, Unalmiŝer S. Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat?  Surg Laparosc Endosc. 1998;8(2):113-116
PubMed   |  Link to Article
Brockmann JG, Kocher T, Senninger NJ, Schürmann GM. Complications due to gallstones lost during laparoscopic cholecystectomy.  Surg Endosc. 2002;16(8):1226-1232
PubMed   |  Link to Article
Sathesh-Kumar T, Saklani AP, Vinayagam R, Blackett RL. Spilled gall stones during laparoscopic cholecystectomy: a review of the literature.  Postgrad Med J. 2004;80(940):77-79
PubMed   |  Link to Article

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