British Journal of Radiology 75 (2002),393-394 © 2002 The British Institute of Radiology
The one that got away
C Offiah, BSc, FRCS
P Robinson, MRCP, FRCR
and
C S Keeling-Roberts, FRCR
Department of Diagnostic Radiology, Stepping Hill Hospital, Poplar Grove, Stockport SK2 7JE, UK
Correspondence: Dr P Robinson, Department of Radiology, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Introduction
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A 75-year-old man presented with a 3-week history of loin pain associated with weight loss, anorexia and lethargy. Past medical history consisted of a laparoscopic cholecystectomy 3 years previously. On clinical examination there was fullness and tenderness in the right lumbar region. Ultrasound performed in the health centre demonstrated a complex mass in the right side of the abdomen. Haematological results showed a raised erythrocyte sedimentation rate (ESR). The patient was referred for a surgical opinion. Spiral CT of the abdomen and pelvis with intravenous and oral contrast media was performed (Figures 1a,b
). What abnormalities are evident on these axial images?
The axial images confirmed previous cholecystectomy. There was a thick-walled soft tissue mass in the posterior abdomen occupying the right subhepatic space and retroperitoneum (Figure 1a
). The mass was predominantly of low attenuation, consistent with fluid, but enhancing walls and septae were evident after intravenous contrast medium. The features were consistent with an abscess and, given the presence of at least one calcified opacity within the mass (Figure 1b), a presumptive diagnosis of gallstone abscess was made.
Initially, the collection was drained percutaneously, with insertion of a large bore catheter and surgical disruption of adhesions. The patient improved clinically and 1 week later was referred for percutaneous removal of the calculus under radiological guidance. Under intravenous sedation/analgesia, retrieval was attempted using a "Dormia" basket introduced through the catheter (Figure 2). However, the calculus was adherent to the adjacent tissues. A subsequent attempt under regional anaesthesia was successful in removing the calculus.
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Figure 2. Plain radiograph of the right hypochondrium demonstrating catheter, Dormia basket and calculus (arrowheads).
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Laparoscopic cholecystectomy is the operative treatment of choice for symptomatic cholelithiasis. Post-operative morbidity and recovery time are reduced compared with open cholecystectomy and the procedure is now increasingly used in the treatment of acute cholecystitis [1, 2]. However, in comparison with open surgery there is an increased risk of gall bladder perforation, estimated at 15–30% [1, 3]. Gall bladder perforation may result in leakage of bile and stones, and actual spillage of stones following gall bladder rupture is not uncommon (10–12%) [3]. Gall bladder perforation and stone spillage is most likely to occur at two particular stages of laparoscopic cholecystectomy: during dissection of the gall bladder from the liver bed; and during extraction of the resected gall bladder through the abdominal wall port [4, 5], and is more likely during laparoscopic cholecystectomy for acute cholecystitis [5]. The incidence of abscess formation resulting from spilled stones is very rare (approximately 0.3%) and observation of stone spillage during surgery is not an indication to convert to an open procedure [4].
Abscess formation and inflammatory masses containing gallstones usually occur in the subhepatic space or the retroperitoneum inferior to the subhepatic space as in this case. Other locations reported include the thorax, the subphrenic space, the pouch of Douglas and the ovary, as well as abdominal wall port sites [1, 3–6]. This variability in abscess location is because the pneumoperitoneum created as part of the procedure can carry stone fragments into obscure tissue planes [4].
Ultrasound and CT are reliable in demonstrating these collections and the associated calculus, which is essential for making the diagnosis [1, 2]. Identification of the calculus is essential because it is the focus of the inflammatory process and complete resolution is only possible on its removal.
The time courses reported in the literature for the development of abscesses range from 4 months to 10 years after surgery [1, 2, 4]. The diagnosis should therefore be considered even when abscess or fistula formation occurs years after laparoscopic cholecystectomy.
Received for publication December 6, 2000.
Accepted for publication January 24, 2001.
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References
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