The Lost Gallstone: Thoracoscopic Removal of Retained Gallstone Following Cholecystectomy

Authors: Aulon Jerliu, Brian Wong Won, Alicia McKelvey

Abstract

Cholecystectomy, the surgical removal of the gallbladder, is a common abdominal operation often performed laparoscopically due to its minimally invasive nature. Despite its safety and efficacy, rare complications such as gallstone retention outside the biliary system can occur. One unusual complication is the migration of gallstones into the thoracic cavity, potentially causing severe outcomes like pleural effusion, empyema, or bronchopleural fistula, which present diagnostic challenges due to their rarity and varied symptoms. Advanced imaging techniques are essential for diagnosis, while treatment ranges from conservative management for asymptomatic cases to surgical intervention for significant complications. This report details the case of an 80-year-old male who presented with epistaxis and hemoptysis, later found to have a retained thoracic gallstone postcholecystectomy. Despite initial normal imaging and clinical improvement, further investigation revealed a gallstone eroding through the diaphragm into the thoracic cavity. The patient underwent successful thoracoscopic removal of the stone but experienced a prolonged hospital stay due to complications, including atrial fibrillation exacerbation, hemothorax, and lower extremity ischemia. The report underscores the diagnostic complexities of intrathoracic gallstone migration and the severe complications that can arise. A high index of suspicion is necessary for patients with persistent respiratory symptoms following cholecystectomy, and timely imaging and surgical intervention are crucial to minimize morbidity.

INTRODUCTION

Cholecystectomy, the surgical extraction of the gallbladder, ranks among the most frequently performed abdominal operations globally. This procedure is primarily recommended for addressing symptomatic gallstones and cholecystitis. Over time, cholecystectomy has advanced considerably, with laparoscopic techniques becoming the preferred method due to their less invasive approach and faster recovery periods.^1^ Despite its high efficacy and safety, complications can still arise, some of which are infrequent and unforeseen.^2,3^

A rare complication is the retention of gallstones outside the biliary system, such as into the thoracic cavity. Retained gallstones can present a spectrum of clinical issues, from being symptomless to causing severe, potentially fatal sequela. When gallstones find their way to the thorax, they may lead to numerous complications including pleural effusion, empyema, or bronchopleural fistula, posing a particularly challenging diagnosis due to it relatively rare occurrence, unusual location, and broad symptomatology.^4^ Advanced imaging methods, including computed tomography (CT) scans and magnetic resonance imagings (MRIs), are essential for detecting gallstones in the thoracic cavity. The exact mechanisms behind the migration of gallstones into the thorax are not completely described but are thought to involve a mix of factors such as accidental injury during operation, formation of fistulas, and the pressure dynamics between the abdominal and thoracic regions.

Management of thoracic-retained gallstones depends on the patient’s symptoms and the severity of the condition. For asymptomatic patients, conservative treatment might be sufficient, whereas significant complications often necessitate surgical intervention. Surgical options may include thoracoscopic removal of the stones, draining abscesses, and repairing fistulas. However, literature on this disease process is scarce. In this report, we present a patient with symptoms pertaining to a large differential diagnosis, however, was ultimately found to have a retained thoracic gallstone after cholecystectomy, necessitating surgical intervention.

CASE REPORT

The patient is an 80-year-old male with a history of atrial fibrillation, on Eliquis, and 40 pack-year smoking history presented to the emergency department (ED) with epistaxis and hemoptysis. The patient had initially presented to the ED a day prior with the same symptoms but was deemed safe for discharge home after a period of clinical improvement, normal blood tests, and a chest radiograph that was read without discerning findings. Following discharge from ED, he reported worsening hemoptysis with nickel-sized clots. Prior to this, he had been experiencing fatigue and a wet cough with white sputum for 3 weeks leading up to presentation. He denied fevers or chills, dizziness, or lightheadedness. He had no weight loss, night sweats, or hematochezia. A repeat chest radiograph showed streaky consolidation at the right lobe, favoring atelectasis.

In addition to the conditions, the patient’s past medical history was significant for hypertension, hyperlipidemia, a 4.5-cm thoracic aneurysm that was being monitored, and insulin-dependent diabetes mellitus. A year prior, the patient had experienced a cardioembolic event resulting in left lower extremity ischemia. He required an open femoral embolectomy and stent with extension into the above-knee popliteal artery due to the discovery of a 3.8-cm popliteal aneurysm on angiogram. In addition to Eliquis, he was on aspiring 81 mg as an antithrombotic agent. The patient was reliant on a walker for ambulation but was functionally independent at baseline.

On presentation, the patient was hemodynamically stable. A complete blood count conveyed no leukocytosis with a white blood cell count of 10.2 thousand/μL (4–11 thousand/μL). The hemoglobin and hematocrit was stable from the day prior at 13.5 g/dL (13–17.7 g/dL) and 41.9%. On examination, the patient was maintaining A follow-up CT scan of the thorax with contrast demonstrated a complex intra-abdominal mass localized near segment VII of the liver concerning for erosion through the right hemidiaphragm into the thoracic cavity (Figure 1). There was adjacent dense consolidation of the right lower lung lobe involving lateral and posterior basilar segments with occlusion of the corresponding branches of the pulmonary artery, and a 2-cm hyperdensity at the center. In addition, there was a large right hilar node also noted that described as either malignant or reactive.

Due to the uncertain etiology of the right thoracic mass, multiple services were asked to evaluate this patient while in the ED. Initially, interventional radiology was called to evaluate that potential for an image-guided biopsy, but this plan was ultimately abandoned. Subsequently, the thoracic and general surgery services were consulted. On further inquiry, it was ascertained that the patient underwent a challenging laparoscopic cholecystectomy nearly 5 months prior in which the gallbladder had ruptured with retraction and the surgery was ultimately converted to an open procedure due to technically challenging anatomy. This led to the hypothesis that the mass was a retained gallstone that had eroded through the diaphragm and into the right thoracic cavity. Given that the patient was hemodynamically stable and experienced no airway compromise, he was admitted to the medical intensive care unit and was treated supportively. His Eliquis was withheld as a precaution against bleeding. His coughing and hemoptysis improved, and he was transitioned to the floor.

A week into his admission, the patient underwent a thoracoscopic removal of the retained stone. The basilar aspect of the right lower lung lobe was noted to be adherent to diaphragm. The adhesions were dissected away to unearth a pus-filled cavity containing a green-brown stone (Figures 2A, 2B, and 2C). The tract through the diaphragm was noted to walled off and underneath the right lower lung lobe. A 19 French Blake drain was positioned at the base, and a posterior-apical chest tube was placed. Gross pathology confirmed a 2.2 × 1.5 × 1.5 cm ovoid gallstone (Figure 2D).

Postoperatively, the patient experienced a prolonged hospital course culminating in a 21-day length of stay. The patient had an acute exacerbation of atrial fibrillation requiring stepdown level of care. He developed a hemothorax while on therapeutic anticoagulation eventually requiring thoracoscopic drainage for respiratory distress. While on hiatus from anticoagulation, the patient experienced worsening claudication and ischemia to his left lower extremity. He received a superficial femoral to posterior tibial artery bypass, an open thrombectomy, and ultimately, on a subsequent admission, an above-knee amputation.

DISCUSSION

In the era of minimally invasive surgery, the laparoscopic cholecystectomy has become the standard of care for breadth of gallbladder pathology. In the United States, there are nearly more than 700,000 laparoscopic cholecystectomies performed each year due to the promise of decreased pain, decreased postoperative morbidity, and shorter in-hospital length of stay.^1,9^ However, the rate of serious biliary complications remains 2–7 times higher when compared to the open approach.^9^ These complications, which can include bile duct injury, biliary obstruction, and dropped stones, can proceed undiagnosed during surgery only to manifest in illness much later. At an incidence of 0.6%, common bile duct injuries have a classic presentation that includes abdominal pain, sepsis, and jaundice after cholecystectomy that raises clinical suspicion.^2^ In comparison, dropped gallstones are a much rarer commodity at a reported incidence of 0.1–20%—many of which never manifest with clinical symptomatology. When symptomatic, dropped gallstone most commonly serve as a nidus for abscess formation, which occurs at a rate of approximately 0.3%.^3^

The erosion of a dropped gallstone through the diaphragm and into the thoracic cavity remains a scarce finding in the literature. A prior case report and literature review highlighted merely 11 cases reported prior to 2006,^4^ and since then, only a handful have been described. As in the aforementioned patient, common symptoms following cholecystectomy include a persistent cough and hemoptysis, which can be sequalae of diaphragmatic irritation. Cholelithoptysis and broncholithiasis are less common.^5^ There also appears to be an association with gallbladder perforation during the index procedure. Many of the cases were not clearly demonstrable on initial imaging but were later found as a consolidation or empyema on CT scan.^10^ The presentations for complicated intrathoracic gallstones were delayed, ranging from 2 months to as far as 5 years, alluding to a clinically latent period required for an inflammatory process to develop. The preponderance of the cases ultimately required surgical drainage where IR-guided interventions proved inadequate.^12^

In this case report, we intend to emphasize the diagnostic challenges associated with intrathoracic gallstone migration and serious complications that can ensue. Effective detection requires a high index of clinical suspicion for patients who present with chronic cough and hemoptysis after complicated cholecystectomies and a consideration of the associated pathophysiology. This should be followed by CT imaging of the thorax in the stable patient, and a low threshold for surgical drainage to avoid further morbidity. Whenever possible, spilled gallstones should be accounted for and removed at the index operation as the only true preventative measure.