Cheah Yee Lee, Ng Thomas, Shah Kinjal, Patrozou Eleni, Fischer Staci
Department of Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA.
Surg Laparosc Endosc Percutan Tech. 2010 Aug;20(4):265-8. doi: 10.1097/SLE.0b013e3181e1392e.
Spillage of gallstones into the peritoneal cavity (dropped gallstones) is more common in laparoscopic compared with open cholecystectomy. Subsequent infectious complications are often delayed, occurring in 0.1% to 2.9% of cases. We present the first reported case of Salmonella enterica subphrenic abscess and empyema complicating dropped gallstones, treated with video-assisted thoracoscopic surgery (VATS), and surgical retrieval.
A 67-year-old male with symptomatic cholelithiasis underwent an uncomplicated laparoscopic cholecystectomy. Four years later, he presented with a mass in his right flank, and an abdominal computed tomography (CT) revealed a right flank intramuscular abscess containing gallstones. The abscess was drained surgically with removal of gallstones. He was readmitted 15 months later with right upper quadrant pain, fever, and dyspnea. Chest and abdominal computer tomography (CT) showed a right pleural effusion and a right subphrenic abscess containing a dropped gallstone. The gallstone was localized with a needle using CT guidance. He subsequently underwent a right VATS for decortication. A separate flank incision was made at the site of the needle to drain the subphrenic abscess and retrieve the gallstone. Cultures from his empyema grew S enteritidis. The patient made an uneventful recovery.
During laparoscopic cholecystectomy, efforts should be made to retrieve dropped gallstones as they can cause abscess and empyema, which might necessitate furthermore surgical intervention. The use of VATS has been established as a safe and effective alternative to thoracotomy, including the treatment of empyema. Needle-localization resulted in a successful retrieval of the gallstone in our patient. Culture of the abscess is important, as unusual organisms such as Salmonella could be present. S. enteritidis has not been implicated as a cause of cholecystitis and is rarely associated with abdominal abscesses. We postulate that the organism reached the gallbladder through the bile or bloodstream after gastrointestinal colonization and that its persistence in the gallbladder may have been facilitated by gallstones.
与开腹胆囊切除术相比，胆囊结石掉入腹腔（掉落结石）在腹腔镜胆囊切除术中更为常见。随后的感染性并发症往往出现较晚，发生率为0.1%至2.9%。我们报告首例因掉落结石并发肠炎沙门氏菌膈下脓肿和脓胸的病例，采用电视辅助胸腔镜手术（VATS）及手术取出结石进行治疗。
一名67岁有症状胆结石男性患者接受了无并发症的腹腔镜胆囊切除术。四年后，他右侧胁腹出现肿块，腹部计算机断层扫描（CT）显示右侧胁腹肌内脓肿并含有胆结石。通过手术引流脓肿并取出结石。15个月后，他因右上腹疼痛、发热和呼吸困难再次入院。胸部和腹部计算机断层扫描（CT）显示右侧胸腔积液和右侧膈下脓肿并含有一枚掉落结石。在CT引导下用针定位结石。随后他接受了右侧VATS剥脱术。在针穿刺部位另做一个胁腹切口以引流膈下脓肿并取出结石。脓胸培养出肠炎沙门氏菌。患者顺利康复。
在腹腔镜胆囊切除术中，应努力取出掉落的胆结石，因为它们可导致脓肿和脓胸，这可能需要进一步的手术干预。VATS已被确立为开胸手术的一种安全有效的替代方法，包括用于治疗脓胸。针定位使我们的患者成功取出了胆结石。脓肿培养很重要，因为可能存在如沙门氏菌等不常见的病原体。肠炎沙门氏菌尚未被认为是胆囊炎的病因，很少与腹部脓肿相关。我们推测该病原体在胃肠道定植后通过胆汁或血液到达胆囊，并且胆结石可能促进了其在胆囊中的持续存在。
