Thoracic complications from retained abdominal gallstones after laparoscopic cholecystectomy: is it always mandatory a thoracic approach?

BACKGROUND: Thoracic complications from retained abdominal gallstones are quite rare and the incidence rate ranges between 0.08% and 0.3%. Diagnosis and treatment of these complications are challenging due to the uncommon presentations and the debated role of the thoracic approach. This review of all cases reported in literature aims to discuss the best practice of this rare condition.
METHODS: A comprehensive literature search was performed for articles from January 1993 to May 2019 using PubMed, MEDLINE, Embase, ScienceDirect. The following mesh-words were used: “cholelithopthysis”, “thoracic”, “gallstones” “retained”, and “spilled”. All cases of thoracic complications from retained gallstones after laparoscopic cholecystectomy were extrapolated.
RESULTS: Twenty-four patients were included in this study. The most common symptoms were fever, hemoptysis and lithoptysis. Symptoms after laparoscopic cholecystectomy were presented after a mean time of 9.8±14.2 months (range from one week to 60 months). Delayed diagnosis was found in fourteen patients (58.4.%). Only four subjects were treated successfully with antibiotic therapy alone (16.7%), whereas 20 patients needed surgery or interventional radiology (83.3%). Seven patients (29.2%) were successfully managed with an abdominal approach. Three patients were managed using thoracentesis, thoracoscopic-thoracotomic drainage (12.5%). Right lung decortication and pulmonary wedge resections were necessary for ten patients (41.6%).
CONCLUSION: Clinicians always must inquire about the previous cholecystectomy for cholelithiasis related diseases in all patients suffering from recurrent right-sided pleural/lung affections, to improve diagnostic delay. The escalated approach must be performed: empirical antimicrobial therapy followed by targeted therapy as soon as microbiological data are available; afterwards, abdominal surgery is effective in approximately 30% of patients while the remaining patients have to be submitted to a thoracic approach.

Laparoskopik kolesistektomi sonrasý kalan safra taþlarýndan kaynaklanan torasik komplikasyonlar: Torasik bir yaklaþým her zaman zorunlu mudur?

AMAÇ: Kalan safra taþlarýndan kaynaklanan torasik komplikasyonlar oldukça nadirdir; insidanslarý %0.08 ile %0.3 arasýnda deðiþmektedir. Bu komplikasyonlarýn taný ve tedavisi, nadir görülen prezentasyonlarý ve torasik yaklaþýmýn tartýþmalý rolü nedeniyle zordur. Literatürde bildirilen tüm olgularý içeren bu yazý, bu nadir duruma dair en iyi uygulamayý tartýþmayý amaçlamaktadýr.
GEREÇ VE YÖNTEM: PubMed, Medline, Embase, ScienceDirect kullanýlarak, Ocak 1993’ten Mayýs 2019’a kadar makaleler için kapsamlý bir literatür taramasý yapýldý. Taramada þu týbbi konu baþlýklarý (MeSH (Medical Subject Headings)) kullanýldý: “kolelitoptizi”, “torasik”, “safra taþlarý” “kalmýþ”, “dökülmüþ”. Laparoskopik kolesistektomi sonrasý kalan safra taþlarýndan kaynaklanan torasik komplikasyonlarý olan tüm vakalar ekstrapole edilmiþtir.
BULGULAR: Çalýþmaya 24 hasta dahil edildi. En yaygýn semptomlar ateþ, hemoptizi ve litoptiziydi. Semptomlar laparoskopik kolesistektomi sonrasý ortalama 9.8±14.2 ay (1 hafta ile 60 ay arasý) sonra ortaya çýktý. On dört hastada (%58.4) gecikmiþ taný saptandý. Sadece dört hasta tek baþýna antibiyotik tedavisi ile baþarýlý bir þekilde tedavi edildi (%16.7); 20 hasta ise cerrahi veya giriþimsel radyolojiye ihtiyaç duydu (%83.3). Yedi hasta (%29.2) abdominal yaklaþýmla baþarýyla tedavi edildi. On hastada (%41.6) sað akciðer dekortikasyonu ve pulmoner kama rezeksiyonu gerekti.
TARTIÞMA: Klinisyenler, tanýsal gecikmeyi önlemek için, tekrarlayan sað taraflý plevral/akciðer rahatsýzlýklarý olan tüm hastalarda, kolelitiyazis ile iliþkili hastalýklar için önceki kolesistektomi hakkýnda her zaman bilgi almak zorundadýr. Arttýrýlmýþ yaklaþým uygulanmalýdýr: ampirik antimikrobiyal tedavi ve ardýndan mikrobiyolojik veriler elde edilir edilmez hedefe yönelik tedavi; daha sonrasýnda yapýlan abdominal cerrahi hastalarýn yaklaþýk %30’unda etkiliyken, geri kalan hastalarda torasik bir yaklaþým gerekir.