A case report: Delayed gallstone abscess formation 10 years post-cholecystectomy

Highlights • Successful removal of gallstones are important to prevent the formation of gallstone abscess and infection.• An increase of reports of gallstone abscess formation shows the importance of awareness in the surgical community of the occurrence and proper treatment techniques.• Proper treatment techniques include abscess drainage either surgically or non-invasive and if possible laparoscopic repair of gallstone abscess.


Introduction
Cholelithiasis affects 20-25 million Americans annually [1]. It is a leading cause for hospital admissions in America with an estimated 1.8 million ambulatory care visits each year [2]. Cholecystectomy is the conventional approach for symptomatic gallstones but can be complicated by gallbladder perforation and gallstone spillage. The incidence of gallstone and bile spillage was approximated to occur in up to 40% of surgeries performed between the years of 1991 and 2015. The most common complication from spilled gallstones is the formation of intra-abdominal abscesses with an incidence of up to 2.9% [3]. We report a rare case of a gallstone abscess that formed 10 years post-cholecystectomy, which is being reported in line with the SCARE criteria [4]. The aim and objective of this study is to increase awareness and prevention of gallstone spillage complications.

Case description
A 73-year-old female with a past medical history of hypertension and prior cholecystectomy presented to the emergency room * Corresponding author.
with acute onset of abdominal pain of 1-day duration. She described right lower quadrant abdominal pain that was constant and worsening since it started. She reported no prior occurrence. There were no alleviating or exacerbating factors. Her symptoms were preceded by five days of constipation refractory to stool softeners. She was briefly febrile four days prior to admission. Surgical history disclosed laparoscopic cholecystectomy in 2010 complicated with a perforated gallbladder. After being discharged following the surgery, she noted having had recurring fevers for ten days and experienced no other symptoms.
On initial assessment, her exam revealed an elderly woman, who was alert, well-oriented, and in mild distress. She had an oral temperature of 99 • F, a heart rate of 89 bpm, blood pressure of 142/63 mmHG, and a respiratory rate of 18 breaths per minute. Her abdominal exam revealed a soft, non-distended stomach with moderate tenderness at the medial right lower quadrant abdomen. There was no guarding or rebound, and she had normal bowel sounds.
Initial labs showed an elevated WBC at 15.2 K/mcl, hemoglobin at 13.3 g/dL and a high platelet count of 552 K/mcl. The patient had normal values for the following: sodium at 135 mEq/L, potassium at 3.   gallstones (Fig. 1). The abscess extended superiorly to the level of Morison's pouch and inferiorly to the right iliac wing (Fig. 2).
The patient was admitted and started on intravenous piperacillin-tazobactam. Dr. Joseph Hartigan, who has over 20 years of experience in laparscopic surgery, performed a laparoscopic drainage of the abscess and removal of the gallstones. The origin of the abscess was found near the umbilicus and tracked cephalad up towards the liver. A 15 Blake drain was placed into the abscess cavity and left in place for four days. A phlegmon of approximately 100 cc's of purulent fluid was drained and cultures grew out E. Coli. The patient recovered well and was discharged on the 3rd postoperative day. The abscess formed by the gallstones was determined to be the cause of the abdominal pain in this case. The drain was removed during the follow-up appointment two weeks after the surgery. There were no complications. The patient was intrigued in the discovery and thankful for the outcome.

Discussion
The risk of perforation and spillage of gallbladder contents is high; however, acute complication incidence is low at 0.8%-8.5% [5]. The most common cause of spilled gallstones is through the perforation of the gallbladder from laparoscopic instruments or during gallbladder dissection from the hepatic bed [6,7]. Gallbladders that are surrounded by dense adhesions or acutely inflamed have an increased risk of perforation [8]. In this case, the patient presented ten years post-cholecystectomy with an abscess that grew Escherichia Coli. Interestingly, of all the documented cases occurring ten years or more following surgery, there is an overwhelming female predominance of 89%. E. Coli is the most common pathogen, as in acute cholecystitis [5]. It is theorized that the presence of nonsterile gallstones in the abdomen caused an inflammatory response leading to the formation of an abscess.
In high-risk situations, it is essential for surgeons to be vigilant for gallbladder perforation and gallstone spillage. If there are spilled gallstones, it is recommended to do preventative measures for infection by irrigation with saline to dilute bile contents and retrieve all stones [9]. Previous studies do not support switching to open surgery as it increases patient morbidity [10]. The recent increase of reported gallstone abscesses illustrates the importance of awareness and technical refinements in the surgical community.
In this case, the surgical management of abscess drainage and stone retrieval agrees with current treatment recommendations [8]. This report emphasizes documentation of spilled gallstones with post-surgical monitoring and prophylaxis to prevent acute or remote abscess formation.

Conclusion
Laparoscopic cholecystectomy may be complicated by gallbladder perforation and spilled gallstones. These stones can present months to years after the cholecystectomy with infectious complications causing morbidity. Gallstone spillage should be avoided by taking precautions and preventive measures. If spillage occurs, documentation in operative notes, monitoring for complications, prophylaxis, and early and aggressive treatment assure the best outcome.

Declaration of Competing Interest
None.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval
None.

Consent
Written informed consent was not obtained from the patient for publication of this case report and accompanying images since there is no are no patient identifying characteristics.

Author contribution
Erina Quinn -literature review, data analysis, data collection, writing.