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Consequences of the spilled gallstones during laparoscopic cholecystectomy: a systematic review
World Journal of Emergency Surgery volume 17, Article number: 57 (2022)
Complications secondary to spilled gallstones can be classified in the category of disease of medical progress because prior to advent of laparoscopic cholecystectomy very few reports published on the topic. The aim of the present study was to investigate the predisposing factors and the complication rate of spilled gallstones during laparoscopic cholecystectomy over the past 21 years.
Embase, Pubmed, Medline, Google scholar and Cochrane library were systematically searched for pertinent literature.
Seventy five out of 181 articles were selected including 85 patients; of those 38% were men and 62% women. The median age of the cohort was 64 years old and ranged between 33 and 87 years. Only 23(27%) of the authors reported the incident of spillage of the gallstones during the operation. Time of onset of symptoms varied widely from the second postoperative day to 15 years later. Ten of 85 patients were asymptomatic and diagnosed with spilled gallstones incidentally. The rest of the patients presented with complications of severe morbidity and almost, 87% of the patients needed to be treated with surgical intervention and 12% with US ± CT scan guidance drainage. Only one perioperative death reported.
Symptomatic patients with lost gallstones present with severe morbidity complications and required mostly major surgical procedures. Therefore, standardisation of the management of spilled gallstones is needed urgently. Hospitals need to review their policy with audits and recommendations and clinical guidelines are needed urgently.
Since 1992, laparoscopic cholecystectomy accepted as a treatment of choice for symptomatic cholelithiasis by consensus statement from the National Institute of health conference . It has been reported that the incidence rate of perforation of gallbladder during laparoscopic cholecystectomy (LC) ranges from 6 to 40% [2, 3]. The incidence rate of spillage of gallstones secondary to perforation reported 16% . In addition, 16 to 50% of spilled stones remained un-retrieved [4, 5]. They may migrate in different regions and the reported complication rate varies from 0.08 to 0.3% . However, most recent evidence reported that the incidence rate of complications of spilled gallstones may ranges from 0.04 to 19% . The management of the spilled gallstones varies widely. Notably, studies which analyse complications of the LCs did not mention perforation of the gallbladder and spillage of stones as complication . In addition, a study from the UK reported that only one fifth of the surgeons document spillage of the gallstones as a potential complication in the consent form. Moreover, only half of them in case of spillage and un-retrieved stones inform the patient. They are reluctant to do that because this may lead to unnecessary stress and repeated examinations for presumed complications of low risk . However, most recent evidence demonstrated that gallbladder perforation and spillage of stones may lead to complications of severe morbidity. In particular, acute cases, older age, male sex, number of spilled stones more than 15 with diameter > 1.5 cm, pigment stones and perihepatic localisation are predicting factors for developing severe complications .
Because of lack of consensus recommendations and guidelines the management of spilled gallstones vary widely between institutions and individual surgeons. Therefore, the need for further evaluation of the accumulated evidence is needed urgently.
The aim of the present study was to evaluate the evidence of the complications rate of the spilled gallstones overtime by conducting a systematic review.
Literature search strategy
From 2000 until today a literature search was performed in Embase, Medline (Pubmed), Cochrane library, Google scholar, and National Institute for Health and clinical Excellence (NICE) databases using free and MeSH terms (spilled, lost gallstones, complications during laparoscopic cholecystectomy, late complications after laparoscopic cholecystectomy, intraabdominal abscess, retroperitoneal abscess, flank abscess, pigment gallstones, cholesterol gallstones). The search strategy was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) .
Study, selection, and inclusion and exclusion criteria
Publications evaluating the complications of spilled gallstones during laparoscopic cholecystectomy were included. Studies referred to open cholecystectomy and editorials without original data were excluded.
Data extraction and outcomes
Two reviewers (PG and NDA) independently extracted the following data from the included studies: name of authors, country, year of publication, age, gender, indication for laparoscopic cholecystectomy, reference to spilled gallstones, type of lost stones, number of stones spilled, size of lost stones, location of lost stones, presenting symptoms, time of onset of symptoms after the laparoscopic cholecystectomy, complications caused by lost stones and location found, type of reintervention, 90-day perioperative mortality.
Seventy-five articles from a pool of 181 articles were selected including 85 patients [11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85], (Fig. 1, Table 1). The median age of the cohort was 64 years and ranged between 33 and 87 years. The percentage of males and females were of 38% and 62%, respectively. The acute cases were 26(31%). Only 23(27%) of the surgeons reported the perforation of the gallbladder and consequently, spillage of the gallstones in the operative notes. The median time of onset of symptoms was 36 months and ranged between 1 and 180 months; the mode was 24 months. The most common site of lost stones was the right subhepatic, perihepatic, retroperitoneal, right flank and pelvis. Ten (12%) out of 85 cases of lost stones discovered incidentally [18, 19, 23, 39, 47, 49, 52, 58, 71, 75]. Type of lost gallstones discovered during the re-intervention reported by 17 authors(20%), [18,19,20, 24, 31, 35, 39, 42, 43, 53, 54, 63, 80]; of those 7 (41%) were pigment and 8 (47%) cholesterol gallstones. Seventeen(20%) of authors reported the number of discovered gallstones [18, 25, 27,28,29, 31, 35, 38, 39, 44, 45, 50, 54, 57, 70, 80, 83]. The size of discovered gallstones was reported by 12(14.11%) authors [18, 19, 25, 28, 31, 35, 37, 52, 63]. The most prevalent presenting symptoms were pain, fever, nausea, vomiting, abdominal swelling, fistula formation, and loss of weight. The most prevalent complications were intrabdominal abscesses 31(36.5%), abdominal wall abscesses 9(10.6%), retroperitoneal abscesses 8(9.4%), thus abscesses in total consisted of 48(56.5%) cases. Notably, 87% of patients underwent a surgical procedure and 12% treated with US ± CT scan guidance drainage, two cases that diagnosed incidentally and were asymptomatic scheduled for regular follow-ups (Table 1). One patient died on the 11th postoperative day after lung decortication for thoracic empyema secondary to lost gallstones .
Complications of the spilled gallstones can be described under the umbrella eponym, disease of the medical progress DOMP. There is a contrasting difference with the open cholecystectomy; because spillage of gallstones during open cholecystectomy is more easier identified and retrieved there are very few reports with the above complication [86, 87].
At the present 96% of all cholecystectomies are performed laparoscopically . In general, the characteristics of the cohorts of patients who underwent laparoscopic and open cholecystectomies differ essentially. The laparoscopic cohort is consisted of younger and healthier patients whereas the open cohort tend to be older, less well, and generally the open cholecystectomy is performed in higher-risk patients [89, 90]. Another important characteristic of the laparoscopic era is the broadening of the indications and the dramatic increase in the number of LCs performed for acalculous disease .
Taking into account that present studies reported that older age is a predicting factor for developing complications following spillage of gallstones . We can see a controversy with the above evidence that demonstrates that the LC cohort includes younger and healthier patients. Therefore, there is a strong indication for further investigation and identification of the co-factors (e. g comorbidities, type of gallstones, acute vs chronic cases) that predispose to above complication. In the present study the median age was 64 years and varied widely from 33 to 87 years (Table 1).
An analysis performed at American College of Surgeons-National Surgical Quality Improvement Program hospitals found the rates of severe morbidity of laparoscopic and open cholecystectomy to be 1.4% and 11.1%, respectively .
Notably, the Swiss Association of Laparoscopic and Thoracoscopic Surgeons (SALTS) database defined the rates following LC for patients only with diagnosis of acute or chronic cholecystitis for intraoperative complications at 7%, postoperative local complications at 4%, and postoperative systemic complications at 2.3% . The above comparison demonstrates that when the investigation is further focused to acute vs chronic cases the incidence rate of severe morbidity of LC increases dramatically from 1.4 to 7% [92, 93]. Although, it is reported that the acute cholecystitis is predisposing factor for complications of spilled gallstones ; in the present study only 31% were the acute cases. Therefore, future studies need to shed further light on the above topic. Moreover, in the present study, only 23(27%) of the surgeons reported the incidence of gallbladder perforation and spillage of gallstones in the operative notes. Furthermore, Mullerat et al. reported that only one fifth of the surgeons included in the consent form spillage of the gallstones as a potential complication. In addition, if this occurred during the operation they do not report it to GPs and patient because they consider it an innocent complication; although this information is going to help colleagues to resolve future diagnostic dilemmas .
Although, it is reported that the number of spilled gallstones more than 15, size > 1.5 cm and pigment type gallstones are predicting factors of complications of spilled gallstones ; in the present study, type of lost gallstones, number, and size of discovered gallstones during the re-intervention reported at 17(20%), 17(20%), and 12(14,11%), respectively. In particular, pigmented and cholesterol gallstones consisted 41% and 47%, respectively. Therefore, future studies should be more meticulous regarding describing type, size, and number of discovered gallstones because the accumulated information will further help describing in details the predicting risk factors and furthermore, this will help in the standardisation of the management of spilled gallstones.
The median time to onset of symptoms was 36 months and ranged from 1 to 180 months. It is obvious that was ranged widely. Considering the above finding and the widely ranged follow-up, the results of the incidence rates of complications should be treated cautiously because time, follow-up, and institutions bias might have influenced the results.
Notably, vast majority of the cases of undiscovered gallstones required open intervention. In particular, 61(72%) patients underwent open surgery and 13(15%) patient laparoscopic procedure, 9(11%) treated either with US and/or CT scan guided drainage. Two cases that detected early postoperatively and were asymptomatic scheduled for regular follow-ups. These finding underlines that although the incidence rate of the complications is low when they become symptomatic the treatment of choice is surgical intervention Therefore, there is urgent need for standardisation and clinical guidelines for the management of spilled gallstones.
The results of the present study should be treated cautiously because all the included studies were case reports. Therefore, institutional, national, underpowered sample size, learning curve, performance and follow-up bias might have influenced the results. Another topic that needs special attention is the incidence rate. Usually, the cases with most complicated presentation and with worst outcomes published as case reports. On the contrary cases with mild symptoms and better outcomes, usually are not publishable. Therefore, an international registry and audit may help to define precisely the incidence rate, and severity of complications of spilled gallstones.
The current evidence demonstrates that although the incidence rate of complications varies widely the majority of the patients demonstrated severe morbidity and required surgical interventions. Therefore, urgent standardisation of the management of spilled gallstones is needed. Surgeons must document all cases of spilled stones in the operative notes. Moreover, GPs and patients should be informed about the incidence, this will help to resolve diagnostic dilemmas in the future. Hospitals should review their policy by conducting audits and surgical societies should use the above information and national databases in order urgently to formulate clinical guidelines.
Availability of data and materials
The authors declare that data supporting the findings of this study are available within the article.
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Gavriilidis, P., Catena, F., de’Angelis, G. et al. Consequences of the spilled gallstones during laparoscopic cholecystectomy: a systematic review. World J Emerg Surg 17, 57 (2022). https://doi.org/10.1186/s13017-022-00456-6
- Laparoscopic cholecystectomy
- Systematic review