Cholecystitis with gallbladder rupture leading to free gallstone migration causing chronic abdominal wall sinus formation: A case report

Abstract

BACKGROUND

Gallstones are frequently observed in patients with cholecystitis, but the migration of free gallstones into the abdominal wall leading to chronic sinus formation is exceedingly rare.

CASE SUMMARY

We report a case of a 72-year-old woman who experienced recurring fever and abdominal pain following laparoscopic cholecystectomy for acute cholecystitis, during which gallbladder rupture was noted. Despite initial conservative management and temporary T-tube placement, the patient developed a chronic sinus in the abdominal wall 9.5 years later, characterized by an area of thickened soft tissue with ulceration and purulent discharge. Surgical exploration revealed the presence of a migrated gallstone at the base of the sinus tract, necessitating careful surgical removal and postoperative wound care.

CONCLUSION

This case highlights the potential long-term complications of retained free gallstones and the importance of thorough surgical retrieval.

Key Words: Cholecystitis; Gallbladder rupture; Free gallstone; Chronic abdominal wall sinus; Laparoscopic cholecystectomy; Case report

Core Tip: This case report details an exceptionally rare complication following laparoscopic cholecystectomy: Chronic abdominal wall sinus formation due to free gallstone migration. Despite initial conservative management, including T-tube placement for gallbladder rupture, the patient developed a persistent subcutaneous abnormality with ulceration and purulent discharge 9.5 years later. Surgical exploration confirmed the presence of a yellow-green stone-like material at the base of the sinus tract. This case highlights the importance of thorough surgical retrieval of all gallstones during cholecystectomy and underscores the potential long-term complications of retained free gallstones. Early recognition and appropriate management are crucial.

INTRODUCTION

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis and acute cholecystitis, occurring in 10%-15% of the general population[1,2]. Of these cases, around 10% progress to acute cholecystitis requiring surgical intervention. The procedure has been widely adopted due to its minimally invasive nature and lower complication rates compared to open surgery[3]. However, despite its safety, complications such as gallbladder perforation and spillage of gallstones can occur, potentially leading to long-term sequelae[4-6]. Chronic abdominal wall sinus formation resulting from the migration of a free gallstone is an exceptionally rare complication, with only a few cases reported in the literature[7,8]. This condition can present with nonspecific symptoms, making diagnosis challenging and often leading to delayed treatment[9]. Herein, we describe a unique case of a patient who developed a chronic sinus in the abdominal wall nearly a decade after laparoscopic cholecystectomy complicated by gallbladder rupture. We also discuss the potential mechanisms of gallstone migration, the importance of thorough surgical technique, and the role of long-term follow-up in preventing such complications.

The delayed onset and unusual presentation of this condition pose significant diagnostic challenges. Understanding the underlying mechanisms and recognizing the potential for long-term complications can help clinicians provide improved care and enhance patient outcomes.

CASE PRESENTATION

Chief complaints

A 72-year-old woman with a medical history of hypertension and type 2 diabetes mellitus presented to our clinic with an already formed chronic sinus and ulceration in her abdominal wall, which had been developing for six months.

History of present illness

The patient reported that the mass had progressively increased in size, eventually ulcerating and discharging pus. She had undergone multiple debridements at an outside facility, but the wound failed to heal.

History of past illness

Notable for a laparoscopic cholecystectomy performed 10 years earlier due to acute cholecystitis. During the surgery, gallbladder rupture was noted, and a T-tube was inserted via endoscopic retrograde cholangiopancreatography for drainage. The patient initially improved with conservative management and opted against further surgical intervention. The T-tube was removed after 1 month, and the patient remained asymptomatic for the next 9.5 years.

Physical examination

Upon physical examination at the time of presentation to our hospital, the patient was noted to have a draining sinus tract with purulent discharge but without a significant subcutaneous mass. The area around the sinus tract was tender on palpation. No signs of systemic infection or sepsis were present.

Laboratory examinations

Laboratory results were within normal limits, including glucose (95 mg/dL), creatinine (0.9 mg/dL), sodium (137 meq/L), potassium (4.0 meq/L), white blood cell count (9800/μL with 73.8% neutrophils, 14% lymphocytes, and 7.4% monocytes), platelets (300000 cells/mm³), hemoglobin (11.5 g/dL), and hematocrit (34.8%).

Imaging examinations

Imaging studies, including ultrasound and computed tomography (CT) of the abdomen, did not definitively demonstrate a connection between the sinus tract and the abdominal cavity. CT imaging revealed thickening and disordered structure of the soft tissues in the anterior abdominal wall, with evidence of a sinus tract that did not connect into the abdominal cavity. No gallbladder or gallstones were visible. Enhanced MRI also showed thickened tissue in the upper anterior abdominal wall, showing heterogeneous enhancement on T2-weighted images, without abnormal signals indicative of complications (Figure 1).

Figure 1 Imaging studies of the abdomen, showing the subcutaneous sinus tract but no definitive connection to the abdominal cavity. A: Axial computed tomography image showing the deepest layer of the abdominal wall sinus tract. White arrow: Points to the thickened and disordered soft tissue structure in the anterior abdominal wall, indicating the presence of a sinus tract. The image shows that the sinus tract does not extend into the abdominal cavity; B: Coronal magnetic resonance imaging with contrast, emphasizing the deepest layer of the abdominal wall sinus tract on T2-weighted images. White arrow: Points to the deepest layer of the abdominal wall sinus tract in the coronal section. The sinus tract is clearly delineated, confirming its location within the soft tissue layer and its lack of involvement with the internal abdominal structures. This coronal view with contrast further illustrates the thickened and heterogeneous enhancement of the tissue in the upper anterior abdominal wall, confirming the absence of any connection to the abdominal cavity or signs of complications. CT: Computed tomography; MRI: Magnetic resonance imaging.

MULTIDISCIPLINARY EXPERT CONSULTATION

Given the complexity of the case, a multidisciplinary approach involving hepatobiliary surgeons was implemented.

FINAL DIAGNOSIS

The final diagnosis was chronic sinus formation due to migration of a free gallstone into the abdominal wall.

TREATMENT

This study has been approved by the Ethics Committee of Zibo Central Hospital, and informed consent was obtained from the patient.

The patient underwent surgical exploration with general anesthesia. Intraoperative findings revealed significant adhesions from the previous surgery, which were carefully dissected. No obvious abnormalities were noted in the abdominal cavity. However, upon exploring the sinus tract, a yellow-green, stone-like material was discovered at its base (Figure 2). This finding was consistent with the hypothesis that a free gallstone had migrated from the site of the initial gallbladder rupture to the abdominal wall, leading to the formation of the chronic sinus. The stone was successfully extracted, and a negative pressure wound therapy (NPWT) device was applied to facilitate wound healing. Postoperatively, the patient was administered antibiotics to prevent infection and monitored closely for signs of wound healing. The NPWT device was maintained and regularly changed until the wound was completely healed.

Figure 2 Intraoperative image showing the yellow-green, stone-like material at the base of the sinus tract. A white gauze pad with blood stains and small fragments of yellow-green material. Orange arrow (1): Blood stains on the gauze pad. Purple arrow (2): Small fragments of yellow-green, stone-like material.

OUTCOME AND FOLLOW-UP

The patient was discharged with instructions for wound care and follow-up appointments. At the one-year follow-up, the patient reported no recurrence of symptoms.

DISCUSSION

The migration of a free gallstone into the abdominal wall, leading to the development of a chronic sinus, is a rare complication of gallbladder disease. Previous studies have suggested several mechanisms that may contribute to this phenomenon. For instance, Salati et al[10] found that the initial retention of small gallstones during laparoscopic cholecystectomy, particularly in cases of gallbladder rupture, can lead to their subsequent migration. In our case, gallbladder rupture likely played a pivotal role in the release of a gallstone into the peritoneal cavity.

In contrast, gallstones causing intestinal obstruction typically involve larger stones that migrate through the biliary tract and enter the intestines, where they cause mechanical blockage[11]. While both conditions result from gallstone migration, the underlying mechanisms differ significantly. Gallstones migrating to the abdominal wall are more likely influenced by local inflammation and pressure from surrounding tissues, promoting their movement within the peritoneum[12]. Additionally, the natural movement of the abdominal wall, especially in areas with previous surgical adhesions, may facilitate the gradual migration of gallstones toward the abdominal wall[13]. The chronic inflammatory response triggered by the presence of a foreign body (the gallstone) can result in the formation of a sinus tract, as observed in our patient.

Furthermore, Tran et al[14] demonstrated that the delayed onset of symptoms, as seen in this case, can be attributed to the slow progression of the inflammatory process and the eventual erosion of the gallstone through the abdominal wall. These findings emphasize the importance of precise surgical technique, including the use of intraoperative cholangiography to identify and retrieve all gallstones, and the necessity of long-term follow-up in patients with a history of complicated cholecystitis.

This case highlights the critical importance of thorough surgical technique in laparoscopic cholecystectomy, specifically the need to ensure the complete retrieval of all gallstones. Techniques such as intraoperative cholangiography and careful inspection of the surgical field can significantly reduce the risk of residual free gallstones. Moreover, the case underscores the need for long-term follow-up in patients with a history of complicated cholecystitis, despite their early apparent recovery. Long-term monitoring can facilitate the early detection and management of potential complications, improving patient outcomes. A multidisciplinary approach, involving hepatobiliary surgeons, radiologists, and wound healing specialists, provides comprehensive care and improves outcomes for patients. Early recognition and appropriate management, including surgical exploration and the use of advanced wound care techniques such as NPWT, are essential for resolving such rare and challenging conditions.

Moreover, recent advances in medical technology have introduced new possibilities for the prevention and treatment of complications caused by free gallstone migration. For instance, novel minimally invasive techniques, such as endoscopic retrieval of spilled gallstones, may offer a less invasive alternative to traditional surgical approaches[15]. Additionally, emerging pharmacological therapies aimed at dissolving gallstones or reducing inflammation could play a crucial role in preventing long-term complications[16]. Future research should focus on exploring these new avenues, including personalized medicine approaches and the use of artificial intelligence to improve diagnostic accuracy and tailor treatment plans for individual patients.

CONCLUSION

The migration of a free gallstone into the abdominal wall resulting in chronic sinus formation is an extremely rare complication of gallbladder disease. This case highlights the potential long-term consequences of retained gallstones and underscores the importance of thorough surgical retrieval during cholecystectomy. Early recognition and appropriate management are critical for achieving a favorable outcome in such cases.