PMC7531285_01
Laparoscopic cholecystectomy. a) Acute cholecystitis. B) Iatrogenic perforation of the gallbladder and pus spilt. C) Pus aspiration.
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Past medical history consisted of diabetes mellitus, hypertension, kidney transplant (immunosuppressive regimen consisting of betalacept and sirolimus), myocardial infarction requiring the placement of a coronary stent, dual chamber pacemaker, anticoagulation for deep venous thrombosis and a laparoscopic cholecystectomy performed five months earlier in the setting of gallbladder empyema (Fig. 1). Furthermore, we retrieved the surgical video, so we had a high index of suspicion of complications due to spilled gallstones (Fig. 1).
Chest X-ray: right pleural effusion.
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Chest X-ray showed moderate sized right pleural effusion (Fig. 2).
Pre-operative Chest CT. A) Axial view. Right loculated pleural effusion associated with passive collapse of the lung and a 31 mm gallstone bellow the right diaphragm. B) Sagittal view. Red mark: Diaphragm. Black mark: A 31 mm gallstone below the diaphragm, in relation to the liver capsule. C) Coronal view. D) Axial view. 23 mm stone located in the relation with the right hepatic lobe. E) Sagittal view. Right loculated pleural effusion and the previous mentioned 23 mm gallstone below the right hepatic lobe F) Axial view (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
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Nodular structures with peripheral calcifications of 23 mm and 31 mm were observed in relation with the right hepatic lobe and below the posterior costo-diaphragmatic recess respectively (Fig. 3).
CT guided thoracostomy tube placement. A) CT guidance and skin mark. B) Thoracentesis needle advancing into the pleural space. C, D) Chest tube placement.
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Due to patient s frailty we opted for a minimally invasive approach placing a thoracic drain guided by CT (Fig. 4).
Decortication via video assisted thoracoscopy. A, B) Identification of a 1 cm diaphragm defect. C, D, E) Exploration of the sub-diaphragmatic space. F) Retrieval of stone remnants and biliary sludge.
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During the procedure a 1 cm defect was observed in the diaphragm (Fig. 5).
Post-operative chest CT. A, B) Axial view. Right pleural effusion with spontaneous hyperdense content.
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The chest CT revealed persistence of the right pleural effusion with spontaneous hyperdense content, suggestive of hemothorax (Fig. 6).
Post-operative chest X-ray.
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Chest x ray showed no pleural effusion or pneumothorax (Fig. 7).
Post-operative chest CT. A, B, C, D) Axial view. Multifocal ground glass patterns with widening of vessels, thickened interlobular and intra lobular lines (crazy paving).
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A new chest CT revealed multifocal ground glass patterns with thickened interlobular and intra lobular lines (Fig. 8).