we report the case of a patient who underwent a laparoscopic cholecystectomy with gallstone spillage 34 months before presenting to the thoracic surgery service .
the patient first complained of streaks of hemoptysis at 6 months from the time of the original procedure .
a lower lobe infiltrate was noted and treated successfully with oral antibiotics . over the next 2 years , the patient 's symptoms waxed and waned .
due to the chronic infiltrate in his lung , a thoracotomy was performed that revealed erosion of the stone through the right diaphragm with formation of a lung abscess .
a high index of suspicion for a gallstone - related problem should be entertained by the practitioner when presented with a patient who has a right lung infiltrate and a history of open or laparoscopic cholecystectomy .
gallbladder perforation during laparoscopic cholecystectomy occurs in 10% to 32% of patients , with gallstone spillage in 0.2% to 20% of cases .
there have been very few reported thoracic complications from this common problem . before laparoscopic cholecystectomy , cholelithoptysis and intrathoracic complications from gallstones were rare because the operative field was packed off to facilitate the open surgery .
introduction of a pneumoperitoneum and intraoperative irrigation facilitates distant migration of gallstones , specifically to the subphrenic space .
a review of the literature reveals 11 reported cases of gallstones being found in the thoracic cavity following cholecystectomy .
eight cases presented as cholelithoptysis and the latest one as massive hemoptysis from a gallstone associated abscess .
we believe these findings reiterate the need for fastidious stone removal at the time of initial cholecystectomy .
furthermore , while most patients with this problem present with cholelithoptysis , a high index of suspicion should be entertained by the practitioner when encountering a patient who has a right lung infiltrate and a history of open or laparoscopic cholecystectomy .
a 73-year - old man with a past medical history of hyper - tension and chronic obstructive lung disease presented with a 4-month history of biliary colic and mild pancreatitis .
after 3 days of conservative management with nothing by mouth and intravenous antibiotics , his pancreatitis resolved , and he underwent laparoscopic cholecystectomy .
he did well postoperatively and was asymptomatic for 6 months until he developed low - grade fevers and streaks of hemoptysis .
computed tomography of the chest revealed a 57-cm pulmonary infiltrate in the posterior basilar segment of the right lower lobe associated with a 59-mm oval calcification at the level of the right diaphragm ( figure 1 ) .
shows eccentric calcification of a soft tissue mass in the lower lobe of the right lung .
a repeat ct scan 2 months later demonstrated marked improvement of the pulmonary infiltrate , but the persistence of a calcified nodule on the surface of the diaphragm . over the next 2 years
, the patient developed episodic bouts of scant hemoptysis every 2 to 3 months that resolved spontaneously .
thirty - four months after his laparoscopic cholecystectomy , after an episode of self - limited hemoptysis , he underwent a surveillance ct scan that revealed a new 53-cm opacity in the posterobasal segment of his right lower lobe .
further evaluation with a mediastinoscopy showed no evidence of malignancy . at the time of exploration ,
the right lower lobe was densely adherent to the diaphragm . to ensure an oncologic resection ,
the final pathology was returned as chronic pulmonary abscess and foreign body giant cell reaction to a gallstone .
transection of the gross lung specimen shows a gallstone encapsulated by surrounding fibrous reactive tissue .
gallstone spillage is estimated to occur in 0.2% to 20% of cases with very few causing complications . a case review of 1130 consecutive laparoscopic cholecystectomies performed at 2 different institutions demonstrated a 0.3% complication rate from intraoperative stone spillage at 13-year follow - up .
complications from gallstone spillage vary from trocar - site wound infections to overt intraabdominal abscess as well as gynecological and intrathoracic complications .
thoracic complications of retained gallstones with pleurobiliary and bronchobiliary fistulas were reported as early as 1955 .
the mean time to onset of complications is 6 months , but a case report exists of a gallstone - associated subphrenic abscess presenting 10 years after the cholecystectomy . our case represents a complication of a spilled gallstone at the time of laparoscopic cholecystectomy that eroded through the right diaphragm and caused pneumonitis presenting as intermittent hemoptysis . although our patient never had an overt intraabdominal abscess , clinically and by imaging , he had a prolonged right subdiaphragmatic inflammatory process that allowed the intrathoracic migration of the gallstone .
if stone spillage occurs , a serious attempt to retrieve as many stones as possible with a larger forceps should be made followed by copious amounts of irrigation with a large bore suction catheter .
this should be performed laparoscopically without conversion to an open procedure , as overall complication rate of stone spillage is 0.3% . before the advent of laparoscopic cholecystectomy , cholelithoptysis and intrathoracic complications from gallstones
coughing up stones ,  was classically due to calcified peribronchial lymph nodes that eroded through the bronchial wall .
there are 11 case reports in the literature of gallstones in the thoracic cavity following cholecystectomy ( table 1 ) .
nine cases presented as cholelithoptysis , and the latest one as massive hemoptysis from a gallstone - associated abscess .
complications of intrathoracic gallstones three possible routes of intrathoracic migration of gallstones exist : the lymphatic channels of ranvier , congenital diaphragmatic defects , and transdiaphragmatic tracts that form from local infection / inflammation .
as seen in our case , prolonged chest symptoms , especially with findings in the rll , following a laparoscopic cholecystectomy should raise the suspicion of intrathoracic gallstones .
one must search for an intraabdominal collection and consider antibiotic treatment , percutaneous drainage , or laparotomy .
thoracotomy is rarely required and only indicated for obstructing pneumonia , refractive hemoptysis , or nodules of uncertain cause .
if stone spillage occurs during a laparoscopic cholecystectomy , documentation in the chart would be valuable to clinicians following the patient , allowing them to have a high clinical suspicion when abdominal or thoracic symptoms occur .
 background : laparoscopic cholecystectomy is one of the most commonly performed procedures in general surgery . 
 there have been very few reported thoracic complications from this surgical procedure.methods:we report the case of a patient who underwent a laparoscopic cholecystectomy with gallstone spillage 34 months before presenting to the thoracic surgery service . 
 the patient first complained of streaks of hemoptysis at 6 months from the time of the original procedure . 
 a lower lobe infiltrate was noted and treated successfully with oral antibiotics . over the next 2 years , the patient 's symptoms waxed and waned.results:due to the chronic infiltrate in his lung , a thoracotomy was performed that revealed erosion of the stone through the right diaphragm with formation of a lung abscess.conclusion:a high index of suspicion for a gallstone - related problem should be entertained by the practitioner when presented with a patient who has a right lung infiltrate and a history of open or laparoscopic cholecystectomy . 