Empyema necessitatis of the gallbladder: laparoscopic management of a rare pathological entity and literature review

Abstract text (incl. references and figure legends)

Case history:An 82-year-old man with history of NYHA III heart failure and recent cardiac surgery for ischemic disease presented to our Department complaining the sudden appearance of a slightly reddened, non-reducible mass in the right upper quadrant.

Clinical findings:No other signs and symptoms were reported.

Investigation/Results:Blood tests showed raised inflammatory markers. Hepatic function tests were normal. US features were equivocal, suggesting possible hernial defect. CT-scan revealed a 10x12.5 cm hypodense parietal lesion with hydro-air level in its context, communicating with the gallbladder.

Diagnosis:Under local anesthesia, the collection was incised with extensive drainage of pus, bile, and multiple stones.

Therapy and Progression:The patient was started on intravenous broad-spectrum antibiotics. After preoperative cardiological evaluation, the patient underwent deferred laparoscopic cholecystectomy. Postoperative course was characterized by transient renal dysfunction requiring diuretic therapy. The patient was discharged home on POD12.

Comments:Empyema necessitatis of the gallbladder is a rare entity characterized by abdominal wall abscess communicating with the gallbladder, usually following chronic inflammation. Incidence and prevalence are greater in women and in the elderly. Cases reported in literature are sparse, mostly treated by open cholecystectomy. However, incision-drainage of abscess followed by deferred laparoscopic surgery is a safe and valid alternative even in frail, elderly patients, allowing for minimally invasive treatment and potentially faster recovery.

References:Ayoub et al, Int J Surg Case Rep 2020;67:42-44. Brimo Alsaman et al, Ann Med Surg (Lond) 2020;59:180-185. ElTinay et al, Ann Med Surg (Lond) 2016;12:106-108. Singh et al, J Clin Diagn Res 2013;7(10):2321-2.

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