Hepatobiliary and Pancreatic: Suture material and bile duct stones

Abstract

A relatively common clinical problem is that of bile duct stones in patients who have previously had a cholecystectomy. In approximately 50% of patients, stones are diagnosed within 1–2 years of surgery and may well have been overlooked at the time of operation. In patients in whom the interval between surgery and diagnosis is several years or decades, it seems likely that new stones form within the bile duct (primary bile duct stones). One area of controversy is the pathogenesis of primary bile duct stones and whether suture material is an important nidus for stone formation. Supporters of this hypothesis highlight the presence of unabsorbed suture material (or even metallic clips) in the center of some bile duct stones. Other authors concede that suture material may be a nidus in a minority of patients but that the majority develop brown pigment stones because of bacterial contamination of bile. The patient whose images are illustrated below was admitted to hospital with abdominal pain and changes in liver function tests. Ten years previously, he had been diagnosed with an hydatid cyst and had been treated by hepatic surgery and a cholecystectomy. An upper abdominal ultrasound study revealed a dilated bile duct while magnetic resonance cholangiopancreatography showed a dilated bile duct with a calculus of moderate size. At endoscopic retrograde cholangiopancreatography, the bile duct was mildly dilated and there was a filling-defect, 2 cm ¥ 1 cm, close to the papilla (Fig. 1). Endoscopic sphincterotomy was performed and a soft calculus was removed containing several centimeters of suture material (Fig. 2). In this case, it seems likely that the suture material came from the region of the hydatid cyst. In most patients, however, the suture material migrates into the bile duct from the cystic duct stump.