S1886 A Case Report of Iatrogenic Common Bile Duct Stricture

Abstract

Introduction: Iatrogenic bile duct injuries (IBDIs) are common postsurgical complications following cholecystectomy. IBDI vary from a minor bile leakage to biliary stricture or a complete occlusion of the common bile duct. The authors report a case of a common bile duct stricture caused by suture material after an open cholecystectomy. Case Description/Methods: A 57-year-old male with history of NAFLD presented with acute onset of severe epigastric abdominal pain, nausea and vomiting. Lipase was elevated. CT scan of the abdomen/pelvis revealed gallbladder wall thickening and dilated extrahepatic bile ducts consistent with cholecystitis and biliary obstruction. The patient underwent an open partial fenestrated cholecystectomy which was complicated by injury of the gastric antrum requiring primary two-layered repair and omental patching. ERCP was not performed due to gastric injury. His symptoms improved and he was discharged home. One month later he returned with severe epigastric pain. Initial work-up revealed elevated lipase and transaminases. CT of the abdomen/pelvis showed peripancreatic fluid and fat stranding with persistent mild biliary dilatation. MRCP identified three choledocholiths at the level of the ampulla. ERCP was performed with sphincterotomy, balloon extraction of several stones and sludge, and placement of a plastic biliary stent. There was an area of resistance felt during balloon sweep. He was discharged after symptom resolution with recommendations to repeat ERCP in 6 weeks for stent removal. A repeat ERCP revealed persistent area of resistance with filling defect on fluoroscopy. (Figure). A spyglass revealed a suture material and mild inflammation in the CBD at the cystic duct takeoff (Figure). Stone formation induced by suture material is thought to be the culprit of the recurrent acute pancreatitis. Discussion: IBDIs account for the majority of postsurgical complications after cholecystectomy. The incidence of IBDIs is higher in laparoscopic cholecystectomy when compared to open cholecystectomy. IBDIs are associated with significant perioperative morbidity, mortality, and prolonged hospital stay. If left untreated, they can result in life-threatening complications such as cholangitis, secondary biliary cirrhosis, and portal hypertension. One of the uncommon postoperative complications is stone formation induced by suture material used in cystic duct ligature. Surgical sutures can function as a nidus for crystallization leading to obstruction and development of large choledocholiths.Figure 1.: Top. ERCP shows filling defect in the common bile duct. Bottom: Spyglass shows suture material and adjacent mild imflammation of the CBD at the systic duct takeoff.