CASE REPORT
THE KOREAN JOURNAL OF
PANCREAS AND BILIARY TRACT
Percutanous Cholangioscopic Removal of a Retained
Surgical Needle 20 Years after Open Cholecystectomy
Wan Jung Kim, Young Koog Cheon, Jong Ho Moon, Young Deok Cho
Department of Internal Medicine, Institute for Digestive Research, College of Medicine, Soonchunhyang University, Seoul, Korea
Recurrent cholangitis resulting from a surgical needle retained in the bile duct following opencholecystectomy is an
extremely rare complication. Such a foreign body can cause
biliary stasis and serve as a nidus for the nucleation of bile
duct stones, resulting in recurrent cholangitis. We report a
case of biliary stones and cholangitis caused by a surgical
needle 20 years after open cholecystectomy that was successfully removed by percutaneous cholangioscopy without
complications.
Key words: Foreign body, Surgical needle, Stone, Cholangitis
management of biliary sepsis status post percutaneous transhepatic biliary drainage (PTBD). She had initially presented
INTRODUCTION
with right upper quadrant pain of two days and found to have
Surgical needles may unfortunately be retained after hep-
intrahepatic duct stones. On physical examination, she had
ato-biliary surgery and foreign body reaction can lead to re-
a fever (38.3 C), anicteric sclera, dehydrated tongue, and ab-
current abdominal pain, choledocholithiasis, cholangitis, and
dominal tenderness in the right upper quadrant and the epi-
1
o
even sepsis. Simple x-ray may assist in the diagnosis, and
gastric area without rigidity or rebound tenderness. The pa-
a CT scan or endoscopic examination should be definitive.
tient had undergone open cholecystectomy for acute gallstone
Endoscopic removal or surgery should be performed without
cholecystitis twenty years before at another hospital. A surgi-
delay. We report a case of biliary stones and cholangitis
cal needle was found in her right upper abdomen on plain
caused by an undisposed surgical needle 20 years after open
x-ray taken one day after open cholecystectomy. Reoperation
cholecystectomy that was successfully removed by percuta-
was performed to removal of retained surgical needle, but
neous cholangioscopy without complications.
surgeon could not find the needle on the surgical field and
failed to removal of it. She refused additional surgery for the
needle removal, and subsequently had repeated hospital-
CASE REPORT
izations due to cholangitis symptoms every three to four
An 86-year-old woman was referred to our center for the
years.
On admission, a plain abdominal x-ray showed a crescent
Corresponding author.
Young Deok Cho
Department of Internal Medicine, Institute for Digestive Research,
Digestive Disease Center, College of Medicine, Soonchunhyang
University, 657, Hannam-dong, Yongsan-gu, Seoul 140-743, Korea
Tel: 82-2-709-9861, Fax: 82-2-709-9696
E-mail: [email protected]
36
metallic shadow in her liver, and PTBD catheter was visible
in her right upper abdomen (Fig. 1). A computed tomography
showed a metallic foreign body in the hilar portion of bile
duct (Fig. 2). Four days later, PTBD tract was dilated up to
th
16 French. On the 14 day of admission, we performed a
Endoscopic Removal of Retained Surgical Needle
37
choledochoscopic examination of the intrahepatic biliary trees
days of admission. Two months later,ultrasonographic exami-
and observed multiple pigment stones with a stricture at the
nation showed no biliary stone and there was no stone and
main left intrahepatic duct (Fig. 3A). The stones were broken
symptom recurrence thus far at 3 years of follow-up.
down with electrohydraulic lithotripsy and removed by
basket. The surgical needle was found just distal to the stricture area (Fig. 3B) and its tip was buried under bile duct
DISCUSSION
mucosa. The needle was carefully grasped in the middle with
Biliary tract foreign bodies are classified into three catego-
biopsy forceps (Olympus FB-19SX-1, Tokyo, Japan) and suc-
ries: (a) postsurgical residues, (b) missiles from penetrating
cessfully removed without bleeding or mucosal damage of
wounds, and (c) ingested materials. The most common for-
bile duct (Fig. 4). She was discharged home after the 20
th
eign bodies following surgery are suture materials and endo-
Fig. 1. A Plain abdominal X-ray showed a crescent-shaped
metallic shadow in the right upper quadrant of the
abdomen.
Fig. 2. Computed tomography showed a biliary stricture at the
hilar portion, multiple intrahepatic duct stones in the left
lobe of the liver, and distal CBD stones. A metallic
foreign body was found at the hilar portion of bile duct.
1
Fig. 3. (A) Cholangioscopic examination revealed multiple brown
pigment stones with a stricture at the main left intrahepatic bile duct. (B) After
removal of bile duct stones,
there was noted a surgical
needle just below the stricture area.
대한췌담도학회지 2011년 16권 1호
Wan Jung Kim et al.
38
Fig. 4. (A-C) The surgical needle
was grasped carefully with
biopsy forceps and retrieved
slowly through the dilated
PTBD tract. (D) The removed
surgical needle was about
20 mm in length with yellow-brownish pigment and
rust staining.
2-4
clips.
Complications resulting from retained surgical needles
5
6
matic period is reported to range from 11 days to 10 months
1
are rarely reported.
and stone formation occurs in one to ten years. The long-
Metallic foreign bodies can reportedly serve as a nidus for
6
term consequences of metal fragments in the biliary tract are
choledocholithiasis. By eroding the adjacent bile ducts, stones
not well known. Human tissue responses of bile duct to metal
are formed around the needle and inflammed ducts through
stents up to 7 months showed collagenous reaction and pres-
7
8
the biliary stasis and nucleation. This hypothesis is supported
sure necrosis. In this case, cholangioscopic biopsies were
by the observations in this case where the CT scan showed
performed in the main intrahepatic duct adjacent to the
the stricture around the needle at the hilar portion, stones lo-
needle. The patient's foreign body reactions of twenty-years
cated primarily distal to the stricture, and biliary cirrhosis.
were confirmed as nonmalignant, but rather nonspecific in-
Another potential mechanism of stone formation may be asso-
flammation with granulation.
ciated with choledochojejunostomy that eliminated the nor-
With the development of therapeutic biliary procedures,
malampullary sphincter function. The proximal migration of
many foreign bodies in the biliary tree can be removed endo-
the needle from the cholecystectomy site to the main bile duct
scopically with a Dormia basket, a grasping forcep, and argon
could be related to the bile reflux.
plasma.
9-11
Depending on the circumstances, radiographic ap-
It took several months for her biliary symptoms to first
proachor surgery may be needed. In this case, the surgical
manifest after laparoscopic cholecystectomy. Such asympto-
needle was lodged in the hilar common hepatic duct; trans-
대한췌담도학회지 2011년 16권 1호
Endoscopic Removal of Retained Surgical Needle
39
papillary approach was difficult because of acute angulation
and dangerous due to sharp end of the needle. With the existing PTBD catheter, we chose the transhepatic approach and
3.
grasped the middle of the needle with a biopsy forcepsand
retrieved it through the percutaneous tract without any
4.
complications.
Because the patient refused needle removal surgery for
many years, she probably experienced most if not all potential
5.
complications of a residual metallic foreign body, including
intrahepatic duct stones, cholangitis, biliary cirrhosis, and
6.
even biliary sepsis. To avoid such a slew of adverse reactions,
intervention by endoscopy or surgery should be performed
as soon as possible. Where surgery is contraindicated, endoscopic removal should be considered. This case illustrates the
7.
8.
undisputable importance of meticulous intraoperative counting of surgical equipments as well as the value of a plain
x-ray.
9.
10.
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