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. 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