Cholangioscopy-Guided Removal of Migrated Sutures Presenting as a Common Bile Duct Stenosis

CASE REPORT Common etiologies of postoperative biliary strictures include thermal injury from surgical cautery devices, direct injury to the bile duct often due to misidentification of anatomy, ischemic injury due to vascular damage, and anastomotic strictures after biliary reconstruction.1 Retained suture material is an uncommon etiology of postsurgical biliary strictures. It is hypothesized that ongoing inflammation from the suture material stimulates fibrosis and scarring, resulting in stone and stricture formation. Endoscopic retrograde cholangiopancreatography (ERCP) is integral in the management of biliary strictures, offering both diagnostic and therapeutic capabilities.2 We present the case of a 73-year-old man who underwent cholecystectomy for symptomatic cholelithiasis complicated by a duodenal injury with subsequent surgical repair. The patient returned approximately 2 months later with elevated liver enzymes. A computed tomography scan revealed biliary ductal dilation suggestive of a stricture. He underwent ERCP, which showed a 10-mm stenosis in the common hepatic duct (Figure 1). A plastic biliary stent was placed, and brushings were obtained for cytology and FISH, which showed atypia on two successive ERCPs. He then underwent an endoscopic ultrasound examination, which revealed symmetrical common hepatic duct wall thickness without masses or lymphadenopathy. The patient then underwent repeat ERCP with cholangioscopy, which revealed significant suture material in the bile duct, along with nodular, raised lesions with uniform projections and dilated, tortious vessels without branching, favored to be reactive changes as opposed to tumor vessels. Under cholangioscopic guidance, cholangioscopy forceps were used to remove all the suture material (Figure 2). The associated stone and debris were attributed to the presence of suture material and were also removed. Two plastic stents were placed, and the patient was noted to have resolution of the stricture on follow-up ERCP (Figure 3).Figure 1.: Fluoroscopic image from initial endoscopic retrograde cholangiopancreatography depicting a stricture in the common hepatic duct with upstream intrahepatic biliary ductal dilation.Figure 2.: Cholangioscopic image depicting suture material in the common hepatic duct with surrounding stone debris.Figure 3.: Fluoroscopic image from follow-up endoscopic retrograde cholangiopancreatography showing resolution of previously seen common hepatic duct stricture and improvement in intrahepatic biliary ductal dilation.Retained suture is a rare cause of postoperative bile duct stricture after cholecystectomy. Presence of retained suture material contributed to inflammation and scarring, which induced the stenosis. Removal may lead to earlier resolution of stenosis and avoidance of surgical intervention (Video 1). {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Cholangioscopy-guided removal of migrated sutures.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_a84g171c"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURES Author contributions: S. Edelson: Study concept and design, drafting of the manuscript. J. Edelson: Study concept and design, drafting of the manuscript. R Shah: Study concept and design, critical revision of the manuscript for important intellectual content. J. Edelson is article guarantor. Financial disclosure: none to report. Informed consent could not be obtained for this case report. All identifying information has been removed.