Virinder Kumar Bansal, Mahesh C Misra, Prashant Bhowate, Subodh Kumar
Department of Surgical Disciplines,
All India Institute of Medical Sciences,
New Delhi
Corresponding Author:
Dr. Virinder Kumar Bansal
Email:drvkbansal@gmail.com
48uep6bbphidvals|203 48uep6bbphidcol2|ID 48uep6bbph|2000F98CTab_Articles|Fulltext A variety of foreign bodies have been reported in the common bile duct which include surgical gauze,[1] fish bone,[2] dormia basket,[3] endo-clips,[4] cherry stalk,[5] splinters and shrapnel,[6] peels of green, balls of thread7 etc. The patients usually present with features of obstructive jaundice, cholangitis or raised liver enzymes. The underlying mechanism due to which foreign bodies, including surgical clips, end up in the biliary system is unknown. Direct introduction during surgery, penetrating injuries, entero-biliary reflux, or erosions with eventual migration into the biliary system have been postulated as possible causes. Bile-duct injuries, inappropriate clip placements, sub-clinical bile leak, and infections also have been postulated to contribute to clip migration.[4]
We report the case of a forgotten biliary stent, which acted as a nidus for stone formation, and we have coined the term “Stentolith” for this.
Case Report
A 62-year-old male patient and a known case of hypertension suffered severe biliary colic in January 2000. He was diagnosed as a case of cholelithiaisis with choledocholithiasis. There was no history of obstructive jaundice or cholangitis. He underwent endoscopic clearance of the common bile duct with papillotomy. A 7 Fr plastic stent was placed in the common bile duct. The patient did not appear for follow up and in January 2006 he once again had a severe attack of acute colicky pain in the abdomen, associated with nausea and vomiting. There was no history of cholangitis or jaundice. On abdominal ultrasound there were multiple stones in the gall bladder with multiple stones in the common bile duct. A plain X-ray abdomen revealed the biliary stent in situ. The liver function tests were within normal limits. (alkaline phosphatase 285 IU/L and SGOT/ SGPT 29/29 IU/L). Magnetic resonance cholangiopancreatography (MRCP) revealed cholelithiaisis with choledocholithiasis. ERCP showed the previous biliary stent in situ. The stent was impacted in the common bile duct and could not be removed endoscopically.
The patient was taken up for laparoscopic CBD exploration. The retained biliary stent was seen encased in a cast of biliary sludge, which had turned into hard calculi. The stent along with the calculi around the stent were removed. (Figure 1) Multiple small fragments of stones were also cleared from the common bile duct. A check choledochoscopy confirmed the clearance of the common bile duct, and a cholecystectomy was done. A T-tube cholangiogram performed a week later, revealed a small residual calculus, which was removed by ERCP 6 weeks later. The patient is doing well at two and a half years follow up.
Discussion
There are numerous reports of a foreign body (FB) acting as a nidus for stone formation within the biliary system.[1,2,3,4,5,6,7] Surgical clips have been reported as the most common FBs that induce iatrogenic biliary stones.[4] Patients typically are first seen with symptoms of biliary obstruction, which can be complicated by life-threatening cholangitis.
Kaji et al[8] have tried to classify this phenomenon according to the pathway through which these foreign bodies can migrate into the common bile duct, i.e. by operative or non-operative means. Through the non-operative pathway the object may be either ingested, such as ascariasis,9 and food particle (e.g. fish bone),[2] or not ingested but acquired through other means (e.g. missile fragments, shrapnel and splinters).[6]
There are many case reports and series in urological literature of calculi forming around the retained ureteric stent.[10] These ‘forgotten stents’ have been documented to obstruct the urinary system and may result even in renal failure and death. A majority of these forgotten stents are dealt with endoscopically.[10]
In a study, which investigated foreign body infection in the biliary tract it was found that implants in the biliary tract impaired the local host defense mechanism, resulting in an increased susceptibility to microbial infection and fibrosis.[11] These plastic stents if kept for a prolonged period promote bacterial proliferation, and release of bacterial beta-glucuronidase, which results in the precipitation of calcium bilirubinate. Calcium bilirubinate is then aggregated into stones by an anionic glycoprotein. Koivusalo et al[12] found that latex tubes were toxic and induced moderate to pronounced fibrosis and epithelial damage on the CBD wall, unlike silicone tubes.
This is the first case report of successful laparoscopic removal of a common bile duct foreign body, a ‘forgotten biliary stent’ which was encased in a calculus, and for which we suggest the term, ‘stentolith’- i.e. a calculus around a stent. Surprisingly, the patient did not have any features of obstruction of the common bile duct for five years. This can be explained by the fact that the previous papillotomy was adequate and bile was draining around the stent.
We recommend setting up of a computerised ‘Stent Registry System’ under the direct supervision of the physician so that the stents placed for various therapeutic procedures are not forgotten both by the patient as well as the physician. Patient education for timely follow up and removal of these stents is important to avoid potentially lethal complications.
References
1. Cipolletta L, Bianco MA, Rotondano G, Prisco A, Catalano M, Gatto A, et al. Endoscopic retrieval of a urgical gauze from the common bile duct. Ital J Gastroenterol Hepatol.1997;29:58–61.
2. Sakai T, Kihara M, Wagayama H, Shimizu A, Kuniyoshi M, Tameda Y. A case of recurrent choledocholithiasis due to foreign bodies (fish bones) after endoscopic sphincterotomy (abs). Nippon Shokakibyo Gakkai Zasshi. 1997;94:143–7.
3. Halfhide BC, Boeve ER, Lameris JS. Percutaneous release of Dormia baskets impacted in the common bile duct. Endoscopy. 1997;29:48.
4. Kitamura K, Yamaguchi T, Nakatani H, Ichikawa D, Shimotsuma M, Yamane T, et al. Why do cystic duct clips migrate into the common bile duct? Lancet. 1995;346:965–6.
5. Kelly MD, Hugh TB. Cherry stalk in the common bile duct. Aust N Z J Surg. 1993;63:571–4.
6. Mitchell R, Kerr R, Barton J, Schmidt A. Biliary obstruction secondary to shrapnel. Am J Gastroenterol. 1991;86:1531–4.
7. Cimsit B, Keskin M, Ozden I, Alper A. Obstructive jaundice due to a textiloma mimicking a common bile duct stone. J Hepatobiliary Pancreat Surg. 2006;13:172–3.
8. Kaji H, Asano N, Tamura H, Yuh I. Common bile duct stone caused by a fish bone: report of a case. Surg Today. 2004;34:268–71.
9. Estrada J, Garcia E. Ascaris lumbrocoides in the common bile duct. J Trop Med. 1942;45:33–6.
10. Aron M, Ansari MS, Singh I, Gautam G, Kolla SB, Seth A, et al. Forgotten ureteral stents causing renal failure: multimodal endourologic treatment. J Endourol. 2006;20:423–8.
11. Yu JL, Andersson R, Wang LQ, Ljungh A, Bengmark S. Experimental foreign-body infection in the biliary tract in rats. Scand J Gastroenterol. 1995;30:478–83.
12. Koivusalo A, Makisalo H, Talja M, Cormio L, Ruutu M, Wolff H, et al. iocompatibility of latex and silicone T tubes in the porcine common bile duct: an experimental study. Res Exp Med (Berl). 1996;196:53–66.
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