Surgical paper XV
Recurrent stones in common bile duct with suture as core
A report of 6 cases
Between 1975 and 1980, we reviewed a group of 70 patients who had undergone reoperations for recurrent cholelithiasis, representing 19% (70/368) of cholelithiasis surgeries during the same period. Of these 70 cases, six had recurrent stones formed around the surgical suture used in their previous operations. This report aims to discuss these specific six cases due to their implications for improving surgical techniques.
- Gender: Male
- Age: 37
- Hospital No.: 1047
- Date of Admission: February 13, 1976
- Medical History: Underwent cholecystectomy, choledocholithotomy, and T-tube external drainage at our hospital a year prior.
- Symptoms: Began experiencing frequent right upper abdominal pain and occasional fever six months after discharge.
- Intraoperative Findings: Discovered a 2cm diameter muddy stone mass formed around a surgical suture in the common bile duct.
- Outcome: Stone removed, T-tube placed, and the patient was discharged 14 days post-op. No recurrence at three-year follow-up.
- Gender: Female
- Age: 28
- Hospital No.: 4893
- Date of Admission: October 6, 1977
- Medical History: Had cholecystectomy, left hepatic lobectomy, and T-tube external drainage two years earlier.
- Symptoms: Upper right abdominal pain, fever, and jaundice half a month prior.
- Intraoperative Findings: Two pieces of 7cm and 4cm sutures were found in the common bile duct, around which loose stone masses of 3cm and 2cm in diameter had formed.
- Outcome: Stones removed, patient was hospitalized for 15 days and discharged. However, the patient died a year later due to intrahepatic stones and severe infection, leading to shock.
- Gender: Female
- Age: 52
- Hospital No.: 5105
- Date of Admission: October 20, 1977
- Medical History: Cholecystectomy and common bile duct T-tube drainage 14 months ago.
- Symptoms: Recurrence of symptoms 8 months post-op, leading to admission 10 hours after the onset.
- Intraoperative Findings: A 4x3x3 cm sand-mud stone mass was found, with the suture from the previous surgery serving as the core.
- Outcome: The patient died of toxic shock 10 hours post-operation.
Note: Three additional cases had similar intraoperative findings and outcomes. All were successfully treated and had no recurrence after a follow-up period of 1 to 3 years.
The recurrence rate of primary hepatobiliary pigmented stones after surgery is high, reaching 19% according to our data. The fundamental cause is metabolic dysfunction in bile composition. However, improper surgical procedures or the retention of foreign objects can also lead to early recurrence of stones. In this report, all six cases of recurrent stones had sutures from previous surgeries as their core. The absence of these sutures could have potentially prevented the recurrence or at least recent postoperative recurrence. Case 3 in our series tragically passed away due to this issue, serving as a serious lesson.
Although we have only identified six such cases, the actual number may be higher. Not every stone removed in reoperations is crushed for examination. Therefore, it is possible that the actual number of such cases is higher. Furthermore, in most reoperations, the original sutures from previous surgeries on the common bile duct were not found. We speculate that once these sutures penetrate into the lumen, the body’s natural rejection mechanisms could expel them into the intestine through the common bile duct, thereby averting harm. However, before being expelled into the intestine, could these sutures serve as a nucleus for stone formation or even cause symptoms? This warrants further investigation. It might also be one of the reasons contributing to the so-called “post-cholecystectomy syndrome,” another aspect deserving attention. Further systematic endoscopic or radiographic studies are needed to draw scientific conclusions.
In our hospital, the common practice for suturing the common bile duct incision involves using non-absorbable No.0 or No.1 silk threads for full-layer continuous suturing, starting from the upper edge of the incision and moving downwards. While this method ensures tight closure and is time-efficient, it has a downside. During the removal of the T-tube, part of the duct wall is inevitably damaged, exposing the suture to the lumen. This can lead to a natural rejection response, causing the suture to adhere to bile sediments before being fully expelled into the intestine, sometimes leading to symptoms. Therefore, we recommend abandoning this suturing method and instead using thinner sutures for submucosal interrupted sutures to prevent the suture from being exposed to the lumen.
Case 3 demonstrated that even the thicker sutures used for the hepatic section can fall into the lumen, illuminating the body’s natural rejection instinct. This is a rare but instructive instance.
Originally published in the Proceedings of the Second Annual Surgical Conference of Anhui Province, 1988; 87; presented at he Yangtze River Full-Line Biliary Surgery Seminar, No. 23. (1987/02/24), Changhang Hospital, Li Mingjie