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| Year : 1981 | Volume
: 27
| Issue : 4 | Page : 248-50 |
Foreign bodies in the biliary stones : (a case report).
Zarger HU, Hussain AA, Ahmed MN, Mir MA, Khan GM
How to cite this article:
Zarger H U, Hussain A A, Ahmed M N, Mir M A, Khan G M. Foreign bodies in the biliary stones : (a case report). J Postgrad Med 1981;27:248 |
Various types of foreign bodies have been found forming the nidus of the biliary calculi. Foreign bodies like ova of ascaris, suture materials, tomato skins, rolled up plums and hair pins forming the nidus of biliary stones have been. reported by various authors.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Although, a previously inadequate operation is undoubtedly the main aetiological factor in residual choledocholithiasis, there have been scanty reports about the stones being formed around unabsorbable suture material.[3], [6] Two cases of the same nature were also reported by Mackie et al.[4]
We also found a coiled up suture material forming the nidus of a mixed common bile duct calculus.
A 54 year old male was admitted to the surgical ward with complaints of colicky pain in the upper abdomen and jaundice, of six months' duration. There were no symptoms of vomiting, dyspepsia or fever. There were also no symptoms suggestive of chronic peptic ulcer. Past history revealed that the patient was operated upon 3½ years ago when cholecystectomy with choledochostomy was done. General physical examination revealed jaundice in an averagely built patient. The systemic examination revealed no organomegaly or ascites. There was mild tenderness on deep palpation in the right upper quadrant but no lump was palpable. Haemogram showed haemoglobin of 10 gm per cent, total leukocytic count of 9500/cu.mm, erythrocyte sedimentation rate of 1 mm after one hour by Wintrobe's method. Differential leucocyte count showed polymorphs 72 per cent, lymphocytes 27 per cent and eosinophils 1 per cent. Urine analysis was normal. Liver function tests showed serum bilirubin to be 2.8 mg per cent, total proteins 6.3 gm%, albumin 4 gm%, globulin 2.3 gm% and serum alkaline phosphatase 30 K.A. Units. Plain skiagram of the abdomen showed no radio-opaque shadow. Intravenous cholengiogram was nonconclusive. The patient was explored under general anaesthesia. The stomach, duodenum, liver and rest of the viscera were normal. Common bile duct was dilated and thickened and a big stone was felt towards its upper end. The duct was explored and the stone removed. There was a coiled up suture material found attached to the stone. [Figs. 1] & [Fig. 2]. Distally, the duct was patent. A T-tube was put in. The post-operative period was uneventful. T-tube was removed on the 8th post-operative day and the patient was discharged on the 12th post-operative day. He has been regularly attending the follow-up clinic without any further complication for the last 31 years.
The stone weighed 15 gm and measured 3 cm x 2½ cm. The chemical analysis of the stone showed it to be constituted of cholesterol and bilirubin.
A residual stone in the common bile duct following cholecystectomy is a distressing but potentially avoidable complication. The reports of recurrent calculi in the bile duct following operation such as cholecystectomy and choledochostomy are not uncommon but there have been sporadic reports of recurrent calculi forming around the unabsorbable suture material. The formation of true common bile duct stone around such suture material has been reported by Homans[3] and Mackie et al.[4] There is no unanimous opinion about the use of suitable suture material for ligating the cystic duct during cholecystectomy or the suture material used while exploring the common bile duct. However, Maingots and Rob and Smithe recommended the use of catgut whereas Gardham and Davies,[3] Rains[6],[7],[8] and Farghuarson[1] advocated the use of unabsorbable suture material.
In our patient, the common bile duct was explored at the time of first surgery and the suture material used was silk for ligating the cystic duct, catgut was used after the exploration of the common bile duct. For cystic duct transfixation, braided silk was used as the duct was quite dilated. The suture material had got introduced into the lumen of the duct and after some time cholesterol and pigment possibly had aggregated around it and thereby promoted the formation of a stone over the nidus of the unabsorbable suture (silk thread). As evident from the scarcity of such reports in the literature, stone formation around the nidus formed by unabsorbable suture material is most unusual. It is amazing that the suture material could not pass harmlessly into the doudenum in spite of the fact that there was no obstruction or stenosis at the sphincter of Qddi at the time of second exploration of the common bile duct.
The chemical examination of the stone revealed that the stone was of a mixed type. This can be explained by the fact that pigment and cholesterol had aggregated around the suture material. Thus the use of absorbable suture material for biliary tract surgery cannot be overemphasized.
| 1. | Farquharson, E. L : "Text Book of Operative Surgery." 4th Edition, Livingston, Edinburgh, 1969, p. 594.  |
| 2. | Gardham, A. J. and Davies, D. R.: "The Operations of Surgery". Churchill, London, 1963, p. 420. |
| 3. | Homans, J.: Ann. Surg., 26: 114, 1897. Quoted by Mackie et al (1973).[4] |
| 4. | Mackie, D. B., Haynes, S. and May, R. E.: Unabsorbable suture material: A rare cause of recurrent stones in the common bile duct. Brit. J. Surg., 60: 23-24, 1973. |
| 5. | Maingot, R.: "Abdominal Operations." Vol. 1, Butterworths, London, 1969, p. 919. |
| 6. | Rains, A. J. H.: Gall stones: An introduction to research into causes and remarks on some problems in treatment. Lecture delivered at the Royal College of Surgeons of England on 4th October, 1960. Ann. Roy. Coll. Surg. Eng., 29: 85-101, 1961. |
| 7. | Rains, A. J. H.: "Gall Stones: Causes and Treatment." Heinemann, London, 1954, p. 176. |
| 8. | Rains, A. J. H., Capper, W. M., Knight, G., Cleland, W. P. and Freeman, M. A. R.: "Baily and Love's Short Practice of Surgery." 15th Edition, H. K Lewis and Co. Ltd., London, 1971, p. 84 &. |
| 9. | Rob, C. and Smith, R.: "Operative Surgery." Butterworths, London, 1969, p. 404. |
| 10. | Smith, R. and Sherlock, S.: "Surgery of The Gall Bladder and Bile Duct." Butterworths, London, 1964, p. 119. |
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