Post written by Najib Nassani, MD, MSc, from CentraCare Interventional Endoscopy Program, St. Cloud Hospital, St. Cloud, Minnesota, USA.

We reported on the case of a 64-year-old woman who had a cholecystectomy several years ago and presented with recurrent choledocholithiasis and cholangitis despite previous ERCPs.

Upon balloon sweep during ERCP, a stone attached to the bile duct via a surgical suture was swept out. Exploration of this patient’s biliary tree with cholangioscopy showed surgical sutures at the cystic duct stump. These were removed with a large-capacity cholangioscopy biopsy forceps under direct visualization. The intraductal sutures are believed to form a nidus for stone reformation that needs to be considered and addressed.

In clinical practice, we encounter a subset of patients with previous biliary surgeries who present with recurrent choledocholithiasis and sometimes cholangitis despite complete stone clearance on ERCP. Exploring the biliary tree via cholangioscopy to ensure duct clearance and to exclude an underlying nidus for these stones to form again is an important step to break the cycle. The nidus in our case was remnant cholecystectomy sutures that were successfully removed using a large-capacity cholangioscopy biopsy forceps.

In patients with previous biliary surgery and recurrent choledocholithiasis, balloon sweep of stones during repeat ERCP might not be enough. Cholangioscopy helps reveal intraductal sutures as an etiology, and these should be removed.

I recently encountered a similar scenario and, based on that experience, performed a cholangioscopy upon follow-up ERCP. Despite not finding a nidus for the recurrent stones and cholangitis, clearing the duct and ruling out a modifiable cause were warranted for completeness and felt to be a step not to be skipped for adequate management.

Large stone attached by a suture to the bile duct seen on balloon sweep during ERCP.

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