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Biliary Stricture Caused by a Fish Bone Masquerading as Anastomotic Recurrence from Distal Cholangiocarcinoma after Pancreaticoduodenectomy

A 62-year-old man was admitted to the hospital with recurrent cholangitis. Diagnosed with the distal cholangiocarcinoma three years ago, he underwent pancreaticoduodenectomy (PD) with R0 resection, and the pathological diagnosis was moderately differentiated adenocarcinoma of cholangiocarcinoma (pT1, according to the American Joint Committee on Cancer). After admission, ultrasonography (USG) showed an isoechoic mass at the hilar bile duct measuring 2.1 · 1.2 cm (shown in Fig. 1A). CT demonstrated a 1.2 · 1.4-cm-sized slightly higher density oval mass at the hepatic duct convergence and anastomotic stricture with a linear radiopaque structure traversing the center of the mass (shown in Fig. 1B). The physical examination showed no abnormality. Laboratory studies showed obviously abnormal liver function tests, whereas other laboratory studies such as WBC, carcinoembryonic antigen (CEA), and CA 19-9 were within normal limits (shown in Table 1). Considering the tumor history, recurrent cholangitis, laboratory results, and radiologic examination results, the biliary-enteric anastomotic stricture was diagnosed definitely and tumor recurrence was strongly suspected. Then the exploratory laparotomy was performed. Operators found no sign of neoplasm recurrence, but some hard objects were palpable in the biliary-enteric anastomotic stoma during the operation. It is amazing that there was a fish stone mixed with some biliary sludge stuck in the stoma (shown in Fig. 2A). Intraoperative choledochoscopy ensured nothing else in the bile duct, and surgical revision of the biliary-enteric anastomotic stricture was performed. AT-tube drainage was placed into the bile duct, and an abdominal drainage was placed in front of the anastomotic stoma. Without any postoperative complications, the abdominal drainage was removed on postoperative day 6, and the patient was discharged on postoperative day 15 with the T-tube. Six weeks later, he removed the T-tube after laboratory and imaging examinations showed normal