Gastrointestinal hemorrhage consequent to foreign body reaction to silk sutures: case series and review

Surgery of the gastrointestinal tract often involves the use of sutures, particularly for luminal re-anastomosis. Nonabsorbable silk sutures or absorbable sutures may be used, depending on the surgeon’s preference. Nonabsorbable sutures, regardless of their original location, have a tendency to migrate toward the luminal surface1 and are often seen during routine endoscopy. However, complications attributed to nonabsorbable sutures used during surgery of the bowel are uncommon. Symptoms attributed to nonabsorbable sutures that have been remedied by endoscopic suture removal include pain, nausea, and vomiting.2 Suture line ulceration, first recognized as a distinct entity by Paterson in 1909,3 is the lesion reported to be responsible for these symptoms. Development of endoscopic technology allowed Small et al.1 in 1968 to estimate that 0.3% of 1008 postgastrectomy patients develop such lesions. A later European series suggested that 153 of more than 600 such patients had ulcerations, 38% being associated with sutures.4 Cotton et al.5 noted that of 20 patients with anastomotic ulcers, 7 had associated sutures. Silk and green Mersilene sutures, both continuous and interrupted, have been implicated in ulceration at gastric anastomoses.6 Histologically, the suture line ulceration has been characterized by a foreign body type reaction, with giant cell infiltration and fibrosis7 and dense capillary proliferation in some.8 Occult blood in the stool, and more uncommonly melena, have been noted in patients with suture line ulceration.1,3,9 Massive upper gastrointestinal hemorrhage related to suture line ulceration is apparently rare but has been reported.7 One patient developed bleeding 2 years after surgery10; another patient with end-stage renal disease had suture line ulceration documented by endoscopy.11 Tanner’s experience during World War II with bleeding associated with silk sutures used in gastric surgery prompted his strong recommendation against their use.12 Recognition of these complications of silk suture material may allow for timely removal either endoscopically or surgically as first reported by Classen and Roesch.13 We report three cases of recurrent upper gastrointestinal hemorrhage after partial gastrectomy related to the use of silk sutures that were not associated with endoscopically evident mucosal ulceration and review the literature concerning this complication as well as the tissue reaction to injury and foreign bodies resulting in rich local microvascularity.