Clip migration into the common bile duct (CBD) is a rare but well-established phenomenon of laparoscopic biliary surgery. The mechanism and exact incidence of clip migration are both poorly understood. Clip migration into the common bile duct can cause recurrent cholangitis and serve as a nidus for stone formation. We present a case, a 54-year-old woman, of clip-induced cholangitis resulting from surgical clip migration 12 months after laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LC+LCBDE) with primary closure.
Laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LC+LCBDE) is currently a widely use technology for patients with gallstone and choledocholithiasis. Clip migration into the common bile duct (CBD) is a rare complication of laparoscopic biliary surgery. Surgical clip migration into the common bile duct can cause recurrent cholangitis and serve as a nidus for stone formation. Up to date, few cases of surgical clip migration have been reported in the literature. The etiology and exact incidence of clip migration are both unclear. We report a case of Hem-o-lok clips migration 1 year after laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LC+LCBDE) with primary closure. The patient was successfully treated with endoscopic sphincterotomy plus balloon dilation (ESBD) and Hem-o-lok clips extraction. The patient improved uneventfully following the procedure. We hope that this case draws laparoscopic surgeon’s attention to this rare phenomenon.
A 54-year-old woman had undergone a successful LC+LCBDE in our hospital on December, 2015. The operation had been performed without difficulty and we had used 2 Hem-o-lok for the duct/artery. Subsequently, primary closure of the incision of CBD was performed with an interrupted 5-0 absorbable suture. A bile leakage was detected on postoperative day 2 and spontaneously resolved after 18 days of conservative treatment. The patient was discharged uneventfully on postoperative day 20.
On January, 2017, this patient was readmitted for intermittent upper abdominal pain for a month without fever and jaundice. Physical examination revealed tenderness in the right upper quadrant of her abdomen. Laboratory examination showed no abnormal parameters. Abdominal US revealed a mildly dilated biliary tree with no visualized CBD stone. Magnetic resonance cholangiopancreatography (MRCP) showed a slightly dilated common bile duct with a low signal filling-defect in the distal common bile duct, considering CBD stone (Figure
Magnetic resonance cholangiopancreatography (MRCP) showed a slightly dilated common bile duct with a low signal filling-defect in the distal common bile duct, considering CBD stone, with the filling-defect being represented by a red arrow.
Endoscopic retrograde cholangiopancreatography demonstrates the filling-defect in the common bile duct.
The extracted Hem-o-lok clip within the duodenal lumen.
Advances in laparoscopy have made LC+LCBDE a widely accepted strategy for patients with gallstones and choledocholithiasis. The single-stage surgical strategy has been shown to be safe, effective, and cost-effective with shorter hospital stays [
Postoperative clip migration is a rare but well-established complication. Migration into the common bile duct after laparoscopic cholecystectomy was first reported in 1992 [
However, the exact mechanism of this condition remains controversial. Multifactor may contribute to the process: the first possible pathogenesis is inappropriate application of clips including incomplete closure of cyst duct and incorrect placement of clips that result in biloma. The number of endoclips used during the initial operation is also an important factor [
To prevent the incidence of clip migration, all the technical factors in the surgery should be considered: confirming the relationship of Calot’s triangle during dissection, minimizing the number of clips, and avoiding unnecessary surgical procedures [
Clinical manifestations of clip migration-induced cholangitis are similar to those of noniatrogenic ones, usually present with abdominal pain, fever, and obstructive jaundice. In our case, pure abdominal pain made us consider the postcholecystectomy syndrome at first. Thus, it emphasizes the importance of early recognition of this complication when patients present with upper abdominal pain or symptoms of biliary obstruction after LC. The diagnosis is suspected on the basis of noninvasive imaging. Ultrasonography is cheap, widely available, and safe and is recommended for patients with suspected foreign body. CT scan is widely used to investigate patients with pain or other abdominal symptoms. MRCP provides clear anatomy of biliary tree with a high sensitivity and specificity.
ERCP is a superior approach to manage the complication with a high success rate of about 85% [
In conclusion, postoperative clip migration has been a well-recognized phenomenon ever since their first use in surgery, albeit rare. Patients who had LC and LCBDE should have a careful surveillance and strict follow-up to ensure the safety. The first investigation might be MRCP and then ERCP for subsequent management.
The study was reviewed and approved by the Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University Institutional Review Board.
The authors declare that there are no conflicts of interest regarding the publication of this article.
This paper is supported by Incubating Program for Clinical Research and Innovation of Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University (Grant no. PYZY16-011).