Endoscopic Removal of Postcholecystectomy Clip Eroding in the Common Bile Duct Causing Recurrent Choledocholithiasis and Acute Cholangitis : ACG Case Reports Journal

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Endoscopic Removal of Postcholecystectomy Clip Eroding in the Common Bile Duct Causing Recurrent Choledocholithiasis and Acute Cholangitis

Chaudhry, Hunza MD1; Sohal, Aalam MD1; Gulati, Alakh MD2; Chintanaboina, Jayakrishna MD2

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doi: 10.14309/crj.0000000000000875
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CASE REPORT

Postcholecystectomy clip migration (PCM) into the common bile duct (CBD) is a rare complication of laparoscopic cholecystectomy (LC) and can lead to recurrent choledocholithiasis and cholangitis. We present a case of a 29-year-old pregnant woman, at 32 weeks' gestation, who presented for right upper quadrant pain, fever, and jaundice. Surgical history included LC performed 5 years before. The liver panel revealed aspartate aminotransferase 87 U/L, alanine aminotransferase 94 U/L, alkaline phosphatase (ALP) 288 U/L, and total bilirubin 3.1 mg/dL. CBD dilation was noted on abdominal ultrasound. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a retained stone, removed by balloon extraction, followed by the placement of a plastic biliary stent. Complete clearance of the biliary tree was confirmed on fluoroscopy. Repeat ERCP postpartum revealed a CBD filling defect, with cholangioscopy confirming a large, retained CBD stone. Electrohydraulic lithotripsy was performed, and a cholecystectomy clip was noted within the stone. A biliary stent was placed, and the procedure was stopped. After multidisciplinary discussion with hepatobiliary surgeons, a plan was made to remove the clip endoscopically. After discussing the potential risks of perforation and bile leak, the patient agreed and ERCP was pursued. The clip was grasped with forceps and successfully removed with gentle traction. The final occlusion cholangiogram showed no contrast extravasation, and a plastic biliary stent was placed. The patient remains asymptomatic.

The sequence of events for PCM remains unclear, but a proposed mechanism includes stump necrosis, leading to clip migration toward a path of low resistance into the CBD.1 The clip can act as a nidus for stone formation and infection. Although rare, PCM should be considered in the differential diagnosis of cholangitis in patients with a history of LC. Endoscopists should be aware of this complication, and detailed fluoroscopic examination, direct visualization by cholangioscopy, and endoscopic removal of the clip can be considered based on local expertise (Video 1; watch the video at https://links.lww.com/ACGCR/A29).

DISCLOSURES

Author contributions: H. Chaudhry, A. Sohal, and A. Gulati reviewed the literature, drafted the manuscript, revised it for important intellectual content, and were involved in the final approval of the version to be published. A. Gulati and J. Chintanaboina revised the article for important intellectual content and were involved in the final approval of the version to be published. H. Chaudhry is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

REFERENCE

1. Chong VH, Yim HB, Lim CC. Clip-induced biliary stone. Singapore Med J. 2004;45(11):533–5.

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© 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.