1263 Endoscopic Management of a Surgical Clip Found Within the Common Bile Duct Following Remotely Performed Laparoscopic Cholecystectomy

Abstract

INTRODUCTION: Minimally invasive surgery with surgical clip placement has become the gold standard for management of cholecystitis and biliary colic due to its favorable safety profile and low risk of complications. Though generally safe, surgical clips can serve as a source of complication years after cholecystectomy by migrating into the common bile duct and serving as a nidus for stone formation. To date, very few cases of this have been reported. While uncommon, this complication should be considered in the differential diagnosis for choledocholithiasis and cholangitis. CASE DESCRIPTION/METHODS: Here we present a 35-year-old female with a past medical history of invasive rectal adenocarcinoma who underwent laparoscopic cholecystectomy over ten years ago. She presented to the hospital with a two-week history of RUQ abdominal pain, chills, and nausea. Physical exam showed scleral icterus and RUQ abdominal tenderness. Labs showed elevated WBC count and LFTs in a cholestatic pattern. Patient was started on antibiotics for suspected cholangitis and underwent MRCP which suggested presence of metallic clip within the common bile duct. Subsequent ERCP revealed large stone impacted against the ampulla of Vater. Sphincterotomy and balloon sweep of the common bile duct were performed with extraction of large stone formed around surgical clip, followed by release of copious amount of purulent bile. Following procedure LFTs showed downward trend and symptoms resolved. DISCUSSION: Though the exact incidence and mechanism of surgical clip migration into the common bile duct is unknown, it is thought to be a slow process with the potential for subsequent stone formation years after surgery. Clinical presentation is the same as non-iatrogenic choledocholithiasis. In most reported cases, stone extraction required surgical intervention due to large size. Here we present a case successfully managed with sphincterotomy and balloon extraction over ten years after laparoscopic cholecystectomy. Though rare, the potential for surgical clip within the common bile duct serving as a nidus for stone formation should be considered in post-cholecystectomy patients presenting with symptoms of choledocholithiasis and cholangitis, regardless of how recently surgery was performed. Minimally invasive surgery and the use of surgical clips has become almost ubiquitous; thus clinicians should be aware of this possible complication and options for management.