2198 Not an Ordinary Cause of a Biliary Stricture: The Case of a Surgical Clip Migration After Open Cholecystectomy

Abstract

INTRODUCTION: Cholecystectomy is the mainstay treatment for gallstone disease. Post-operative complications include bile leaks, duct injury, abscess, and retained stones. Migration of surgical clips are a rare complication of cholecystectomy which is rarer in open cholecystectomy. Migrated clips may be asymptomatic to cholangitis. This case highlights a biliary stricture from a surgical clip after an open cholecystectomy that was endoscopically treated. CASE DESCRIPTION/METHODS: A 77-year-old Male presented with a 2-year h/o progressive abdominal fullness, lethargy and fatigue. He denied fevers, nausea, vomiting, or appetite changes. Initial work up found an elevated bili of 2.3 and an intrahepatic gallbladder (Figure 1). He was referred to surgery for concerns of gallbladder cancer and underwent a lap converted to open cholecystectomy with IOC. Pathology showed chronic cholecystitis with fibrosis and no malignancy. After two weeks he represented with worsening fatigue, low grade fevers, and dark urine. He had a leukocytosis, transaminitis, direct hyperbilirubinemia, and on imaging a hepatic abscess and intrahepatic biliary ductal distention. An ERCP demonstrated a dilatation of the upper third of the main bile duct with a single severe stenosis at the location of surgical clips on fluoroscopy. Spyglass cholangioscopy was performed and a clip with surrounding inflammation and stenosis was noted (Figure 2). The clip was removed with spybite forceps. A 10 F × 9 cm transpapillary plastic stent was placed through the left hepatic duct. The patient had downtrending LFTs and was discharged. Repeat ERCP at 6 weeks showed persistence of the stricture. The stricture was dilated and a 10 mm × 8 cm fully covered metal stent was placed. Repeat ERCP at 4 months showed resolution of the stricture with good biliary drainage (Figure 3). Patient continues to do well 2 months post procedure with improving LFTs. DISCUSSION: This is a case of a biliary stricture caused by a surgical clip post cholecystectomy that was managed endoscopically with clip removal and serial biliary ductal stenting. Intrabiliary foreign body is rarely described in the literature. Studies have described clip migration after cholecyestomy with the median time of presentation at 26 months. This patient presented at 14 days after cholecystectomy. One study found 70% of post-cholecystectomy clip migration was managed with ERCP. This patient had complete resolution of his biliary stricture after clip removal, balloon dilation, and stent placement.