Duodenal Hem-o-Lok clip migration after laparoscopic cholecystectomy

Abstract

Introduction: Post-cholecystectomy clip migration (PCCM) is a rare late complication, with only 13 cases of clips found in duodenum, of whom 2 attributable to Hem-o-Lok. Methods: We present the case of a 77 years old male, admitted with a history of epigastric pain and vomiting over the previous 3 days. Medical history included a laparoscopic cholecystectomy performed for chronic cholecystitis three months earlier. A CT scan showed a suspect of a covered perforation of peptic ulcer close to a surgical clip, thus inducing mild abdominal symptoms but inflammatory high occlusion. After failure of conservative treatment (PPI), patient underwent an esophagogastroduodenoscopy that confirmed a duodenal ulcer with an outcropping hem-o-lok, thus a Roux-en-y gastro-jejune anastomosis (GJA) was performed, with regular post- operative course and discharge on POD 4. Results: Etiology of PCCM is an open issue. Three inconclusive and feeble randomized trials and few case reports ruled out the central role of different methods of cystic duct stump (CDS) closure. PCCM mainly based on the following points: anatomic proximity of the CDS to the duodenum, an underlying inflammatory course, and a pre-existing ulcer. The clinical onset is really variable, ranging between 3 days to 15 years. Conservative treatment (PPI and/or endoscopic removal) is effective in 80% of cases, while gastrectomy or GJA are rarely performed. Conclusions: The central issue is not the method of CDS closing but the proper way to do it (circumferential dissection of the duct). Use of Hem-o-Lok is justified by its efficacy despite the rarity of migration.