Multiple Surgical Clips Found in Duodenum after Balloon Dilation

Abstract

Purpose: Laparoscopic cholecystectomy with use of metallic surgical clips is a safe procedure with a less than 3% overall complication rate. We are reporting a rare case of migrated cholecystectomy clips into the duodenum associated with postbulbar stricture and ulcer. 68 year old female with history of cholecystectomy, metastatic colon cancer treated with right hemicolectomy, chemotherapy, and radiofrequency ablation of liver lesions. She was disease free for 5 years until a new right hepatic lobe lesion was discovered and treated with stereotactic radiation therapy with incomplete success. A year later, she presented with obstructive jaundice from malignant biliary stricture which was treated with a metal stent. Recently, she presented with acute cholangitis and gastric outlet obstruction. EGD showed an intrinsic postbulbar duodenal stricture requiring balloon dilation to 15 mm. There were no complications post dilation and cholangitis was treated with stenting. Progressive duodenal stricture lead to repeat endoscopic evaluation showing the postbulbar stricture and a deep ulcer with metallic clips seen at the ulcer base. Simultaneous fluoroscopic imaging confirmed that these were cystic duct clips eroding into the duodenum. This was also confirmed with CT scan. Many clip-associated complications, such as biliary leaks, clip migration into the common bile duct, and clip embolism have been reported. Migration of endo-surgical clips into the duodenum is a rare complication, previously reported in only five cases. In all the reported cases, an ulcer was present as in our case. Additionally, the ulcer was large and bleeding, and endoscopic or surgical treatment was required. Our case is the first report of migrated cholecystectomy clips into the duodenum to be associated with stricture and previous radiation. Proposed mechnisms: 1. the base of the cystic duct and artery lie immediately adjacent to the first part of the duodenum and through direct contact clips can erode in bowel wall; 2.) a pre-existing ulcer may have perforated and healed immediately, capturing the clips in the process; 3.) previous endoscopic stenting/radiation can lead ulcer formation. Though exact mechanism is unknown the associated deep ulceration and known complications of bleeding require careful management.Figure: Cholecystectomy clip in duodenum.