S1430 An Alternative Management of Iatrogenic Mirizzi Syndrome Induced by Post-Laparoscopic Cholecystectomy Surgical Clip Migration

Abstract

INTRODUCTION: The prevalence of laparoscopic cholecystectomy is growing. This method involves leaving surgical clips in the bed of the biliary tree. Patients can present with a variety of post-cholecystectomy syndromes that can occur within the first few days to years after surgery. This case will highlight a rare complication and approach to Mirizzi Syndrome and surgical clip migration that was managed outside the current recommended guidelines. CASE DESCRIPTION/METHODS: 58 year-old male s/p laparoscopic cholecystectomy one year prior, presented with abdominal pain. He reported sharp, colicky, non-radiating pain in the mid-epigastric region. Laboratory results showed a mildly elevated LFT, CBD stone, and negative MRCP and US. The patient was admitted for observation and reported spontaneous resolution of his abdominal pain. He returned to the hospital four days later with a similar presentation and now appeared jaundiced. Serum studies showed worsening LFT (AST 139, ALT 328, ALP 131, T. Bili 5.3) and lipase (14847). CT was consistent with acute pancreatitis without obstruction. An ERCP was contraindicated given presentation of pancreatitis. The next day, a CT was repeated, showing migration of a surgical clip into the CBD. Surgical extraction was delayed until the inflammatory process was controlled. On day 3, laboratory studies showed a normalizing LFT and lipase level. The patient demonstrated clinical improvement, interdisciplinary teams were in consensus to repeat a CT in 2 days, which confirmed the passing of the clip into the colon. DISCUSSION: This case is an extremely rare combination of two notably independent entities: Mirizzi Syndrome, a partial or total biliary obstruction of the bile duct caused by an extrinsic mechanical compression, and surgical clip migration. There are only 69 reported cases of biliary complications from surgical clip migration. The common presentation of those cases was jaundice, biliary colic, and rarely pancreatitis. Nearly 97% underwent an ERCP or surgical extraction, the data for whether an emergent need for ERCP or surgery remains unknown. It could be theorized that those interventions were simply used as it was a recognized standard of care. Despite this case having two of the most consequential complications, close observation and serial imaging demonstrated the ability to pass a clip without any complications or invasive interventions. This brings to question, if close observation with serial imaging can be used as an alternative to the current standard practices of ERCP and surgery.Figure 1.: CT scan post- laparoscopic cholecystectomy, surgical clips in place.Figure 2.: Clip migration noted in the common bile duct, presenting on day 2 of hospital admission.Figure 3.: Successful clip passage in to the lumen of the left colon, presenting on day 3 of hospital admission.