Surgical Clip Migration Leading to Obstructive Choledocholithiasis

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Choledocolithiasis is a known complication related to gallstone disease, but rarely occurs after cholecystectomy. Recurrent choledocolithiasis can occur anywhere from one to thirty years after a cholecystectomy. Few case reports have documented a surgical clip as a potenital nidus formation for choledocolithiasis with a proposed mechanism of involution of the cystic duct leading to necrosis and migration of the surgical clip into the common bile duct following a cholecystectomy. This case demonstrates a surgical clip that is found inside a choledocolith years after a cholecystectomy. A 56-year-old female with history of cholecystectomy two years ago presented with chest pain and found to have significantly elevated liver enzymes (total bilirubin 2.9 mg/dl, AST 1126 u/L, ALT 1998 u/L). Cardiac workup was unremarkable. A chest CTA in the ER did not find any pulmonary embolism but found a linear metallic structure in the distal common bile duct (CBD). Next, an ultrasound (US) was performed which reported the CBD at 10 mm and no evidence of dilated intrahepatic ducts. There was no mention of a choledocolith on both the CTA and US reports. On physical exam, the patient was tender in the epigastric region. It was decided to proceed with an endoscopic retrograde pancreatography (ERCP) for further evaluation. During the procedure, a metallic object was noted on fluoroscopy and appeared to be located in the center of a mobile choledocolith. Additional stationary metallic objects consistent with surgical clips were seen related to the past cholecystectomy. A sphincterotomy and multiple balloon sweeps were performed with successful extraction of biliary sludge and a large choledocolith. The choledocolith was retrieved and found to have a surgical clip in the center. Following the ERCP, the patient's symptoms and liver enzymes improved. The patient was seen in the clinic at follow up with complete normalization of her liver enzymes and was asymptomatic. This case demonstrates a rare complication that can occur years after a cholecystectomy related to surgical clip migration into the common bile duct which then serves as a nidus for choledocolith formation. Therefore, it is important to understand the mechanism of how a surgical clip is able to migrate into the common bile duct so that late presentations of stone formation can be more proactively identified and addressed or even prevented in the future.1340_A.tif Figure 1: Linear metallic object in the distal common bile duct1340_B.tif Figure 2: Mobile choledocolith with centrally located linear dense object1340_C.tif Figure 3: Extracted choledocolith with surgical clip