Surgical clip migration

following laparoscopic
cholecystectomy as a cause
of cholangitis
Evangelos S. Photi , Gemma Partridge,
Michael Rhodes, Michael P.N. Lewis

Journal of Surgical Case Reports, Volume 2014,

Issue 4, April 2014, rju026,
https://doi.org/10.1093/jscr/rju026
Published: 17 April 2014 Article history

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Abstract
Gallstone disease is a common surgical
presentation, and laparoscopic
cholecystectomy is the favoured method
of surgical management. Ligation of the
cystic duct is usually performed with
surgical clips, which have the potential to
migrate into the common bile duct with
time. This paper describes a case of
cholangitis secondary to clip migration in
a 42-year-old male patient 9 years after
the initial laparoscopic cholecystectomy.
Magnetic resonance
cholangiopancreaography imaging
revealed a surgical clip lodged in dilated
common bile duct. The patient was
managed successfully by endoscopic
retrograde cholangiopancreatography.

Topic: nuclear magnetic resonance,

cholangitis, bile duct common dilatation,
endoscopic retrograde cholangiopancre-
atography, common bile duct, cystic duct,
ligation, surgical procedures, operative, di-
agnostic imaging, laparoscopic cholecystec-
tomy, cholelithiasis, surgical clips
Subject: Upper GI Surgery
Issue Section: Case reports

INTRODUCTION

Gallstone disease is a common presentation in

secondary care, and laparoscopic
cholecystectomy is the most commonly used
procedure for this condition with >60 000
procedures being carried out per year in the
NHS.

Surgical clip migration following

cholecystectomy is a rare but well-documented
complication. The timeframe between the
initial cholecystectomy and development of
complications can be variable with case reports
describing migration after as much as 14 years
[1].

In most reported cases, the migrated surgical

clip acts as a nidus for choledocholithiasis and
subsequent biliary obstruction [2]. The exact
pathophysiological process by which this
occurs is not clearly understood but is thought
to involve involution of the cystic duct with the
attached clip into the lumen of the common bile
duct as a consequence of compression by local
structures, such as the liver [3]. Complete
inversion and necrosis of the involuted duct
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leaves the surgical clips free within the
lumen
PDFofSplit
the common
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subsequent complication such as obstructive
jaundice, cholangitis, biliary colic or
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pancreatitis [4]. Most cases are treated
successfully by endoscopic retrograde
cholangiopancreatography (ERCP). This case
report describes a patient who developed
cholangitis secondary to surgical clip migration
9 years after the initial laparoscopic
cholecystectomy.

CASE REPORT

A 42-year-old male with a history of cerebral

palsy, learning difficulties and epilepsy was
admitted with a 24-h history of nausea,
vomiting and abdominal pain. Past surgical
history included laparoscopic cholecystectomy
with operative cholangiogram 9 years
previously and laparotomy and drainage of a
pancreatic pseudocyst 16 years previously.

Examination revealed a midline laparotomy

scar and a distended, tender abdomen.

Laboratory tests revealed elevated liver

function tests: ALP 285 U/l, ALT 465 U/l, GGT
669 U/l with a normal bilirubin. Magnetic
resonance cholangiopancreatography
demonstrated marked dilatation of the
common bile duct to 15 mm (Fig. 1). A surgical
clip was noted in the distal common bile duct,
presumed to have migrated from the cystic
duct, which it had been used to close 9 years
previously.

Figure 1:

Open in new tab Download slide

A coronal view of magnetic resonance

cholangiopancreatography showing the presence of a
surgical clip and common bile duct dilatation.

The patient had an ERCP and sphincterotomy

during which the clip was removed leading to
complete resolution of symptoms and return of
biochemical markers to normal.

DISCUSSION

Although a rare complication of laparoscopic

cholecystectomy, surgical clip migration is a
well-documented event with several case
reports published.

The mechanism by which surgical clip

migration takes place is unclear but is thought
to be partly affected by technical factors such as
correct placement and use of minimal numbers
of clips [5].

A proposed mechanism of clip migration by

Kitamura et al. [3] initially involves the
compression of the clipped cystic duct by the
liver. The cystic duct and clips then become
inverted into the lumen of the common bile
duct. Over time, this structure becomes
necrotic, and the clips fall away into the
common bile duct where they can then act as a
nidus for gallstone formation.

The time scale for this pathophysiological

process can vary. Indeed, the time period
between cholecystectomy and development of
complications has been reported by Chong et al.
[4] to be anything from 11 days to 20 years with
a median of 26 months. The most common
diagnoses at presentation are obstructive
jaundice (37.7%), cholangitis (27.5%), biliary
colic (18.8%) and acute pancreatitis (8.7%) [4].
The majority of cases are treated successfully
with ERCP (77%) or surgery (20.2%) [4].

REFERENCES

1 Brandt LJ. Surgical clip migration and stone

formation in a gallbladder remnant after
laparoscopic cholecystectomy, Gastrointes
Endosc , 2009, vol. 70 pg. 781
Google Scholar Crossref

2 Attwell A, Hawes R. Surgical clip migration and

choledocholithiasis: a late, abrupt
complication of laparoscopic
cholecystectomy, Dig Dis
Sci , 2007, vol. 52 (pg. 2254-6)
Google Scholar Crossref PubMed

3 Kitamura K, Yamaguchi T, Nakatani H,

Ichikawa D, Shimotsuma M, Yamane T, et
al. Why do cystic duct clips migrate into the
common bile
duct?, Lancet , 1995, vol. 346 (pg. 965-6)
Google Scholar Crossref PubMed

4 Chong VH, Chong CF. Biliary complications

secondary to post-cholecystectomy clip
migration: a review of 69 cases, J Gastrointest
Surg , 2010, vol. 14 (pg. 688-96)
Google Scholar Crossref PubMed

5 Cetta F, Baldi C, Lombardo F, Monti L, Stefani

P, Nuzzo G. Migration of metallic clips used
during laparoscopic cholecystectomy and
formation of gallstones around them: surgical
implications from a prospective study, J
Laparoendosc Adv , 1997, vol. 7 (pg. 37-46)
Google Scholar Crossref

Published by Oxford University Press and JSCR

Publishing Ltd. All rights reserved. © The Author 2014.

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