Choledocholithiasis caused by migration of a surgical clip into the biliary tract following laparoscopic cholecystectomy

Cholecystectomy clip-induced biliary stone: Case report and literature review

ABSTRACT

Migration of cholecystectomy surgical clip into the common bile duct with subsequent stone formation is a rare phenomenon, one which may lead to complications including obstruction, pain, nausea, vomiting and fever. The mechanism of migration is largely unknown but may result from a combination of factors including necrosis, intra-abdominal pressure or poor surgical technique with migrated clip serving as a nidus for stone formation. We present a 55-year-old woman with clip-induced stone impacted at the distal common bile duct 12 years post-cholecystectomy and a review of the literature related to cholecystectomy clip stone formation. In addition, we reviewed relevant English language case reports and literature reviews by searching PubMed using search terms 'stone', 'clip', 'cholecystectomy' and 'biliary'. There was no limit to the date of publication. Our study found 68 unduplicated cases of clip-induced stones which had a wide range of onset and presenting systems. Further research is needed to identify risk factors, methods of prevention and benefits of early detection screening.

Clip as Nidus for Choledocholithiasis after Cholecystectomy-Literature Review

Background and Objectives

Foreign material in the biliary tree may serve as a nidus for stone formation and would usually present as choledocholithiasis with jaundice or cholangitis. Overall it is a rare occurrence, but there are many anecdotal reports of ingested matter or surgical material such as suture or clips causing biliary stones. Especially interesting are the cases in which there is migration of a metallic clip used in laparoscopic cholecystectomy. Cholecystectomy is such a common operation that although the phenomenon is rare, it is important because it is preventable, and as such a review of the topic seems worthwhile.

Methods

The available literature was searched using the EMBASE and Ovid databases and reviewed. The various devices and sutures used to occlude the cystic duct in laparoscopic cholecystectomy are discussed with reference to their safety.

Results and Conclusion

We found that the harmonic scalpel is a reasonable alternative with minimal complications but is however limited by cost. Electrosurgical vessel-sealing, ultrasonic shears, absorbable sutures such as endoloops (PDS), and polymer clips as well absorbable magnesium-calcium-zinc alloy clip are discussed.

Clip-stone and T clip-sinus: A clinical analysis of six cases on migration of clips and literature review from 1997 to 2017

Introduction:

With the development of laparoscopic skills, the laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) has become the standard surgical procedure for choledocholithiasis. We usually use Hem-o-lok clips to control cystic duct and vessels, which is safe on most occasions and has few perioperative complications such as major bleeding, wound infection, bile leakage, and biliary and bowel injury. However, a rare complication of post-cholecystectomy clip migration (PCCM) increases year by year due to the advancement and development of LC, CBD exploration as well as the wide use of surgical ligation clips.

Materials and Methods:

Six patients whose clips are found dropping into CBD or forming T-tube sinus after laparoscopic surgery in our department.

Results:

Six patients whose clips are found dropping into CBD (clip-stone) (3/6) or forming T-tube sinus (T clip-sinus) (3/6) after LCBDE or LC.

Conclusions:

PCCM is a rare but severe complication of LCBDE. A pre-operative understanding of bile duct anatomy, the use of the minimum number of clips and the harmonic scalpel during the surgeries is necessary. Considering clip-stone or clip-sinus in the differential diagnosis of patients with biliary colics or cholangitis after LCBDE even years after surgery, the detailed medical history and pre-operative examination are inevitable, especially for these patients who had undergone LCBDE.

Post-laparoscopic cholecystectomy Mirizzi syndrome induced by polymeric surgical clips: a case report and review of the literature

BACKGROUND

Laparoscopic cholecystectomy is the gold standard treatment of gallbladder disease. Post-cholecystectomy syndrome is a severe postoperative complication which can be caused by multiple mechanisms and can present with multiple disorders. The wide use of laparoscopy induces the need to understand more clearly the presentation and pathophysiology of this syndrome. Post-cholecystectomy Mirizzi syndrome is one form of this syndrome and, according to literature, this is the first report that clearly describes it.

CASE PRESENTATION

We describe the case of a 62-year-old Greek woman who underwent laparoscopic cholecystectomy because of gallstone disease. A few days after surgery, post-cholecystectomy syndrome gradually developed with mild bilirubin increase in association with epigastric pain, nausea, and vomiting. After performing ultrasound, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography, we conducted a second laparoscopic surgery to manage the obstruction, which was converted to open surgery because of the remaining inflammation from the post-endoscopic retrograde cholangiopancreatography acute pancreatitis. Four polymeric laparoscopic clips were removed because they were identified as the cause of her post-cholecystectomy syndrome. She had a quick recovery without further complications.

CONCLUSIONS

Postoperative Mirizzi syndrome induced by the migration of polymer laparoscopic clips is a rare (only one case referring to polymeric clips has been published in the literature) but a well-identified complication of laparoscopic cholecystectomy which can confuse the diagnostic and therapeutic field requiring simultaneous immediate management.

Biliary complications secondary to post-cholecystectomy clip migration: a review of 69 cases

INTRODUCTION

Post-cholecystectomy clip migration (PCCM) is rare and can lead to complications which include clip-related biliary stones. Most have been reported as case reports. This study reviews cases of clip migration reported in the literatures.

METHOD

Searches and reviews of the literatures from "PubMed," "EMBASE," and "Google Scholar" search engines using the keywords "clip migration" and "bile duct stones" were carried out. Eighty cases from 69 publications were identified but details for only 69 cases were available for the study.

RESULTS

The median age at presentations of PCCM was 60 years old (range, 31 to 88 years; female, 61.8%) and the median time from the initial cholecystectomy to clinical presentations was 26 months (range, 11 days to 20 years). Of primary surgeries, 23.2% was for complicated gallstones disease. The median number of clips placed during surgery was six (range, two to more than ten clips). Common diagnoses at presentations of PCCM were obstructive jaundice (37.7%), cholangitis (27.5%), biliary colic (18.8%), and acute pancreatitis (8.7%). The median number of migrated clip was one (range, one to six). Biliary dilatation and strictures were encountered in 74.1% and 28.6%, respectively. Of the 69 cases of PCCM-associated complications, 53 (77%) were successfully treated with endoscopic retrograde cholangiopancreatography (ERCP), 14 (20.2%) with surgery, and one (1.4%) with successful percutaneous transhepatic cholangiography treatment. One patient had spontaneous clearance of PCCM. There was no reported mortality related to PCCM.

CONCLUSION

PCCM can occur at any time but typically occur at a median of 2 years after cholecystectomy. Clinical presentations are similar to those with primary or secondary choledocholithiasis. Most can be managed successfully with ERCP.

Migrated endoclip and stone formation after cholecystectomy: A new danger of acute pancreatitis

Endoclip migration into the common bile duct following laparoscopic cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into the common bile duct can cause obstruction, serve as a nidus for stone formation, and cause cholangitis. We report a case of obstructive jaundice and acute biliary pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after LC. The patient underwent early endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and stone extraction.

Surgical clips: a nidus for foreign body reaction after hepatic resection

This case report describes a patient who underwent segment IV hepatic resection and 7 months later developed an abdominal wall abscess. This was a foreign body reaction to the surgical clips. The patient required an exploratory laparotomy with debridement and excision of the inflammatory mass in the anterior abdominal wall. Although occurrence is rare, foreign body reactions to surgical clips have been reported, especially as a complication of laparoscopic surgery.

Surgical Clips Found at the Hepatic Duct After Laparoscopic Cholecystectomy

Surgical clip migration and subsequent stone formation in the common bile duct is a rare but well-established complication after laparoscopic cholecystectomy. There are some suggestions about the mechanisms of the migration process, but the details are still unclear. We report here a case in which common bile duct stones were formed around surgical clips, and other clips were found to have penetrated into the common hepatic duct, which we believe were in the process of migration after laparoscopic cholecystectomy. The patient required a laparotomy to retrieve the bile duct stones due to the distal stricture, and another laparotomy was necessary to remove the penetrating clips, which were deeply embedded in the bile duct wall. Although a variety of endoscopic and percutaneous interventional procedures are available in this era of modern medical technology, it is sometimes impractical to apply these procedures in such cases as ours, and exploratory laparotomy is sometimes required to correctly treat the patient. This case shows that the metallic surgical clips can penetrate into the intact bile duct wall through serial maceration, and we believe that careful application of clips may be the only way to prevent their migration after laparoscopic cholecystectomy.