Surgical Clip Migration into the Common Bile Duct Decades After Laparoscopic Cholecystectomy: A Rare Cause of Obstructive Jaundice

Brief Description

A 53-year-old woman with a remote history of laparoscopic cholecystectomy (LC) presented with nonspecific abdominal pain, jaundice, and cholestatic liver enzyme elevation nearly 30 years after surgery. A computed tomography (CT) scan showed a metallic density in the distal common bile duct (CBD), confirmed on magnetic resonance cholangiopancreatography (MRCP) to be a migrated surgical clip. She underwent endoscopic retrograde cholangiopancreatography (ERCP), which showed a migrated surgical clip embedded within a CBD stone. Successful endoscopic sphincterotomy and balloon extraction removed the clip–stone complex, with complete resolution of her symptoms and normalization of liver function tests.

Surgical clip migration into the CBD is a rare and delayed complication of LC. The migrated clip may act as a nidus for choledocholithiasis, leading to complications such as obstructive jaundice, acute cholangitis, or acute pancreatitis. Due to the nonspecific presentation and decades-long latency, a high index of suspicion and timely imaging are essential in postcholecystectomy patients presenting with biliary symptoms. CT or MRCP facilitates diagnosis, whereas ERCP remains the diagnostic and therapeutic modality of choice.

Practical Implications for Endoscopists

• Consider clip migration in post-LC patients presenting with biliary symptoms, regardless of how long ago the surgery occurred. Latency may exceed 30 years.

• CT or MRCP should be used early to detect metallic densities or filling defects within the CBD when biliary obstruction is suspected.

• ERCP remains the first-line therapeutic approach, with high success rates for clip–stone complex extraction via sphincterotomy and balloon techniques.

• Improper clip placement, cystic duct anatomical variants, bile leakage, and localized inflammation near the cystic duct stump can all promote clip migration. Precise surgical technique during LC is essential.

• Complications of clip migration include obstructive jaundice, choledocholithiasis, acute cholangitis, pancreatitis, and, rarely, fistula formation, Mirizzi syndrome, duodenal ulceration, or clip embolism ([Figs. 1] [2] [3] [4]).[1] [2] [3] [4] [5]

Fig. 1 Coronal abdominal CT image showing a hyperdense linear metabolic object (yellow arrow) in the distal CBD, consistent with a migrated surgical clip. CBD, common bile duct; CT, computed tomography.

Fig. 2 Axial abdominal CT image demonstrating the same surgical clip (yellow arrow) lodged within a biliary stone in the distal CBD. CBD, common bile duct; CT, computed tomography.

Fig. 3 Area of major papilla during ERCP, demonstrating a CBD stone with a centrally embedded migrated surgical clip. CBD, common bile duct; Endoscopic retrograde cholangiopancreatography.

Fig. 4 Extracted stone–clip complex following endoscopic removal.

• References

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