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.

INTRODUCTION

During laparoscopic cholecystectomy, surgical clips are used to close the cystic duct and cystic artery as an alternative to suturing. Closure is intended to facilitate healing and prevent bile drainage. Although surgical clips are considered overall a fairly safe option for closure, complications related to surgical clip migration can occur.[1] Migration of the clip into the common bile duct and subsequent stone formation around the clip may lead to obstruction, and patients may present with symptoms such as pain, jaundice and fever.[2] Clip stones are visualised with common radiographic methods such as X-ray or computed tomography (CT) scan. Treatment of the clip stones is by endoscopic retrograde cholangiopancreatography (ERCP) with the removal of the stone by balloon or basket extraction or by open choledochotomy with stone extraction.[3]

Clip-induced stone formation may begin with the clip eroding through the common or cystic bile duct wall and into the lumen of the common bile duct. Inflammation in the area surrounding the clip due to the clip itself or due to bile leakage may contribute to the erosive process.[4] Movement or migration of the clip may depend on the number of clips placed, the length of the cystic duct or artery, necrosis or incorrect placement.[1] Another possibility includes pressure from surrounding organs and normal body movement. It is also a possibility that pressure from surrounding organs and normal body movement may push the clip through the bile duct wall. In addition, if there is a stone starting to form around the partially migrated clip, there could be an associated pull force.

CASE REPORT

A 55-year-old woman, who had undergone cholecystectomy for acute calculous cholecystitis 11 years prior, presented with right upper quadrant abdominal pain, nausea and chills. The patient was afebrile and without jaundice. Laboratory data were notable for normal white blood cell count (6.1 × 10³/uL) with elevated bilirubin (1.8 mg/dl), aspartate aminotransferase (239 U/L), alanine aminotransferase (213 U/L) and alkaline phosphatase (242 U/L). Amylase and lipase were normal. Abdominal CT revealed an 8-mm calcification in the region of the distal common bile duct concerning for stone versus a displaced surgical clip, and the number of surgical clips in the right upper quadrant was noted to have decreased from four to three surgical clips. Magnetic resonance cholangiopancreatography showed a filling defect in the distal common bile duct concerning for a stone versus a clip. At ERCP, a 10-mm ovoid yellowish-greenish stone impacted at the distal common bile duct with an embedded 6-mm surgical clip [Figures 1-3] was removed. The distal common bile duct was observed to have a saccular dilation, with a transverse diameter of 12 mm concerning for the pressure effect created by the impacted stone. After the stone removal, the patient had an improvement of liver function laboratory and had an otherwise uneventful recovery.

Figure 1.

(a) Normal endoscopic retrograde cholangiopancreatography (ERCP) 2 months prior, (b) Distal common bile duct with embedded clip (‘cat’s eye calculi’) on ERCP

Figure 3.

(a) Common bile duct stone with an embedded cholecystectomy clip, (b) Fragmented stone with clip (arrow) displayed

Figure 2.

Endoscopic retrograde cholangiography post-sphincterotomy with stone seen at the orifice

DISCUSSION

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. The first case of a clip-induced stone as a complication from open cholecystectomy was reported in 1979[1] and in Ongehena et al., 1992[5] for laparoscopic cholecystectomy. Since then, there are relatively few reports in the literature describing clip-induced stone formation despite the increasing number of laparoscopic cholecystectomies performed. Almost all mentions of clip-induced stone formation are reported as a case report, with five major reviews of the literature, most recently in 2020.[1,2,3,4,6] Publications with case reports are listed in Table 1.

Table 1.

Published case reports

Author	Study type	n (cases)	Age (years), gender	Symptoms	Surgery	Surgery - symptoms of clip-induced stone
Walker et al., 1979[7]	Case	1	63, female	Upper abdominal pain, chills, fever and postprandial colicky epigastric pain with occasional nausea and vomiting	Cholecystectomy	2 years
Brutvan et al., 1982[8]	Case	1	84, female	Repeated attacks of epigastric pain over a period of 6 weeks	Cholecystectomy	3 years
Margolis, 1986[9]	Case	1	72, male	RUQ pain	CBDE	1 year
Davis et al., 1988[10]	Case	1	49, male	Obstructive jaundice	Cholecystectomy	3 years
Farr et al., 1989[11]	Case	1	36, female	Pancreatitis; abdominal pain, fever, abnormal laboratories	Cholecystectomy	5 years
Janson and Cotton, 1990[12]	Case	1	48, female	Nausea, excruciating abdominal pain, fever and mild jaundice	Cholecystectomy	9 years
Onghena et al., 1992[5]	Case	1	59, female	RUQ pain	LC	11 weeks
Dhalla and Duncan, 1992[13]	Case	1	70, male	Jaundice, decreased appetite, pruritus, change in stool and urine colour	Cholecystectomy	4 years
Ghazanfari et al., 1992[14]	Case	1	42, male	Jaundice, colicky pain	Cholecystectomy	4 years
Raoul et al., 1992[15]	Case	4	(1) 34, female (2) 65, female (3) 51, female (4) 47, female	(1) Intense abdominal pain, fever and jaundice (2) Severe abdominal pain and nausea (3) Abdominal pain without fever or jaundice (4) Abdominal pain, jaundice and fever	(1) LC (2) LC (3) LC (4) LC	(1) 10 months (2) 6 months (3) 5 months (4) 8 months
Mansvelt et al., 1993[16]	Case	1	88, male	Abdominal pain, jaundice, mild fever and cholestasis	OC	4 years
Wu et al., 1993[17]	Case	1	79, male	Abdominal pain, jaundice, dark urine, acholic stools	Cholecystectomy	4 years
Youssef et al., 1994[18]	Case	1	62, male	Jaundice, dark urine, fever	Cholecystectomy	4 years
Khawaja, 1995[3]	Case + literature review	1	57, male	RUQ pain, fever, shaking chills	Cholecystectomy	10 years
Martinez et al., 1995[19]	Cases	2	(1) 86, female (2) 68, male	(1) RUQ pain (2) Abdominal/back pain	(1) OC (2) OC	(1) 3 years (2) 1 year
Rizzo et al., 1995[20]	Case	1	74, female	Abdominal pain	LC	1 year
Shibata et al., 1996[21]	Case	1	69, male	Obstructive jaundice	LC	(1) 2 years
Bradfield and Granke, 1997[22]	Case	1	58, female	4 months of postprandial epigastric pain that was dull and radiated to back, with nausea and vomiting, but no chills. Significant weight loss with decreased oral intake secondary to the pain and nausea	Cholecystectomy	7 years
Herline et al., 1998[23]	Case	1	78, female	Several months of colicky abdominal pain worsened by meals and a 1-month history of jaundice, anorexia, nausea and vomiting	Cholecystectomy	16 years
Alberts et al., 1999[24]	Case	1	52, male	Vague abdominal pain, primarily RUQ	LC+LCBDE	2 years
Ng et al., 1999[25]	Case	1	64, female	Epigastric pain	LC	6.5 years
Ammann et al., 2000[26]	Case	1	32, female	Dyspnoea	OC	1.5 years
Mansoa et al., 2000[27]	Case	1	40, female	Upper right quadrant pain, jaundice and fever	LC	3 years
Matsumoto et al., 2000[28]	Case	1	71, female	Abdominal pain, high fever and jaundice	LC	1 year
Yoshizumi et al., 2000[29]	Case	1	63, male	Severe upper abdominal pain	LC	1 year
Petersen, 2002[30]	Case	1	79, female	Right upper quadrant pain, nausea and vomiting, anorexia and shaking chills. Light-coloured stool and dark urine	OC	14 years
Tsumura et al., 2002[31]	Case	1	57, male	Vomiting and pain in the right hypochondrium, admitted for investigations of jaundice and liver dysfunction	LC	5 years
Dell’Abate et al., 2003[32]	Case	1	67, female	Jaundice associated with abdominal pain. No fever, nausea or vomiting	LC	1 year
Hai et al., 2003[33]	Case	1	57, male	Pruritus and jaundice	LC	6 years
Chong et al., 2004[34]	Cases	2	(1) 58, male (2) 54, female	(1) Cholangitis leading to septic shock (2) 1-week history of loss of appetite and some loss of weight	(1) LC (2) LC	(1) 4 years (2) 3 years
Ahn et al., 2005[35]	Case	1	56, female	Right upper abdominal pain and jaundice	LC	1 year
Khanna and Vij, 2005[36]	Case	1	Middle-aged female	Jaundice	LC	5 years
Mouzas et al., 2005[37]	Case	1	31, female	Acute abdomen and chyloperitoneum	LC	6 years
Attwell and Hawes, 2007[38]	Case	1	57, male	Biliary stricture and subsequent colicky abdominal pain and nausea	LC	6 years
Dolay et al., 2007[39]	Case	1	56, female	Severe upper abdominal pain radiating to the back with vomiting. No fever, icteric sclera and tenderness in the upper right quadrant	LC	0.5 year
Steffen et al., 2007[40]	Case	1	83, female	Fever, abdominal pain and jaundice	Cholecystectomy	15 years
Goshi et al., 2009[41]	Case	1	68, male	RUQ tenderness	LC	6 years
Kager and Ponsioen, 2009[42]	Case	1	65, female	Colicky RUQ pain without fever or jaundice. Elevated liver enzymes	LC	5 years
Rajendra et al., 2009[43]	Case	1	41, female	RUQ colic pain	LC	14 years
McMahon et al., 2010[44]	Case	1	32, female	Mid-common bile duct calculus	LC	8 years
Munoz et al., 2010[45]	Case	1	57, female	Abdominal pain	Cholecystectomy	30 years
Gonzalez et al., 2011[46]	Case	1	78, female	Severe right upper quadrant pain with vomiting. No fever, the sclera was icteric and tenderness on RUQ and epigastric area	LC	14 years
Prichard and Mahmud, 2011[47]	Case	1	82, male	Colicky upper abdominal pain, anorexia, vomiting and jaundice	Cholecystectomy	4 years
Ray and Bhattacharya, 2013[48]	Case	1	62, male	Recurrent abdominal pain, intermittent jaundice for 6 months	LC	6 years
Ghavidel, 2015[1]	Case + literature review	1	44, female	48 h of intense abdominal pain, fever and jaundice	LC	2 months
Qu et al., 2017[49]	Case	1	54, female	Intermittent upper abdominal pain for a month without fever and jaundice	LC+LCBDE	1 year
Schreuder et al., 2018[50]	Case series	4	(1) 66, female (2) 63, male (3) 50, male (4) 48, female	(1) Upper abdominal pain and subfebrile temperature (2) Upper abdominal pain, jaundice, nausea and fever (3) Colic pains in the RUQ (4) Intermittent colic pains without jaundice, discoloured stools or fever	(1) LC (2) LC (3) LC (4) LC	(1) 6 years (2) 12 years (3) 17 years (4) 5 years
Hussameddin et al., 2018[51]	Case	1	70, male	RUQ pain, fever and chills for 1 week	LC	16 years
Roh et al., 2019[52]	Case	1	65, male	Upper abdominal pain and fever for 3 days	LC	13 months
Pang et al., 2019[6]	Cases + literature review	3	(1) 61, female (2) 72, female (3) 64, female	(1) Repeated episodes of jaundice and RUQ pain (2) Not specified (3) Fever, jaundice and pruritus	(1) LC (2) LCBDE (3) LCBDE	Not specified
Kim et al., 2019[53]	Case	1	74, female	Postprandial, non-radiating epigastric abdominal pain	Cholecystectomy	14 years
Hamid et al., 2020[4]	Case + literature review	1	82, male	2-day history of severe upper abdominal pain	LC	22 years
Liu et al., 2022[54]	Case	1	59, female	Fever and acute RUQ pain	LC+LCBDE	2 months
Wu et al., 2023[55]	Case series	4	(1) 72, female (2) 62, female (3) 88, male (4) 69, male	(1) + (2) were admitted due to epigastric pain (3) + (4) were admitted due to epigastric pain with chills and fever	LC+LCBDE (all)	(1) 2 (2) 48 months (3) 19 months (4) 17 months

OC: Open cholecystectomy, LC: Laparoscopic cholecystectomy, LCBDE: Laparoscopic common bile duct exploration, CBDE: Common bile duct exploration, RUQ: Right upper quadrant

RESULTS

A total of 68 unduplicated cases of clip-induced stones were included in this review, including our own. The mean age of patients was 61.5 (range: 31–88 years). The majority of patients were female 42 (62%). Symptoms related to clip-induced stone had a range of 2 months–30 years until onset. Procedures consisted of 36 (53%) laparoscopic cholecystectomies, 17 (25%) cholecystectomies, 7 (10%) laparoscopic cholecystectomy + laparoscopic common bile duct exploration (LCBDE), 5 (7%) open cholecystectomies, 2 (3%) LCBDE and 1 (1%) CBDE. The most common symptoms were related to obstruction including jaundice, pain, nausea, vomiting and fever. Most stones were primarily treated with ERCP or surgery.

CONCLUSION

Cholecystectomy clip migration can cause problems and can occur at any time post-cholecystectomy. In our patient, her symptoms occurred 11 years after her initial surgery and her presenting symptoms were similar to those reported in the literature. Our case adds to the body of literature related to clip-induced stone formation, and we have presented an up-to-date review of the literature. Prevention of clip-induced stone formation could include careful placement of clips, using a minimum number of clips, avoiding blind application of clips and consideration of absorbable clips. Due to the lack of research in this area, we suggest that future research focus on risk factors and prevention of cholecystectomy clip migration, as well as benefit of screening for early detection of clip migration and stone formation before patients become symptomatic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.