Migrated Surgical Clip as a Nidus for Choledocholithiasis 8 Years Postcholecystectomy

ABSTRACT

Surgical clip migration is a rare but important cause of delayed postcholecystectomy complications. An 83-year-old man presented 8 years after laparoscopic cholecystectomy with abdominal pain and jaundice. Imaging showed biliary dilation with a 20-mm common bile duct stone. Endoscopic retrograde cholangiopancreatography with cholangioscopy identified a migrated surgical clip serving as the nidus. Electrohydraulic lithotripsy achieved fragmentation, followed by balloon extraction and placement of a fully covered metal stent. The patient recovered uneventfully. This case highlights the need to consider clip migration in patients with late-onset biliary obstruction after cholecystectomy and supports cholangioscopy-guided lithotripsy as a definitive therapy.

INTRODUCTION

Laparoscopic cholecystectomy is a standard management strategy for symptomatic gallstones. Postcholecystectomy clip migration is a rare complication. Incidence ranges from 0.1% to 0.5%, typically occurs within the first 2 years after surgery, although delayed presentations have been reported decades later.^1,2 The migrated clip may act as a nidus for stone formation, resulting in recurrent choledocholithiasis that mimics primary stone disease.¹ Endoscopic therapy is generally first-line, with cholangioscopy-guided lithotripsy reserved for complex stones.³ Delayed clip migration may be underdiagnosed because its symptoms resemble primary choledocholithiasis, prompting initial evaluation toward more common biliary etiologies.

CASE REPORT

An 83-year-old man with a history of laparoscopic cholecystectomy 8 years ago presented with abdominal pain, nausea, vomiting, and jaundice. Laboratory workup included leukocytosis of 17,300/μL, lipase 238 U/L, alkaline phosphatase 172 U/L, total bilirubin 3.3 mg/dL, and direct bilirubin 2 mg/dL (Table 1). Imaging studies demonstrated intrahepatic and extrahepatic biliary ductal dilation with a large stone in the common bile duct. There were no features to suggest a mass lesion or biliary stricture on initial. The patient was hemodynamically stable without hypotension or altered mentation.

Table 1.

Summary of laboratory findings

Parameter	Result	Reference range
WBC	17,300 per μL	4,000–10,000 per μL
ALT, U/L	87	0–40
AST, U/L	36	0–40
Alkaline phosphatase, U/L	172	40–130
Total bilirubin, mg/dL	3.3	0.2–1.2
Direct bilirubin, mg/dL	2.0	<0.3
Lipase, U/L	238	0–160

ALT, alanine aminotransferase; AST, aspartate aminotransferase; WBC, white blood cell

An endoscopic retrograde cholangiopancreatography revealed a 20-mm stone encasing a migrated surgical clip on fluoroscopy (Figure 1) and further confirmed through cholangioscopy (Figure 2). Electrohydraulic lithotripsy was performed to fragment the stone, followed by balloon sweeps and placement of a temporary fully covered metal biliary stent (Figures 3 and 4). Symptoms resolved postprocedure. The stent was removed 4 weeks later.

Figure 1.

Fluoroscopy demonstrating a surgical clip within the bile duct associated with a filling defect.

Figure 2.

Cholangioscopy confirming a migrated surgical clip embedded within the stone.

Figure 3.

Retrieved clip after biliary stone removal.

Figure 4.

Fluoroscopy showing biliary stent placement after removal of stones and the surgical clip.

DISCUSSION

Surgical clip migration is an infrequent late complication of cholecystectomy and may occur years after surgery.¹ Proposed mechanisms include local inflammation with erosion of the clip through the cystic duct remnant and subsequent entry into the bile duct, where it serves as a nidus for stone formation.⁴ Reports document presentations ranging from months to several decades after surgery.⁵ Cross-sectional imaging or endoscopic retrograde cholangiopancreatography may reveal a radiopaque focus within an obstructing stone.^4,6 Direct cholangioscopy may be necessary for confirming the diagnosis and guiding therapy.

Endoscopic management is preferred for clip-associated stones.¹ Standard extraction may be difficult when a clip is embedded within a large or hard stone. Cholangioscopy-guided electrohydraulic or laser lithotripsy facilitates fragmentation and complete duct clearance in most cases, avoiding surgery.² Current guidelines and quality statements for difficult stones endorse adjunctive lithotripsy techniques when the stone is large or when standard methods fail.⁷ Evidence from prior series indicates that recurrence is uncommon once the migrated clip and stones are fully cleared.^1,4

Limitations: This is a single case without long-term outcome data.

Learning point: In patients with late-onset biliary obstruction following cholecystectomy, consider clip migration as a potential cause. Cholangioscopy enables definitive diagnosis and facilitates targeted lithotripsy for complex, clip-centered stones.

DISCLOSURES

Author contributions: A. Kaur and A. Subedi drafted the initial manuscript. HMA Khan supervised the case management and contributed to critical revisions. A. Chaar, A. Hussain, and B. Sapkota provided additional clinical input, revisions, and editorial feedback. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work. HMA Khan is the article guarantor.

Financial disclosure: None to report.

Previous presentation: This case has been accepted for poster presentation at the American College of Gastroenterology (ACG) Annual Meeting 2025, October 25–30, 2025.

Informed consent was obtained for this case report.