An elderly patient with a history of laparoscopic cholecystectomy presented with recurrent abdominal pain. Imaging revealed a dilated common bile duct (CBD) with filling defects. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated multiple linear metallic clips with a halo of calculus material (figure 1). Attempts at removing the clips following a 10 mm sphincteroplasty resulted in horizontal impaction of clips beneath the trawling balloon (figure 2), increasing the risk of CBD injury. A plastic biliary stent was placed (figure 3) with a plan to repeat ERCP in 6 weeks with a larger sphincteroplasty and covered metal stent placement to facilitate passage of clips. However, at repeat ERCP, the clips had passed spontaneously and remaining stones were removed with balloon trawl (figure 4).
Figure 1.
Linear densities with a halo of calculus material in the common bile duct (arrows).
Figure 2.
Clip impacted in a horizontal position below the balloon (arrow).
Figure 3.
Numerous clips in the common bile duct with a plastic stent in situ at the end of the first endoscopic retrograde cholangiopancreatography.
Figure 4.
Clear common bile duct on occlusion cholangiogram at the final endoscopic retrograde cholangiopancreatography.
Surgical clip migration is rare and can occur any time after surgery, but median interval is 2 years.1 Common presentations included jaundice, cholangitis, biliary colic and acute pancreatitis. Technique-related factors, short cystic duct stump, ischaemic necrosis of the stump or infection can lead to migration.2 Application of minimum necessary clips away from cystic duct and CBD, or absorbable clips can reduce the incidence of migration. Success rate of ERCP in management is approximately 80%1 as demonstrated in this case.
Footnotes
Contributors: SK: involved in patient care in outpatient and inpatient setting, performed endoscopic retrograde cholangiopancreatography (ERCP); involved in writing the manuscript. TW: involved in patient care in outpatient and inpatient setting, performed ERCP, involved in writing the manuscript. PB: involved in patient care in outpatient and inpatient setting, performed ERCP, involved in writing and revising the manuscript.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; internally peer reviewed.
References
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