A 54-year-old patient presented with a 3-week history of jaundice, pain, dark urine, pruritus, and weight loss. Relevant surgical history included open cholecystectomy and common bile duct (CBD) exploration (CBDE) for cholangitis 3 years ago at an outside hospital, with placement of a CBD T-tube that was removed 2 months postoperatively. The previous operation noted a very short and wide cystic duct, which was amputated at the CBD junction. On examination, the patient was jaundiced, with elevated bilirubin levels (202 μmol/L), raised liver function enzymes, and a C-reactive protein level of 34 mg/L. Computed Tomography scan showed multiple surgical clips in the gallbladder fossa with CBD measuring 16 mm. Magnetic Resonance Imaging showed three large CBD calculi with a linear hypointense structure in between the two largest (Figure 1). Endoscopic Retrograde Cholangiopancreatography revealed a metallic clip within a gallstone (Figures 2 and 3). This was successfully removed, and the patient was discharged with relief of symptoms and a declining serum bilirubin level. These images highlight a rare complication, “post-cholecystectomy clip migration” (PCCM), of which fewer than 100 cases have been described 1. Time from surgery to complication has ranged from 2 weeks to 35 years 2. While the exact pathophysiology of clip involution into the common bile duct is unclear, suggested theories include local pressure, inflammation, incorrect clip placement, and bile duct leakage or injury 3. Specifically, in patients who have undergone CBDE, collapse of surrounding tissues following T-tube removal may push clips into the CBD. This risk is likely increased if clips are placed too close to where the T-tube enters the bile duct 4. The consequence of clip migration into the CBD is stone formation around a foreign body 5. Modifiable operative factors that may reduce clip migration include placing fewer clips on the cystic duct and avoiding placement of clips too close to the CBD repair following CBDE with or without T tube placement 3, 4. These factors may have contributed to the development of PCCM in the above patient 6. Alternatives to metallic clips for controlling the cystic duct include non-absorbable polymer clips, such as Hem-o-loks (Teleflex Inc., NC, USA). They offer improved security for wider cystic ducts and may be less prone to dislodgement and subsequent bile leakage secondary to their distinct locking mechanism 7. Polymer clips may offer a lower risk of PCCM, but this is yet to be proven, and PCCM has also been documented following use of polymer clips 8. While rare, given growing rates of acute cholecystectomies in New Zealand 9, PCCM incidence may increase. While the exact aetiology is uncertain, the above patient serves as a reminder to surgeons of the risks of PCCM. Possible strategies to avoid PCCM include precise placement of 1–2 clips away from the CBD. Use of polymer rather than metallic clips may also reduce PCCM. Verbal consent was obtained and documented for use of the patient's images for the purposes of this submission. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Henderson et al. (Thu,) studied this question.