An 88-year-old woman with a history of open cholecystectomy for
symptomatic gallstones 12 years previously was admitted due to colicky right
upper quadrant pain and obstructive jaundice. Abdominal ultrasonography showed
extrahepatic bile duct dilatation (12 mm) and choledocholithiasis in the
distal common bile duct (CBD). At endoscopic retrograde
cholangiopancreatography (ERCP) before contrast injection, she was noted to
have a mobile, metal foreign body inside the distal CBD ([Fig. 1 a, b]), in addition to the
cholecystectomy clip that was seen at the cystic duct. Cholangiogram revealed
that this foreign body was located in the center of a 10-mm oval-shaped defect
that was suggestive of choledocholithiasis ([Fig. 1 c]).
Fig. 1 Radiographic images
during endoscopic retrograde cholangiopancreatography (ERCP). a, b Plain radiographs before contrast injection
showing a mobile, metallic foreign body (asterisks), in addition to the
cholecystectomy clip at the cystic duct. c Cholangiogram
showing the metal clip located in a 10-mm oval-shaped defect suggestive of
choledocholithiasis.
A sphincterotomy was performed, after which removal of a black
calculus was achieved with a retrieval balloon, and a subsequent repeat
cholangiogram was normal. On further examination, the calculus was found to
have a metallic protuberance ([Fig. 2]). A plain
radiograph of the calculus showed this to be the end of an embedded metal
surgical clip ([Fig. 3]).
Fig. 2 The extracted 10-mm
black calculus with a metallic protuberance at one end.
Fig. 3 Plain radiograph of the
calculus (right) showing the metallic clip situated within the
choledocholithiasis that it had induced.
The migration of a surgical cystic-duct clip into the CBD leading to
stone formation was first described in 1978 and to date 80 cases have been
reported [1]. Therefore, it remains a rarity in spite of
the increasing number of laparoscopic cholecystectomies that are performed
annually. Migration typically occurs at a median of 2 years
post-cholecystectomy, albeit it has been described as much as 30 years after
surgery [1]
[2]. The process of
migration is likely to be influenced by inaccurate surgical clip placement,
especially with short and/or wide cystic ducts [3], which
results in bile duct injury, suppurative inflammation, and erosion of the clip
through the bile duct into the lumen. Afterwards, the clip acts as the nidus
for further calculus formation.
ERCP with sphincterotomy is the treatment of choice, although
extraction using a balloon dilator and a rat-tooth forceps, in order to avoid
papillotomy complications, has been recently reported [2].
Endoscopy_UCTN_Code_CCL_1AZ_2AD
