Laparoscopic cholecystectomy is now an established treatment for cholecystolithiasis or acute cholecystitis [1]
[2]
[3], but adverse events such as endoclip migration into the biliary tract may occur [4]. Usually, migrated endoclips can be removed by standard bile duct stone removal techniques. However, if endoclips have migrated into the intrahepatic bile duct, removal of the endoclip is sometimes challenging. In addition, bile duct injury may occur during removal [5]. Herein, we describe technical tips for the safe removal of a migrated endoclip under direct digital single-operator cholangioscopy guidance.
A 56-year-old man who had undergone cholecystectomy without any adverse events 1 month previously was found during a follow-up computed tomography (CT) scan to have a common bile duct stone. He was therefore admitted for removal of this stone. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted; however, it was observed that there had been endoclip migration into the intrahepatic bile duct ([Fig. 1 a]). Unsuccessful attempts were made to remove the endoclip using standard techniques, such as a balloon or a basket catheter, and he was therefore admitted to our hospital for removal of the migrated endoclip under direct visualization with cholangioscopy.
Fig. 1 Radiographic images showing: a a migrated endoclip in the left intrahepatic bile duct; b an intraductal cholangioscope (SPY-DS) inserted into the biliary tract (arrow in each image indicates the endoclip).
First, an intraductal cholangioscope (SPY-DS; Boston Scientific, Natick, Massachusetts, USA) was inserted into the common bile duct ([Fig. 1 b]) and the migrated endoclip was clearly observed ([Fig. 2 a]). This migrated clip was grasped by a SPY-Bite device ([Fig. 2 b]) and successfully removed into the duodenum without any adverse events ([Fig. 2 c]; [Video 1]). Following this, the SPY-Bite was exchanged for a large grasping forceps and the clip was extracted.
Fig. 2 Cholangioscopic images showing: a the endoclip within the left intrahepatic bile duct; b the endoclip being grasped by the SPY-Bite device; c the migrated endoclip being successfully removed into the duodenum.
Video 1 A migrated endoclip is identified in the left intrahepatic bile duct on intraductal cholangioscopy. The SPY-Bite device is used to grasp the endoclip and successfully remove it to the duodenum.
Our technique for removal of a migrated endoclip proved to be safe in this patient. Direct visualization with the intraductal cholangioscope was helpful in this case because of the four-way bending of the device.
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