Surgical clip migration after laparoscopic cholecystectomy and Roux-en-Y bypass: a case report and literature review

Abstract

Surgical clip migration into the common bile duct (CBD) after laparoscopic cholecystectomy or transcystic CBD exploration is a rare but significant complication that may lead to recurrent obstructive jaundice, pancreatitis, cholangitis, or biliary colic. We report the case of a 57-year-old man presenting with postprandial epigastric pain and pale stools for four days. His medical history included a laparoscopic Roux-en-Y gastric bypass in 2010 and a laparoscopic cholecystectomy with CBD exploration nine months prior to admission. Physical examination revealed mild tenderness in the right upper quadrant without fever, nausea, or vomiting. Laboratory findings demonstrated a cholestatic pattern with elevated AST (123 U/l), ALT (440 U/l), AP (340 U/l), GGT (640 U/l), and total bilirubin (4.3 mg/dl). Imaging with CT and MRCP showed an obstruction of the distal CBD, consistent with a solitary choledocholithiasis measuring 7–12 mm. Due to the altered anatomy from the previous gastric bypass, laparoscopic CBD exploration was performed. Following a transverse choledochotomy, choledochoscopy revealed a fixed stone at the ampulla of Vater encapsulating a migrated hem-o-lok clip surrounded by bile debris. The clip was successfully retrieved using a Dormia basket, and the duct was irrigated and closed with interrupted PDS 4/0 sutures. The postoperative course was uneventful, with normalization of liver function tests and discharge on postoperative day four. This case highlights that although rare, clip migration should be considered in patients presenting with late biliary obstruction after cholecystectomy, and laparoscopic retrieval offers a safe and effective treatment option.