Hem-o-lok clip migration to duodenal bulb post-cholecystectomy: A case report

Abstract

BACKGROUND

Hem-o-lok clips are typically used to control the cystic duct and vessels during laparoscopic cholecystectomy (LC) and common bile duct exploration for stones in the bile duct and gallbladder. Here, we report a unique example of Hem-o-lok clip movement towards the duodenal bulb after LC, appearing as a submucosal tumor (SMT). Additionally, we provide initial evidence of gradual and evolving endoscopic manifestations of Hem-o-lok clip migration to the duodenal bulb wall and review the available literature.

CASE SUMMARY

A 72-year-old man underwent LC for gallstones, and Hem-o-lok clips were used to ligate both the cystic duct and cystic artery. Esophagogastroduodenoscopy (EGD) 2 years later revealed an SMT-like lesion in the duodenal bulb. Due to the symptomatology, the clinical examination did not reveal any major abnormalities, and the patient was followed up as an outpatient. A repeat EGD performed 5 months later revealed an SMT-like lesion in the duodenal bulb with raised edges and a central depression. A third EGD was conducted, during which a Hem-o-lok clip was discovered connected to the front side of the duodenum. The clip was extracted easily using biopsy forceps, and no complications occurred. Two months after the fourth EGD, the scar was surrounded by normal mucosa.

CONCLUSION

Clinicians should be aware of potential post-LC complications. Hem-o-lok clips should be removed if symptomatic.

Key Words: Hem-o-lok clip, Migration, Duodenum, Laparoscopic cholecystectomy, Laparoscopic common bile duct exploration, Case report

Core Tip: Migration of Hem-o-lok clips to the duodenal bulb may manifest as a slightly raised lesion resembling a submucosal tumor in the duodenal bulb. A gradual alteration in the endoscopic view of the lesion could be seen as the Hem-o-lok clip migrates through the wall of the duodenal bulb. Although Hem-o-lok clip migration to the duodenal bulb is infrequent, clinicians must be highly attentive and vigilant regarding these complications to avoid misdiagnosis.

INTRODUCTION

Migration of a Hem-o-lok clip to the duodenal bulb after laparoscopic cholecystectomy (LC) is rare in clinical practice[1]. Herein, we report on a gradual and evolving process of Hem-o-lok clip movement towards the duodenal bulb subsequent to LC. In addition, we have examined the research papers on the migration of Hem-o-lok clips to the duodenal bulb post-LC that were indexed in the PubMed database. We conducted the search using keywords including “Hem-o-lok clip”, “migration”, “duodenum”, “laparoscopic cholecystectomy”, and “laparoscopic common bile duct exploration”. Approximately 6 cases were retrieved, and we provide a summarization and analysis of them in detail.

CASE PRESENTATION

Chief complaints

A 72-year-old man presented with a complaint of abdominal pain, which had persisted over the previous 10 d.

History of present illness

The patient had undergone LC for symptomatic gallstone disease 2 years previously and presented to the hospital complaining of the persistent abdominal pain. Hem-o-lok clips had been used to control the cystic duct and artery during the LC. An adhesion in the gallbladder triangle and an inflamed and dilated bile duct had been discovered during surgery, and the operation had been difficult. Two years after the LC, he underwent a screening esophagogastroduodenoscopy (EGD), which revealed a submucous tumor (SMT)-like lesion in the duodenal bulb with normal overlying mucosa (Figure 1A). Nevertheless, he remained asymptomatic after the EGD and was monitored as an outpatient. After 5 months, he underwent a second EGD, which revealed an SMT-like lesion in the duodenal bulb with raised edges and a central depression (Figure 1B). Physical examination revealed no major abnormalities. Therefore, he continued with outpatient follow-up. After 5 months, he was hospitalized due to the 10 d of abdominal discomfort.

Figure 1 The esophagogastroduodenoscopy results. A: The first esophagogastroduodenoscopy (EGD) revealed a submucosal tumor (SMT)-like lesion in the duodenal bulb with normal overlying mucosa; B: The second EGD revealed an SMT-like lesion in the duodenal bulb with raised edges and central depression; C: The third EGD revealed an SMT-like lesion, covered by white exudates, with erosions and edema. The lesion was active and hard when touched with biopsy forceps; D: Olympus grasping forceps removed the foreign body; E: The foreign body was a Hem-o-lok clip; F: The fourth EGD revealed the duodenum was covered with normal mucosa.

History of past illness

The patient had a clinical history of primary esophageal, hypopharyngeal, and lung cancers. Additionally, he had hypertension and coronary artery disease.

Personal and family history

The patient had a history of excessive tobacco use and consumption of alcoholic beverages.

Physical examination

Vital signs were stable for the patient. He also showed no tenderness or rebound tenderness upon palpation, and the abdomen was flat and soft.

Laboratory examinations

Routine coagulation test and tumor marker test results were within normal limits.

Imaging examinations

An SMT-like lesion, with a fixed foreign body, covered by white exudates, was observed in the duodenal bulb during the third EGD (Figure 1C). Around the lesion, erosions and edema were observed in the duodenum. When the biopsy forceps were used to touch the lesion, it was hard and active. Abdominal computed tomography (CT) revealed that the foreign body had migrated into the duodenal bulb (Figure 2).

Figure 2 Computed tomography scan examination. Computed tomography scan shows a foreign body in the duodenum.

FINAL DIAGNOSIS

The patient was diagnosed as foreign body in duodenal bulb.

TREATMENT

Olympus grasping forceps were used to remove the foreign body (Figure 1D), which was the Hem-o-lok clip (Figure 1E). The patient was discharged from the hospital the next day without complications such as hemorrhage and perforation.

OUTCOME AND FOLLOW-UP

After 2 months, we performed another EGD. The clip was no longer visible, and the duodenum exhibited a healthy mucosal covering (Figure 1F).

DISCUSSION

Since the Hem-o-lok clip’s inception in 1999, it has been used for a wide variety of applications in the urinary tract, hepatobiliary, and gastrointestinal surgeries. Complications associated with postoperative Hem-o-lok clip displacement have been reported[2-5]. Postoperative clip displacement can lead to various complications, such as rectal elevated lesion caused by Hem-o-lok clip migration after prostate cancer surgery, abscess in the fallopian tube caused by Hem-o-lok clip migration after laparoscopic appendectomy, and dysphagia caused by Hem-o-lok clip migration into the esophagus subsequent to clamping of the azygous vein after radical resection of distal esophageal cancer[6-8]. LC and laparoscopic common bile duct exploration (LCBDE) are the most effective way to treat gallbladder stones, gallbladder polyps, and cholecystitis[9,10]. Hem-o-lok clips are commonly utilized for clamping the arteries and ducts of the gallbladder during LC and LCBDE. Although several previous reports have described Hem-o-lok clip migration in the biliary system, which can lead to stones, bile leakage, and cholangitis, very few reports have described the Hem-o-Lok clip’s postoperative migration to the duodenal bulb[11-13].

Migration of the Hem-o-Lok clip to the duodenal bulb can manifest as various endoscopic findings, including ulcers, erosions of the mucosa, and lesions resembling SMTs[14,15]. In this particular instance, the Hem-o-lok clip migrated to the duodenal bulb following LC and presented as a lesion resembling an SMT, requiring differentiation from polyps, cysts, stromal tumors, ectopic pancreatic lipomas, and carcinoids. Initially, the patient exhibited a gradual and evolving endoscopic presentation of Hem-o-lok clip movement towards the wall of the duodenal bulb.

After conducting a thorough search in the PubMed database, we discovered a total of 6 cases (4 women/2 men) since 2010 where Hem-o-lok clip migration to the duodenal bulb occurred following a LC. These cases are documented in Table 1 with corresponding references. The latest migration occurred 2 years post-LC and LCBDE, and the earliest occurred at nearly at 4 months. Minimum and maximum ages were 41 years and 67 years, respectively[14]. Of these, 1 patient was asymptomatic and 5 were symptomatic (e.g., melena or abdominal pain). The clinical manifestations of clip migration to duodenal bulb were also atypical, including abdominal pain, nausea, vomiting, gastrointestinal bleeding, and anemia. It is easy to miss diagnosis and misdiagnosis[1,15]. The clip was discharged spontaneously without complication in 1 case.

Table 1 Review of case reports of Hem-o-lok clip migration to the duodenal bulb post-cholecystectomy.

Ref.	Patients, n	Age in yr	Sex	Clips	Type of surgery	Time from surgery	Symptoms	Diagnosis	Treatment
Mantoo et al[13], 2010	1	57	F	Hem-o-lok	LC	1 yr	Melena	EGD	Endoscopic removal
Seyyedmajidi et al[14], 2013	1	41	M	Hem-o-lok	LC	8 months	Abdominal pain	EGD	Endoscopic removal
Soga et al[15], 2016	1	66	F	Hem-o-lok	LC	13 months	Asymptomatic	EGD + CT	PPI/spontaneous detachment
Padmanabhan et al[18], 2016	1	59	F	Hem-o-lok	LC	2 yr	Melena	EGD + CT	ND
Zheng et al[19], 2018	1	54	M	Hem-o-lok	LC + LCBDE	4 months	Abdominal pain	EGD	Observation
Yang et al[20], 2023	1	67	F	Hem-o-lok	LC	ND	Abdominal pain	EGD + CT	Endoscopic removal

CT: Computed tomography; EGD: Esophagogastroduodenoscopy; LC: Laparoscopic cholecystectomy; LCBDE: Laparoscopic common bile duct exploration; ND: Not described; PPI: Proton pump inhibitor.

However, there is no clear etiology or exact incidence for clip migration[16-18]. We considered three possible mechanisms for clip migration into the duodenum. First, due to the anatomical proximity between the cystic duct ligation site and the duodenum, a fistula could form around the cystic duct clip and extend into the duodenum through a rejection-response mechanism. Second, in the case of severe cholecystitis combined with Calot’s triangle severe inflammation and adhesion, the severe inflammation around the anastomosis would gradually erode the duodenal wall near the anastomosis and ultimately cause the Hem-o-lok clip to enter the duodenal wall. Third, when an undiagnosed duodenal ulcer persists, the duodenum may adhere to the gallbladder fossa, causing inflammation. In our case, the migration of the Hem-o-lok clip to the duodenum could potentially be accounted for by the second mechanism.

There is no clear consensus on the management of clip migration to the duodenal bulb after LC. According to earlier findings, the majority of Hem-o-lok clips that migrated postoperatively were typically extracted using endoscopic methods. In 2010, a 57-year-old male patient, who had previously undergone LC, experienced migration of a Hem-o-lok clip to the duodenal bulb at 1-year post-LC. This case was reported by Mantoo et al[13] and the clip was successfully removed using biopsy forceps. Similar treatments were reported by Seyyedmajidi et al[14]. In addition, a few cases also showed that displaced clips dislodged spontaneously over time. A 66-year-old man experienced a natural separation of a Hem-o-lok clip that had moved into the duodenum, as documented by Soga et al[15]. Likewise, Zheng et al[19] also adopted a watch-and-wait strategy after postoperative clip displacement. The migration of clips can lead to various complications such as abdominal pain, ulcers, bleeding, and anemia. In addition, due to most patients being asymptomatic and detection occurring during physical examination, the incidence of postoperative clip migration is likely to be overlooked. Clinicians should be mindful of the potential for migration of Hem-o-lok clips in patients with recurring abdominal pain who have undergone LC or LCBDE, and consider arranging CT scans and gastroscopy. Based on the above, clinicians can adopt a watch-and-wait strategy post-LC if no clip-related complications are observed. Once symptomatic, however, clips should be removed in a timely manner.

CONCLUSION

Migration of the Hem-o-lok clip to the duodenal bulb after LC is uncommon in clinical practice and may manifest as a lesion resembling SMT, slightly protruding in the duodenal bulb. Clinicians need to be aware of the potential complications post-LC. While the Hem-o-lok clip has migrated, clinicians can adopt a watch-and-wait strategy post-LC if the patient is asymptomatic. Clips should be removed if symptomatic.