Clip-stone and T clip-sinus post laparoscopic biliary surgery: Two case reports and review of the literature

Abstract

BACKGROUND

Laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) are widely used in gallbladder and biliary tract diseases. During these procedures, vessels or tissues are commonly ligated using clips. However, postoperative migration of clips to the common bile duct (CBD) or T-tube sinus tract is an overlooked complication of laparoscopic biliary surgery. Previously, most reported cases of postoperative clip migration involved metal clips, with only a few cases involving Hem-o-lok clips and review of the literature.

CASE SUMMARY

This report describes two cases in which Hem-o-lok clips migrated into the CBD and the T-tube sinus tract following laparoscopic surgery. Case 1 is a 68-year-old female admitted due to abdominal discomfort, and two Hem-o-lok clips were found to have migrated into the CBD 17 months after LC and LCBDE with T-tube drainage, and were removed using a stone extraction balloon. The patient was discharged smoothly after recovery. Case 2 is a 74-year-old male who underwent LC and LCBDE with T-tube drainage and laparoscopic biliary tract basket stone extraction. Nine weeks postoperatively, following T-tube removal, a Hem-o-lok clip was found in the sinus tract, and was extracted from the T-tube sinus tract. The patient recovered smoothly postoperatively. This study also reviews the literature from 2013 to July 2024 on using Hem-o-lok clips in LC and/or LCBDE treatment of gallbladder and biliary diseases and the postoperative migration of these clips into the CBD, T-tube sinus tract, or duodenum.

CONCLUSION

In patients with a history of LC and/or LCBDE, clip migration should be considered as a differential diagnosis.

Key Words: Hem-o-lok; Clip migration; Laparoscopic biliary surgery; Laparoscopic cholecystectomy; Laparoscopic common bile duct exploration; Common bile duct stone; T-tube sinus tract; Case report

Core Tip: Postoperative migration of clips is an overlooked complication of laparoscopic biliary surgery. This report describes two cases in which Hem-o-lok clips migrated into the common bile duct (CBD) and T-tube sinus tract after laparoscopic cholecystectomy (LC) and laparoscopic CBD (LCBDE) exploration operation. One clip was removed using a stone extraction balloon, while the other was expelled spontaneously without treatment. Furthermore, literature regarding clip migration following laparoscopic biliary surgery was reviewed. In patients with a history of LC and LCBDE presenting with biliary colic, cholangitis, or abdominal discomfort, clip migration should be considered a differential diagnosis.

INTRODUCTION

Gallbladder and biliary tract diseases have a high incidence rate domestically and internationally. Currently, laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) are widely used in the surgical treatment of gallbladder and CBD stones[1,2]. Post-laparoscopic BD surgery, ligation clip migration is a rare but definite complication, with metallic clip migration being more common, while Hem-o-lok clip migration is less frequent[3-5]. According to a study report, among all complications after LC and LCBDE, 11.8% of patients experienced clip migration, with a 1.8% incidence of non-metallic clip migration[4]. In 1978, Walker et al[6] reported the first clip migration into the CBD after cholecystectomy, forming a gallstone with the clip as the core. Subsequently, similar cases have also been reported[7-15]. Moreover, studies have reported rare instances of clip migration into the CBD, T-tube tract, or duodenal bulb following LC and/or LCBDE[8,16].

Therefore, this article reports two cases of Hem-o-lok clip migration into the CBD or T-tube tract after LC and LCBDE in our department, and reviews the relevant literature from 2013 to July 2024, summarizing the diagnosis, mechanism, treatment, and prevention of Hem-o-lok clip migration into the biliary tract.

CASE PRESENTATION

Chief complaints

Case 1: A 68-year-old female patient was admitted on September 22, 2022, complaining of recurrent abdominal distension for over 8 years, worsening over the past 3 months.

Case 2: A 74-year-old male patient was admitted on January 18, 2023, for T-tube removal 9 weeks after biliary drainage.

History of present illness

Case 1: Eight years prior, the patient experienced unexplained abdominal distension and poor appetite. More than 1 year ago (April 23, 2021), her symptoms worsened, accompanied by upper abdominal distension and pain. Upper abdominal magnetic resonance imaging (MRI) revealed multiple stones in the CBD and gallbladder, as well as chronic cholecystitis. Contraindications were excluded and the patient underwent LCBDE with stone extraction, T-tube drainage, and LC under general anesthesia, resulting in significant symptom relief post-surgery. Three months ago (July 11, 2022), the patient experienced a recurrence of the aforementioned symptoms. An abdominal ultrasound suggested possible sludge-like stones or biliary sludge in the CBD. Ten days ago (September 13, 2022), she sought medical attention again, and an endoscopy indicated chronic non-atrophic gastritis with erosive bleeding and mild bile reflux. The diagnoses considered were BD stones, post-cholecystectomy status, and chronic non-atrophic gastritis with bile reflux. Upon admission, a computed tomography (CT) scan showed a high-density shadow in the CBD (Figure 1), and magnetic resonance cholangiopancreatography (MRCP) suggested a filling defect in the BD (Figure 2).

Figure 1  Computed tomography coronal view shows a strip of high-density shadow in the common bile duct.

Figure 2 Magnetic resonance cholangiopancreatography showing a low-signal foreign body in the common bile duct (the external shape is similar to a Hem-o-lok clip). A-C: High-density shadow in the common bile duct.

Case 2: Nine weeks prior (October 30, 2022), the patient was admitted to our hospital due to intermittent right upper abdominal pain and yellow urine for 1 day. An abdominal CT scan revealed multiple stones in the gallbladder and CBD, mild dilation of intrahepatic and extrahepatic BDs, an enlarged gallbladder, and multiple high-density spots in the right lobe of the liver, suggesting possible intrahepatic BD stones. After excluding surgical contraindications, the patient underwent endoscopic sphincterotomy (EST), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic nasobiliary drainage (ENBD) under local anesthesia (October 31, 2022). After 8 days, the patient underwent LCBDE with T-tube drainage, laparoscopic biliary tract basket stone extraction, and LC (November 8, 2022). He recovered well and was discharged. During this admission, a CT scan showed high-density shadows (Figures 3 and 4).

Figure 3  A high-density strip shadow can be seen near the T-tube sinus.

Figure 4  High-density shadows can be seen.

History of past illness

Case 1: The patient had no history of chronic diseases such as high blood pressure (BP), diabetes, and heart disease, and no history of infectious diseases such as hepatitis and tuberculosis.

Case 2: The patient had no history of chronic diseases such as high BP, diabetes, and heart disease, and had no history of infectious diseases such as hepatitis and tuberculosis. But the patient has a history of bronchial asthma and is treated regularly.

Personal and family history

Case 1: There is no similar patient in the family, and his siblings are in good health. Grandparents, parents, brothers, and sisters have no history of hereditary disease.

Case 2: There is no similar patient in the family, and his siblings are in good health. Grandparents, parents, brothers, and sisters have no history of hereditary disease.

Physical examination

Case 1: Temperature 36.5 °C, P 84 times/min, BP 116/73 mmHg, and respiratory rate (RR) 18 times/min. The patient was conscious and energetic, with obvious stomachache. Anorexia was evident, with weight loss of 5 kg. The skin and sclera were not jaundiced. Superficial lymph nodes throughout the body were not palpable. There was no edema in both lower limbs. Specialist physical examination showed that the abdominal wall was soft, with no tenderness, no rebound tenderness, and no palpable mass, and the liver and spleen were not palpable under the ribs. Murphy's sign (-), shifting dullness (-). Bowel sounds were normal at 2 times/min.

Case 2: Temperature 36.5 °C, P 72 times/min, BP 131/73 mmHg, RR 18 times/min, and oxygen saturation 98%. The skin and sclera were not jaundiced. The neck was soft and superficial lymph nodes throughout the body were not palpable. Specialist physical examination showed a flat abdomen, no varicose veins in the abdominal wall, and no gastrointestinal pattern or peristaltic waves. The abdominal wall was soft, there was no tenderness in the whole abdomen, no rebound tenderness or muscle tension, Murphy's sign (-), the T-tube was in place, the fixation line was loose, the drainage was smooth, no mass was touched in the abdomen, and the liver and spleen were not touched under the ribs. The boundaries of liver dullness are percussion pain (-) and moving dullness (-) in the normal kidney area. Bowel sounds were normal at 4-6 times/min, and there was no circumference, percussion pain in the liver area (-), or vascular murmur. There was no edema in both lower limbs.

Laboratory examinations

Case 1: July 8, 2022: Liver enzyme combination + liver function combination + electrolyte three items: Total bilirubin (TBIL) 28.99 μmol/L, direct bilirubin 10.10 μmol/L, indirect bilirubin 18.89 μmol/L.

Case 2: October 30, 2022 emergency liver enzymes + emergency liver function: TBIL 92.83 μmol/L, alanine aminotransferase 392 U/L, aspartate aminotransferase 532.86 U/L; October 30, 2022 emergency blood routine: White blood cells 10.41 × 10⁹/L, neutrophil percentage 92.8%.

Imaging examinations

Case 1: Upon admission, a CT scan showed a high-density shadow in the CBD (Figure 1), and MRCP suggested a filling defect in the BD (Figure 2).

Case 2: A CT scan showed high-density shadows (Figures 3 and 4).

FINAL DIAGNOSIS

Case 1

(1) BD stones; (2) Post cholecystectomy status; and (3) Chronic non-atrophic gastritis with bile reflux.

Case 2

(1) CBD stones with acute suppurative cholangitis; (2) Bronchial asthma; and (3) Abnormal liver function.

TREATMENT

Case 1

The patient underwent EST, ERCP, ENBD, and endoscopic balloon dilation. During surgery, two large Hem-o-lok clips were found (Figure 5), which were covered with black-brown stones (Figure 6). The stones were removed using a stone extraction balloon, and a nasobiliary drainage tube was placed post-surgery.

Figure 5  Endoscopic retrograde cholangiopancreatography shows a stone in the common bile duct centered on the Hem-o-lok clip.

Figure 6  Stone fragments and two large Hem-o-lok clips were removed using a stone balloon.

Case 2

After completing relevant auxiliary examinations, the patient further received BD stone extraction via the fistula tract (January 18, 2023). A 3 mm choledochoscope was introduced through the original T-tube tract, revealing a brown stone inside the T-tube, which was removed along with the original T-tube. Stones and a small Hem-o-lok clip were found in the lumen. The ectopic Hem-o-lok clip was extracted from the T-tube sinus tract, and a 16 Fr T-tube was placed in the original sinus tract and fixed to the abdominal wall.

OUTCOME AND FOLLOW-UP

Case 1

Ultimately, the patient was discharged smoothly after recovery.

Case 2

The patient returned to the ward without any discomfort during the procedure and recovered smoothly.

DISCUSSION

With the widespread adoption of minimally invasive methods and the rapid development of laparoscopic surgery, LC and LCBDE have emerged as pivotal treatment strategies for patients with gallbladder and biliary tract diseases. Compared to open surgery, laparoscopic procedures offer numerous advantages, including smaller incisions, less trauma, faster postoperative recovery, shorter hospital stays, and fewer complications[17-19]. Moreover, ligation clips can effectively seal the cystic duct and blood vessels, improving surgical efficiency. Therefore, ligation clips have been increasingly used in biliary tract surgery. Initially, metallic titanium clips were adopted, but these clips were found to loosen, detach, migrate, and cause significant pathological changes in the surrounding tissues. In 1999, non-absorbable polymer Hem-o-lok clips were developed and introduced into laparoscopic surgery, demonstrating good sealing and biocompatibility. Hem-o-lok clips feature integrated anti-slip teeth, arched prongs, and flexible hinges, providing flexibility and secure ligation while minimizing interference with postoperative CT and MRI examinations[20]. Hence, Hem-o-lok clips are widely used in laparoscopic biliary surgery[21]. Despite the large number of laparoscopic gallbladder and biliary surgeries performed globally each year, reports of postoperative clip migration are rare, with only occasional cases mentioned.

The PubMed, Web of Science, MEDLINE, and Scopus databases were searched from 2013 to July 2024 using the keywords “clip migration and laparoscopic cholecystectomy or clip migration and LCBDE.” After screening, 17 articles were identified, describing 30 cases of Hem-o-lok clip migration following LC and/or LCBDE[7-16,22-27] (Table 1). Among previous laparoscopic surgeries, 14 cases involved both LC and LCBDE (47%), while 16 cases involved LC or LCBDE alone (53%). The patient ages ranged from 31 to 88 years. The time of migration ranged from 6 weeks to 4 years post-LC and/or LCBDE. Among these, 8 patients remained asymptomatic and were diagnosed as an incidental finding during surgical cholangioscopy or ERCP. The most common manifestations of clip migration were symptoms of acute cholecystitis and CBD obstruction, such as abdominal pain, fever, and chills. Some patients presented with jaundice, which was differentiated from non-iatrogenic CBD stones, or anemia, which required investigation for duodenal ulcers. In the 24 cases, the clips were wedged in the CBD. In three cases, the clips became part of the T-tube tract; in another three cases, the clips migrated into the duodenum. Most migrated Hem-o-lok clips were treated with surgical cholangioscopy or ERCP stone extraction, while clip migration into the duodenum was managed by endoscopic removal or observation.

Table 1 Literature review of Hem-o-lok clip migration into the biliary tract or duodenum after laparoscopic cholecystectomy and laparoscopic common bile duct exploration.

Ref.	Case number	Age	Initial operations	Time to clip migration after initial surgery	Migration site	Clinical manifestation	Imaging approach	Treatment for the migrated clips
Liu et al[16], 2024	1	72	LC	2 years	Duodenum	Abdominal pain	EGD, CT	EGD, biopsy forceps
Zhu et al[22], 2024	1	72	LC	2 years, 2 months	CBD	Upper abdominal pain, fever	MRCP, CT, ERCP	ERCP, stone basket
Wu et al[7], 2024	4	62-88	LC + LCBDE	17 months-24 months	CBD	Varying degrees of epigastric pain (2/4), epigastric pain with chills and fever (2/4)	MRI, MRCP, CT	LCBDE (1/4); LCBD, adhesions removed (3/4)
Slim et al[23], 2023	1	88	LC	6 months	CBD	Asymptomatism	ERCP	ERCP, balloon catheter
Liu et al[8], 2022	1	59	LC + LCBDE	2 months	CBD	Fever, acute right upper abdominal pain.	CT, ERCP	ERCP, stone basket
Tan et al[9], 2021	1	72	LC + LCBDE	4 years	CBD, the hepatic bile duct	Abdominal pain	MRCP, ultrasound	LCBDE, T-tube drainage
Kihara et al[10], 2021	1	80	LC	3 years	CBD	Asymptomatism (Inflammatory pseudotumor)	CT, MRCP	Laparoscopic bile duct resection and reconstruction, removed by ERCP
Jiang et al[11], 2021	1	67	LCBDE	12 months	CBD	Acute right upper abdominal pain	CT	LCBDE, primary closure
Desai et al[12], 2021	1	74	LC	1.5 years	CBD	Abdominal pain, nausea, vomiting	Endoscopic ultrasound, CECT, ERCP	ERCP
Roh et al[13], 2019	1	65	LC	13 months	CBD	Upper abdominal pain, fever	CT, ERCP	ERCP, balloon catheter
Kou et al[14], 2019	1	84	LC+LCBDE	3 years	CBD	Upper abdominal pain, chills, hyperpyrexia	ERCP, ENBD, LCBDE	LCBDE, T-tube biliary drainage
Pang et al[15], 2019	6	31-83	LCBDE (5/6); LC (1/6)	2 months-1.5 years	CBD (3/6), T-tube sinus (3/6)	Asymptomatism (3/6); Right upper abdominal pain (3/6)	CT (1/6); Choledochoscopy (3/6); Abdominal ultrasound (1/6); T-tube cholangiography, digital subtraction angiography of the biliary tract (1/6)	Choledochoscope, reticular basket (3/6); Exploratory laparotomy, bile duct exploration, and J tube drainage (1/6); Roux-en-Y (1/6); PTBD and stent implantation (1/6)
Rou et al[24], 2018	1	53	LC	10 months	CBD	Abdominal pain	CT	ERCP, stone basket
Zheng et al[4], 2018	6	NA	LC + LCBDE T-tube drainage (4/6); LC + LCBDE primary closure (2/6)	6 weeks-50 months	Duodenum (1/6), CBD (5/6)	Abdominal discomfort (1/6); Jaundice (2/6); Asymptomatism (3/6)	EGD (1/6); Laparotomy operation (1/6); Choledochoscope (1/6); Choledochoscope check through T-tube sinus (3/6)	Not processed (1/6); Laparotomy operation, stone retrieving basket (1/6); LCBDE, stone basket (4/6)
Qu et al[25], 2017	1	54	LC + LCBDE, primary closure	12 months	CBD	Intermittent upper abdominal pain	MRCP, ERCP	ENBD tube was inserted after ESBD
Ribeiro et al[26], 2016	1	75	LC	2 years	CBD	Abdominal pain	Abdominal ultrasound, ERCP	ERCP, balloon sweep
Seyyedmajidi et al[27], 2013	1	41	LC	8 months	Duodenum	Severe abdominal pain	Upper gastrointestinal endoscopic	Upper gastrointestinal endoscopy, olympus grasping forceps

CBD: Common bile duct; CECT: Contrast-enhanced computed tomography; CT: Computed tomography; EGD: Esophagogastroduodenoscopy; ENBD: Endoscopic nasobiliary drainage; ERCP: Endoscopic retrograde cholangiopancreatography; ESBD: Endoscopic sphincterotomy plus balloon dilation; LC: Laparoscopic cholecystectomy; LCBDE: Laparoscopic common bile duct exploration; MRCP: Magnetic resonance cholangiopancreatography; MRI: Magnetic resonance imaging; NA: Not available; PTBD: Percutaneous transhepatic biliary drainage.

The exact mechanism underlying Hem-o-lok clip migration after laparoscopic biliary surgery remains incompletely understood. Based on previous literature, several possible mechanisms can be hypothesized. First, incomplete closure of the cystic duct may lead to the formation of a bile tumor, causing clip migration[7,8,25]. Second, surrounding structures may exert pressure on the clip[14,15,22]. Third, inflammation and necrosis of the tissue around the clip may result in fistula formation, leading to erosion of the BD wall, causing the clip to enter the CBD or even the duodenum. Additionally, the clip itself may also trigger an immune rejection reaction and infection, resulting in migration[11,12,14,16,22,27]. Fourth, improper surgical techniques, including excessive or incorrectly placed clips, may damage the BD and surrounding structures, accelerating migration[13]. Fifth, certain anatomical factors might affect the stability of the clip[10,15,28]. Finally, increased abdominal pressure or exacerbation of pre-existing pathological conditions in the patient may affect the stability of the clip, leading to migration[13]. In this study, 1 patient had an ectopic clip in the T-tube sinus tract, which may be due to the clip being placed too close to the T-tube sinus. In another patient, the migrated clip was found in the CBD, possibly due to increased fragility of the BD wall caused by local inflammation around the clip. Moreover, the clip itself is a foreign object and may elicit a rejection reaction.

Hem-o-lok clip migration in the BD typically does not cause noticeable symptoms in the early stages. Abdominal discomfort may only occur when clamping the T-tube before its removal. Furthermore, the long-term presence of a Hem-o-lok clip in the BD can alter BD motility, potentially becoming a site for gallstone formation and possibly causing cholangitis. Clip migration to the duodenum may cause duodenal ulcer and perforation, presenting clinical manifestations similar to other conditions, such as CBD stones, cholangitis, or duodenal ulcers[29]. Preoperative imaging studies such as CT and MRI often cannot clearly distinguish between Hem-o-lok clips and stones, requiring surgical cholangioscopy or ERCP. Patients with clip migration to the duodenal bulb may manifest atypical clinical symptoms. Hence, for patients undergoing LC or LCBDE who present with recurrent abdominal pain, clinicians should be aware of the possibility of Hem-o-lok clip displacement and consider scheduling CT scans and gastroscopy[16]. Notably, all types of surgical clips carry a risk of migration. Due to the lack of specific clinical symptoms and imaging features, clip migration is often confused with CBD stones or duodenal ulcers, potentially misleading physicians and causing delays in diagnosis and treatment.

With the rapid development of endoscopic technology, ERCP and cholangioscopy have emerged as the preferred methods for managing clip migration, offering advantages such as speed, cost-effectiveness, minimal invasiveness, and fewer complications[11,14,15,26]. According to the article, preoperative ERCP combined with LC is associated with a higher rate of CBD stone clearance and a lower rate of postoperative bile leakage compared to LCBDE + LC, while LCBDE + LC may be associated with shorter hospital stays[7,30]. In this study, 1 of the 2 patients had the migrated clip identified and removed through the sinus tract via cholangioscopy, as the T-tube had not yet been removed. The other patient presented with significant symptoms 17 months post-surgery, and had the clip removed via ERCP without the need for a CBD incision, resulting in less trauma and faster recovery. According to previous research, Hem-o-lok clips migrated into the CBD should be removed regardless of symptoms[7,8,22,23]. For clips migrated into the duodenum, symptomatic cases should be managed endoscopically or surgically, while asymptomatic cases may consider conservative treatment[16]. Therefore, treatment plans should be individualized based on the patient's condition to optimize safety, while minimizing trauma and medical resources.

Although reports of Hem-o-lok clip migration into the biliary tract are relatively rare, the increasing use of Hem-o-lok clips in laparoscopic biliary surgery has led to a gradual rise in such cases, which warrants our attention. Surgeons should be vigilant in employing proper techniques, selecting clips appropriately, or exploring alternative methods. In patients with a history of LC or LCBDE who present with biliary colic, cholangitis, or abdominal discomfort, clip migration into the biliary tract or other body parts should be considered a differential diagnosis. Further research will provide a deeper understanding of this postoperative complication, promoting the development of more suitable solutions.

CONCLUSION

Although Migration of the Hem-o-lok clip to the CBD, T-tube sinus tract or duodenum are relatively rare, the increasing use of Hem-o-lok clips in laparoscopic biliary surgery has led to a gradual rise in such cases, which warrants our attention. Surgeons should be vigilant in employing proper techniques, choosing and using clips appropriately, or exploring alternative methods. In patients with a history of LC and/or LCBDE who present with biliary colic, cholangitis, or abdominal discomfort, clip migration into the biliary tract or duodenum should be considered a differential diagnosis. It is believed that we will gain a deeper understanding of this postoperative complication over time and discover more suitable solutions.