P2317 - Unclipped: Surgical Clip Migration Leading to Bile Leak and Pneumoperitoneum

Samantha Pendleton, DO¹, Tiago Martins, DO¹, Andrew Ng, MD¹, Sabah Sikander, DO², Nha Duong, DO¹
1University of Massachusetts Chan Medical School - Baystate Health, Springfield, MA; 2Baystate Medical Center, Springfield, MA

Introduction: Laparoscopic cholecystectomy is a standard surgical approach for patients presenting with biliary pathology. During the procedure, Hem-o-lok clips are commonly used to ligate the cystic duct and associated vessels.¹ Although generally safe, these clips carry a small risk of perioperative complications.¹ We report an unusual case of a patient who developed pneumoperitoneum and a bile leak due to a migrated surgical clip following cholecystectomy, resulting in a prolonged hospitalization.

Case Description/

Methods: A 55-year-old woman with a history of Roux-en-Y gastric bypass presented to the emergency department with epigastric pain exacerbated by oral intake. Laboratory testing revealed elevated liver enzymes: AST 280 U/L, ALT 203 U/L, total bilirubin 2.1 mg/dL, and alkaline phosphatase 252 U/L. Right upper quadrant ultrasound showed choledocholithiasis, with a 0.8 cm common bile duct (CBD) stone and CBD dilation to 1.4 cm. These findings were confirmed on CT imaging of the abdomen and pelvis.

She initially underwent an unsuccessful laparoscopically assisted ERCP and a laparoscopic cholecystectomy. Due to the failed ERCP, an EUS-directed transgastric ERCP (EDGE) procedure was performed.

Post-procedure, the patient developed pneumoperitoneum, raising concern for perforation. An exploratory laparotomy and CT failed to reveal a source of perforation. She was managed conservatively with placement of surgical drains, which produced bilious output—indicative of a bile leak.

Following clinical stabilization, the patient underwent endoscopic ultrasound, which identified a 12 × 7 mm stone containing hyperechoic artifacts suggestive of surgical clips embedded within it (Figures A and B). A successful ERCP was then performed through the gastric-gastric fistula, facilitating removal of both the stone and the LAMS. The patient recovered without further complications.

Discussion: Surgical clip migration is a rare but potentially serious complication following cholecystectomy. Its incidence is estimated at less than 1%, with fewer than 100 cases reported in the literature since 1992.² In this case, the patient developed pneumoperitoneum following a cholecystectomy. This case highlights clip migration as an important, though rare, differential diagnosis in patients with a history of cholecystectomy who present with signs of biliary obstruction, sepsis, or unexplained pneumoperitoneum. Early recognition may help prevent serious complications and reduce the length of hospitalization.

Disclosures:
Samantha Pendleton indicated no relevant financial relationships.
Tiago Martins indicated no relevant financial relationships.
Andrew Ng indicated no relevant financial relationships.
Sabah Sikander indicated no relevant financial relationships.
Nha Duong indicated no relevant financial relationships.

Samantha Pendleton, DO¹, Tiago Martins, DO¹, Andrew Ng, MD¹, Sabah Sikander, DO², Nha Duong, DO¹. P2317 - Unclipped: Surgical Clip Migration Leading to Bile Leak and Pneumoperitoneum, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.