S3435 Unclipped: Surgical Clip Migration Leading to Bile Leak and Pneumoperitoneum

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. Although generally safe, these clips carry a small risk of perioperative complications. 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 computed tomography imaging of the abdomen and pelvis. She initially underwent an unsuccessful laparoscopically assisted endoscopic retrograde cholangiopancreatography (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 computed tomography 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. A successful ERCP was then performed through the gastric-gastric fistula, facilitating removal of both the stone and the lumen apposing metal stent. 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. 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.