Tombstone of surgical clip in common bile duct

Laparoscopic cholecystectomy has gained popularity over open cholecystectomy due to the benefits of shorter hospital stay, lesser pain and smaller scar. The frequent use of surgical clips during laparoscopic cholecystectomy occasionally leads to migration of the clip into the bile duct. The migrated clip acts as a nidus for stone formation (cat’s eye calculus).[1] These stones (tombstone for the clips) may cause symptoms like biliary colic, obstructive jaundice, cholangitis and acute pancreatitis. We report here two patients who underwent laparoscopic cholecystectomy and subsequently developed symptoms due to formation of cat’s eye calculi. Case reports Case 1 A 57-year-old man underwent laparoscopic cholecystectomy in 2004 for acute cholecystitis. He was asymptomatic till November 2009 when he developed painless jaundice, high grade fever with chills and pruritus. Clinical examination was normal except for icterus and scar of previous laparoscopy. Laboratory investigations revealed a hemoglobin of 11.9 mg/ dL; total leukocyte count of 11,100/cumm; differential counts of neutrophils 98%, band forms 1%; and a normal coagulation profile. Liver function tests (LFT) revealed a total bilirubin (TB) of 19.5 mg%, direct bilirubin (DB) of 16.1 mg%; SGOT at 83 U/ L (normal 0-37); SGPT at 77 U/L (normal 0-40) and serum alkaline phosphatase (ALP) at 223 U/L (normal 40-125). Serum amylase and lipase were normal. Ultrasound (USG) abdomen revealed a dilated common bile duct (CBD) with a calculus and dilatation of intrahepatic biliary radicles. He was diagnosed to have choledocholithiasis with cholangitis and started on antibiotics. An urgent ERCP showed a 20 mm radiolucent filling defect with linear metallic density within the defect which was initially thought to be cholecystectomy clips left behind in the CBD (Figure 1). Since he was on clopidogrel, a 7 Fr, 10 cm double pig tail stent was placed. He became afebrile in 2 days and his LFT and blood counts improved. Seven days later, repeat ERCP and sphincterotomy were performed. Stone retrieval however was unsuccessful. Hence, he underwent surgery (CBD exploration) with removal of stones. Examination of stone revealed 3 clips embedded within it. There were no postprocedure complications. He was asymptomatic at discharge with normal LFT.