# Clip‐Centered Common Bile Duct Stones Managed by Endoscopic Sphincterotomy Plus Endoscopic Papillary Large Balloon Dilation Years After Cholecystectomy

## TL;DR

A woman developed bile duct stones years after gallbladder surgery due to migrated surgical clips, which were successfully removed using a specialized endoscopic technique.

## Contribution

Demonstrates successful long-term management of clip-induced bile duct stones using endoscopic papillary large balloon dilation without lithotripsy.

## Key findings

- Clip migration into the bile duct can lead to stone formation years after laparoscopic cholecystectomy.
- Endoscopic papillary large balloon dilation effectively removed stones composed mainly of calcium bilirubinate.
- Symptoms and complications can appear years after clip migration, highlighting the need for long-term monitoring.

## Abstract

Migration of clips used in laparoscopic cholecystectomy (LC) is rare, but when a clip migrates into the bile duct, it can serve as a nucleus for common bile duct stone formation and trigger acute cholangitis. An elderly woman in her 80s underwent LC for cholecystolithiasis at another hospital in year X. Abdominal computed tomography in year X+1 revealed that two clips had migrated into the bile duct, but this was not noted at the time, and she remained asymptomatic. In year X+5, she underwent bioprosthetic aortic valve replacement for severe aortic regurgitation. In year X+6, she presented to our emergency department with fever and right upper quadrant pain, and she was diagnosed with acute cholangitis. On the day of admission, only drainage was performed, resulting in rapid improvement of the inflammation. On the sixth hospital day, endoscopic sphincterotomy and endoscopic papillary large balloon dilation (EPLBD) were performed, and the stones were completely removed. Infrared analysis of the retrieved stones showed that over 98% consisted of calcium bilirubinate. Even if clip migration occurs relatively early after LC, there may be a time lag of several years before stone formation and symptom onset; EPLBD achieved complete, safe removal without lithotripsy.