the prevalence of gallstones in the united states is approximately 6% in men and 9% in women .
older age , female sex , and obesity are a few risk factors for gallstones .
usually gallstones do not cause any symptoms throughout the lives of most of the people harbouring them .
these stones are called incidental gallstones and they are identified when imaging studies are done for different reasons ( e.g. , evaluation of abdominal pain , pelvic disease , and abnormal liver function tests [ lft ] ) . if the person becomes symptomatic due to stones , the condition is called gallstone disease .
uncomplicated gallstone disease refers to a state associated with biliary colic in the absence of any complications .
while the majority of patients with incidental gallstones will not develop symptoms attributable to the gallstones , approximately 1525% will become symptomatic during 1015 years of follow - up , but their initial symptoms are typically not severe . patients who develop symptoms initially report biliary colic rather than symptoms associated with the complications of gallstone disease . since the mortality rate related to incidental gallstone disease is remarkably lower than that associated with treatment , prophylactic cholecystectomy is not indicated in asymptomatic patients .
once symptoms develop , they tend to recur and thereby increasing the risk for the complications of the gallstone disease . therefore , cholecystectomy must not be delayed after the development of biliary symptoms .
elective nonsurgical treatment of gallstones is advised in all symptomatic patients who are poor candidates for surgery .
an estimated 750,000 laparoscopic cholecystectomies ( lc ) are performed annually in the united states ( approximately 90% of all cholecystectomies ) .
the overall serious complication rate still remains higher than that seen in open cholecystectomy , despite increasing experience with the procedure over the last so many years .
laparoscopy in the present time is done by 3-port , 4-port , or single - port technique , though it may also be performed through an open upper right abdominal incision . as the laparoscopic approach does not require the cutting of the rectus abdominis muscle , it is associated with less postoperative pain and good cosmetic effect .
a short hospital stay resulting in reduced days off work are additional advantages over open cholecystectomy . in an lc operation ,
serious complications that occur with lc include bile leaks , bile duct injury , bleeding , and bowel injury at times .
one of the complications of cholecystectomy is the migration of surgical clips into the common bile duct ( cbd ) , albeit very rare .
secondary stones , which are the commonest , form in the gallbladder and then migrate into the cbd .
stasis plays an important role in the formation of bile duct stones and can be due to stricture or other causes of obstruction like foreign bodies
. the migrated surgical clip could be one of the foreign bodies providing the nidus for the bile duct stones .
migration of surgical clips is a well - known phenomenon ever since their use in surgery .
migration of the surgical clip into the cbd as a cause of biliary stone was first recognised in 1979 after open cholecystectomy .
both of these complications ( migration of surgical clips and retained cbd stones ) can be missed easily .
presenting symptoms of both of these complications could be acute or recurrent cholangitis over a variable period of time .
a 38-year - old lady presented with repeated episodes of jaundice . jaundice used to be mild and fluctuating in nature lasting for 56 days according to her history .
upper right quadrant abdominal pain lasting for less than 6 h accompanied the jaundice . each episode was associated with mild pruritus all over the body .
she also developed nausea and vomiting for the past few days when she decided to seek medical attention .
there was no past history of abdominal pain , fever , or jaundice before lc .
ultrasonography ( usg ) done just before lc showed non - dilated cbd with normal lft .
she was found to have a temperature of 39.2c with associated tachycardia ( hr 130/min ) .
laboratory indices were as follows : wbc 12,100/ml , alt 112 u / l ( normal up to 41 ) , ast 169 u / l ( normal up to 40 ) , alp 671 u / l ( normal up to 130 ) , and total bilirubin 9.6 mg / dl ( normal up to 1.2 ) .
u / l ( normal up to 96 ) and serum lipase was 28 u / l ( normal up to 51 ) .
a small amount of contrast was injected in the cbd , which demonstrated multiple filling defects in the lower cbd with 2 linear metallic densities in one of the defects ( fig 1 ) .
wide papillotomy was done and a few stones , including the one encasing 2 metallic surgical clips , were removed by a dormia basket ( fig 2 ) . pain and fever disappeared after the procedure with progressive normalisation of lft .
most of the stones form de novo , while a few can form due to direct complications of surgery .
suture materials or metallic clips can migrate into the cbd where they act as a nidus for stone formation .
the first case of surgical clip migration after lc was reported in 1992 . in spite of the very large number of lc performed worldwide , less than 100 cases of surgical clip migration
the median time of clip migration is usually 2 years , but it can vary from 11 days to 20 years , while the median number of migrated clip is 1 ( range 16 ) . the exact sequence of events leading to clip migration is poorly understood . a possible initial event could be cystic duct stump necrosis
. this can be due to pressure exerted from intra - abdominal organ movements , ischemia , or infective complications .
in due course of time , the whole clip eventually falls away into the cbd as the stone becomes larger in size .
clip migration causing duodenal ulcer or emboli has also been reported [ 8 , 9 ] .
the clinical presentation of stones formed due to clip migration is similar to non - iatrogenic stones .
application of a minimum number of clips with proper placement away from the cystic duct and cbd junction or use of absorbable clips could probably prevent the incidence of clip migration .
this case also highlights another important issue of retained cbd stones after cholecystectomy because there were multiple stones in the cbd apart from the one formed over the migrated clips .
unexpected retained cbd stone after cholecystectomy is a rare but recognised complication with a reported incidence of about 0.52.3% [ 10 , 11 ] .
the frequency of asymptomatic cbd stones in those undergoing cholecystectomy is around 10% in the literature .
abdominal usg and lft , could still miss retained cbd stones in many cases , like the present one .
therefore , the use of on - table cholangiogram or intra - operative laparoscopic ultrasound to reduce the incidence of retained cbd stones could be the better option , but no conclusive evidence exists to date [ 13 , 14 ] .
they should be considered in the differential diagnosis of recurrent cholangitis in post - cholecystectomy cases .
 laparoscopic cholecystectomy ( lc ) is currently the treatment of choice for symptomatic gallstones . 
 associated complications include bile duct injury , retained common bile duct ( cbd ) stones , and migration of surgical clips . 
 clip migration into the cbd can present with recurrent cholangitis over a period of time 
 . retained cbd stones can be another cause of recurrent cholangitis . 
 a case of two surgical clips migrating into the common bile duct with few retained stones following lc is reported here . 
 the patient had repeated episodes of fever , pain at epigastrium , jaundice , and pruritus 3 months after lc . 
 liver function tests revealed features of obstructive jaundice . 
 ultrasonography of the abdomen showed dilated cbd with few stones . in view of acute cholangitis , 
 an urgent endoscopic retrograde cholangiopancreatography was done , which demonstrated few filling defects and 2 linear metallic densities in the cbd . 
 a few retained stones along with 2 surgical clips were removed successfully from the cbd by endoscopic retrograde cholangiopancreatography after papillotomy using a dormia basket . the patient improved dramatically following the procedure . 
Introduction
Case Report
Discussion
Conclusion
Statement of Ethics
Disclosure Statement