Post written by Chukwunonso Ezeani, MD, from Baton Rouge General Medical Center, Baton Rouge, Louisiana, USA.

This is a case of an 88-year-old woman with a history of cholecystectomy 30 years prior who presented with acute-onset right upper quadrant pain, nausea, and vomiting. Laboratory and imaging data were consistent with choledocholithiasis, with the bile duct measuring 2.2 x 1.2 cm.

The patient underwent initial ERCP, which confirmed filling defects, and sphincterotomy with balloon sweeps were performed. Repeat cholangiogram showed a persistent filling defect and an encasing metallic density suspicious for a migrated surgical clip. A 10F x 5-cm double-pigtail catheter was then placed.

Our video demonstrates Spyglass cholangioscopy (Boston Scientific, Marlborough, Mass, USA) with electrohydraulic lithotripsy that led to successful fragmentation of the stone. Next, the biliary tree was swept with a 15-mm balloon. The clip was successfully swept out. Final occlusion cholangiogram showed no evidence of a filling defect.

It was important to showcase this video because (1) stones associated with post-cholecystectomy clip migration are difficult to extract and associated with mechanical lithotripsy failure, and (2) this case highlights that cholangioscopy-assisted lithotripsy is safe and effective for the removal of an adherent stone around a migrated surgical clip when conventional techniques have failed.

Based on this experience, other endoscopists can learn to consider direct cholangioscopy with Spyglass, especially in patients who have failed conventional ERCP.

Future studies are needed to evaluate the role of cholangioscopy as first line in patients with bile duct stones associated with clip migration after cholecystectomy.

Metallic density representing the migrated surgical clip in the common bile duct.

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