Duodenal Clip Migration after Laparoscopic Cholecystectomy Undergone Many Years before

Laparoscopic cholecystectomy (LC) is the gold standard for gallbladder disease 1, but clip migration may be one of its complications, usually occurring with a median of two years later 2.We describe the history of an 86-year-old man undergone LC ten years before, presented with melena, vomiting and severe anemia (Hb 6.8.g/dL).Comorbidities were arterial hypertension, acute on chronic renal failure (serum creatinine 5.2 mg/dL), type 2 diabetes mellitus.No previous history of peptic ulcer disease, gastrointestinal bleeding, use of non-steroidal antiiInflammatory drugs, anticoagulants were noted.Endoscopic examination revealed a duodenal ulcer (Fig. 1), containing migrated surgical clips, with a choledochoduodenal fistula (Fig. 2), adherent to the inferior wall of the distal duodenal bulb.Adjacent to the fistulous tract, several migrated surgical clips were observed.Proximal to these clips, a visible vessel with signs of recent bleeding was noted.Hemostasis was achieved by a 12/6 atraumatic Ovesco clip closing the vessel.A 12/6 Ovesco over-the-scope clip was successfully applied to avoid re-bleeding.Surgical clips visualized by computed tomography protruded into the outer wall of the duodenum (Fig. 3).Conservative management approach to the fistula was chosen, resulting in clinical improvement and no recurrence of gastrointestinal bleeding after implantation of the 12/6 Ovesco over-the-scope clip on the duodenal ulcer.Clip migration into the duodenum was rarely reported, but choledochoduodenal fistula was even much rarer 3.There are two main characteristics to be emphasized in our clinical case: 1) clip migration in patients with previous LC could happen even many years later than the median of two years; 2) fistula formation, although rarest (only one previous case reported in the literature 3), could complicate the scenario of gastrointestinal bleeding.However, a tailored conservative approach 4, limited to prevent re-bleeding, may provide, as in our high-risk patient, substantial benefit, avoiding further complications associated with more invasive interventions.