Endobiliary clip migration after left hepatectomy: a surprising cause of postoperative biliary fistula

A 67-year-old male underwent a laparoscopic left hepatectomy with hepatic pedicle lymphadenectomy and cholecystectomy for a cholangiocarcinoma located in segment 3. The left bile duct was sectioned during parenchymal transection between 10mm Hem-o-lok® clips. Postoperative course was uneventful until post-operative day (POD) 5, when a biliary fistula appeared through the surgical drain following a transient peak of bilirubin (total/conjugated = 45/38 μM) mimicking choledochal migration. Biliary MRI at POD 13 revealed a leak from the left hepatic duct. Endoscopic ultrasound at POD 24 revealed material in the common bile duct (CBD). Following sphincterotomy, Hem-o-lok® clips were extracted from the CBD, including one measuring 10 mm long. A plastic stent was placed to cover the fistula, which resolved 5 days later. This is the first description of Hem-o-lok® clip migration from the left hepatic bile duct into the CBD, resulting in postoperative biliary fistula.