Duodenal Adenocarcinoma Versus Foreign Body Granuloma in the Background of Postcholecystectomy Migration of Endoclip Into Duodenum: A Histopathological Surprise.

ABSTRACT

A surgical endoclip in the cystic pedicle rarely migrates to the duodenum and is considered a rare complication of laparoscopic cholecystectomy. Duodenal adenocarcinoma endoscopically mimicking a foreign body granuloma in the background of postcholecystectomy endoclip migration has never been reported before. A 53-year-old Indian male presented with progressive weakness and melena for the last three months. He underwent laparoscopic cholecystectomy a year ago with an uneventful clinical course and post-operative recovery. A complete hemogram revealed hemoglobin of 4.5g/dL. Upper gastrointestinal endoscopy revealed a large necrotic polypoidal mass arising from the lateral wall of the first part of the duodenum. Contrast-enhanced computed tomography (CT) of the abdomen showed an impacted surgical clip into the lateral wall of the first part of the duodenum. Intraluminal extension of the surgical clip was not appreciated in the imaging. We suspected the diagnosis to be foreign body granuloma in the duodenal wall. He underwent open duodenal wedge resection. Microscopic evaluation of resected specimens revealed poorly differentiated adenocarcinoma. All the resection margins were free. He had an uneventful recovery and was discharged on the seventh post-op day. He was symptom-free and doing well on follow-up at 12 months. The purpose of reporting the case was to make the readers aware of the delayed massive upper gastrointestinal hemorrhage as a rare complication of endoclip migration (ECM) post laparoscopic cholecystectomy. In our case, the duodenal adenocarcinoma mimicked a foreign body granuloma endoscopically, and hence a possibility of duodenal adenocarcinoma as a potential delayed complication of ECM cannot be ruled out. Although rare, in case of upper gastrointestinal hemorrhage in the background of the previous history of laparoscopic cholecystectomy, endoclip migration should be kept as a differential diagnosis.