The patient is an 88-year-old woman with a history of diabetes mellitus (HbA1c 9.1%) and had been under regular follow-up for pancreatic duct dilatation and gallstones. A progressively enlarging hypoechoic mass was detected in the tail of the pancreas, prompting referral to our department. CT revealed a 25 mm hypovascular mass in the pancreatic tail, along with upstream pancreatic duct dilation and parenchymal atrophy. Based on a diagnosis of pancreatic tail cancer, the patient underwent laparoscopic distal pancreatectomy with lymph node dissection and cholecystectomy. The surgery lasted 3 hours and 44 minutes, with 100 mL of blood loss. The initial postoperative course was favorable, and the drain was removed on POD 5.
However, on POD 13, the patient developed abdominal pain and vomiting. Blood tests showed elevated inflammatory markers, and contrast-enhanced CT revealed ascites. Ascitic fluid analysis showed normal triglyceride and bilirubin levels but elevated amylase, suggesting pancreatic fistula with peritonitis. A drain was placed, and antibiotics were started. Inflammatory markers improved, and CT confirmed reduced ascites. The drain was removed on POD 32, and oral intake was resumed.
On POD 38, the patient again developed fever and inflammation. Contrast-enhanced CT showed increased ascites, fat tissue density, and a foreign object at the papilla. Compared to the previous imaging, one metal clip at the pancreatic stump was missing. Based on its shape and characteristics, the object was identified as a migrated surgical clip. It was inferred that clip migration into the pancreatic duct caused increased ductal pressure and recurrence of pancreatic fluid leakage. As antibiotics were ineffective, ERCP was performed, and a metallic clip was retrieved using a flower basket. A drain was reinserted, and with antibiotics, inflammation resolved. Follow-up CT showed resolution of the abscess, and the patient was discharged on POD 122. Pathology confirmed invasive ductal carcinoma (pT3N1bM0, Stage IIB).
This case highlights the rare complication of surgical clip migration into the pancreatic duct, resulting in obstruction and recurrent pancreatic fistula.