Rare Metallic Allergy Reaction Presentation to Cholecystectomy Surgical Clip

Abstract

Metal allergies have been a growing concern in the general population over the past several decades. Laparoscopic cholecystectomy is the standard treatment for gallbladder diseases such as cholelithiasis and cholecystitis, during which surgical clips composed of metals such as nickel or titanium are often used to clamp the arteries and ducts. These metals are documented to produce hypersensitivity reactions. Here, we present the case of a 53-year-old male patient who successfully underwent laparoscopic cholecystectomy and two weeks later reported constant right upper quadrant pain accompanied by nausea that was exacerbated by exercise and food. After several months of severe interference with the patient's lifestyle, we removed the surgical clips after ruling out all possible organic causes of the pain. A total of six surgical clips were removed during surgery, and the patient reported a substantial resolution of symptoms post-operation. Post-cholecystectomy syndrome (PCS), allergy to the metallic surgical clips, and migration or improper clip placement during surgery were all considered possible causes for the pain. Still, the clinical presentation and laboratory studies pulled focus toward metallic surgical clip allergy as the most plausible cause for the presenting symptoms. The metallic haptens released by the surgical clips activate the innate and adaptive immune response cascades and pre-sensitize the CD8 and B cells to the metallic allergens. With reexposure, these pre-sensitized CD8 and B cells trigger a hypersensitivity reaction. Standardizing allergy tests as part of the pre-operation checklist can prove to be an inexpensive way to eliminate such post-surgical complications. Furthermore, alternatives like absorbable sutures or even different hypoallergenic metal or plastic clips can be considered viable options to replace nickel or titanium-made surgical clips during surgery.

Hemoclip migration after revision carpal tunnel release: a case report

“…Mozafari et al . [ 16 ] found that allergies secondary to hemoclip placement may cause type IV hypersensitivity symptoms most commonly because of the composition of nickel or titanium in metallic clips. The patient in our case received metal clips and if unnoticed, this may have developed into a larger acute inflammatory process.…”

“…The patient in our case received metal clips and if unnoticed, this may have developed into a larger acute inflammatory process. There is no standardized regulation of allergy testing before procedures and given the high prevalence of metal allergies within the general population at 10%–15%, it remains questionable whether the convenience of using hemoclips versus other materials is beneficial [ 16 ].…”