Department of Surgery, Madigan Healthcare System, Madigan Army Medical Center, 9040-A Fitzsimmons Avenue, Tacoma, WA 98431, USA.
Am J Surg. 2013 May;205(5):547-50; discussion 550-1. doi: 10.1016/j.amjsurg.2013.01.011.
Metal clips are commonly used to secure the cystic duct during cholecystectomy, although use of an ENDOLOOP (Ethicon Endo-Surgery, Blue Ash, OH) is often touted as a more secure closure when postoperative endoscopic retrograde cholangiopancreatography (ERCP) is anticipated. The objective of this study was to test the strength of 3 different cystic duct closure methods in a model simulating postoperative biliary insufflation.
The extrahepatic biliary system, including common bile duct, gallbladder, and cystic duct, was harvested en bloc from 22 swine postmortem. A cholecystectomy was performed and the cystic duct was secured using 1 of 3 randomly assigned methods: metallic clips (Ethicon Endo-Surgery), an ENDOLOOP (Ethicon Endo-Surgery), or an ENSEAL tissue sealing device (Ethicon Endo-Surgery). The common bile duct was cannulated with a pressure-monitoring system and insufflated with air. The burst pressures, location of rupture, and size of the common bile duct and cystic duct were recorded and compared.
There were 7 pigs each in the ENDOLOOP and ENSEAL groups and 8 in the metallic clip group, with no statistical significance between cystic and common bile duct size. Mean burst pressure was 432 mm Hg for metallic clips, 371 mm Hg for the ENDOLOOP, and 238 mm Hg for the ENSEAL device (P = .02). Post hoc analysis revealed clips to be statistically superior when compared with the ENSEAL (P= .01). There was no statistical difference between the ENDOLOOP and metal clips or between the ENDOLOOP and the ENSEAL.
All 3 closure methods successfully secured the cystic duct, with mean burst pressures exceeding 195 mm Hg. Metallic clips demonstrated the highest burst pressures and no cystic duct stump leaks. This study challenges the traditional dogma of additionally securing the cystic duct with an ENDOLOOP when postoperative biliary instrumentation is expected and also suggests that an adequately secure closure may be obtained with thermal sealing devices.
在胆囊切除术中，通常使用金属夹来固定胆囊管，尽管当预期进行术后内镜逆行胰胆管造影（ERCP）时，常推荐使用 ENDOLOOP（Ethicon Endo-Surgery，Blue Ash，OH）进行更安全的闭合。本研究的目的是在模拟术后胆道充气的模型中测试 3 种不同的胆囊管闭合方法的强度。
从 22 头猪死后采集包括胆总管、胆囊和胆囊管在内的肝外胆道系统。进行胆囊切除术，并使用 3 种随机分配的方法之一固定胆囊管：金属夹（Ethicon Endo-Surgery）、ENDOLOOP（Ethicon Endo-Surgery）或 ENSEAL 组织密封装置（Ethicon Endo-Surgery）。胆总管用压力监测系统插管并用空气充气。记录并比较破裂压力、破裂位置以及胆总管和胆囊管的大小。
ENDOLOOP 和 ENSEAL 组各有 7 头猪，金属夹组有 8 头猪，胆囊管和胆总管大小无统计学差异。金属夹的平均破裂压力为 432mmHg，ENDOLOOP 为 371mmHg，ENSEAL 装置为 238mmHg（P=.02）。事后分析显示，与 ENSEAL 相比，夹子具有统计学优势（P=.01）。ENDOLOOP 与金属夹或与 ENSEAL 之间无统计学差异。
所有 3 种闭合方法均成功固定胆囊管，平均破裂压力超过 195mmHg。金属夹显示出最高的破裂压力，且无胆囊管残端漏。本研究挑战了在预期进行术后胆道器械检查时额外使用 ENDOLOOP 来固定胆囊管的传统观念，也表明热密封装置可获得足够安全的闭合。
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