Cetta F, Baldi C, Lombardo F, Monti L, Stefani P, Nuzzo G
Interuniversity Center for Research in Hepatobiliary Diseases, Institute of Surgical Clinics, University of Siena, Italy.
J Laparoendosc Adv Surg Tech A. 1997 Feb;7(1):37-46. doi: 10.1089/lap.1997.7.37.
Two groups of patients, with laparoscopic cholecystectomy (LC) were prospectively studied. All patients had serial plain abdominal X-ray examinations at various intervals after operation, to record the position of clips placed during LC. Seventy-one patients had less cystic duct (CD) dissection and > or =4 clips placed during the procedure. One hundred and fifteen patients had a larger CD dissection and only 4 clips placed (2 on the cystic artery and 2 on the CD, without additional clips on smaller vessels). In the former group, 7 patients had clip migration within 1 month and 11 within 1 year vs 1 either at 1 month or 1 year in the latter group (p = 0.01 and <0.001, respectively). During the follow-up, a 72-year-old man belonging to the former group had a recurrent common duct brown pigment stone containing a metallic clip 26 months after operation. He was treated successfully by endoscopic sphincterotomy. Factors predisposing to clip migration were short cystic stump, inadvertent clip dislodgment or incorrect placement, cystic duct ischemic necrosis, and local suppurative complications. Data from 29 patients with GS formed around suture material or phytobezoars observed during a prospective study and from the physicochemical and structural analysis of a cumulative series of 64 GS containing foreign bodies are also presented and discussed. It is suggested that metallic clips can migrate from their initial sites at various intervals within the peritoneal cavity or into the common duct and serve as a nidus for GS formation. Metallic clip migration in most cases is due to technical factors and can usually be prevented. However, it is not possible to prevent either clip migration or GS formation in every case, since even well-placed clips can migrate due to suppurative complications or local ischemic damage, and, once that penetration within the bile tract has occurred, GS are usually going to form, irrespective of the nature and the shape of the foreign body.
对两组接受腹腔镜胆囊切除术（LC）的患者进行了前瞻性研究。所有患者在术后不同时间间隔接受系列腹部平片检查，以记录LC术中放置夹子的位置。71例患者胆囊管（CD）游离较少，术中放置≥4个夹子。115例患者CD游离较多，仅放置4个夹子（2个在胆囊动脉上，2个在CD上，较小血管上未额外放置夹子）。在前一组中，7例患者在1个月内出现夹子移位，11例在1年内出现夹子移位；而后一组在术后1个月或1年内分别仅有1例出现夹子移位（p值分别为0.01和<0.001）。在随访期间，前一组中的一名72岁男性在术后26个月出现胆总管复发性棕色色素结石并含有一个金属夹。他通过内镜括约肌切开术得到成功治疗。夹子移位的易感因素包括胆囊残端短、夹子意外脱落或放置不当、胆囊管缺血坏死以及局部化脓性并发症。本文还呈现并讨论了在前瞻性研究中观察到的29例围绕缝线材料或植物性粪石形成的胆石（GS）患者的数据，以及对64例含有异物的累积系列GS进行的物理化学和结构分析。研究表明，金属夹可在不同时间间隔从其初始位置移至腹腔内或进入胆总管，并成为GS形成的病灶。大多数情况下，金属夹移位是由技术因素导致的，通常可以预防。然而，不可能在每种情况下都预防夹子移位或GS形成，因为即使放置良好的夹子也可能因化脓性并发症或局部缺血损伤而移位，并且一旦夹子进入胆道，无论异物的性质和形状如何，通常都会形成GS。
