Hem-o-Lok clip migration into the duodenum after laparoscopic digestive surgery: a systematic review

Abstract

Introduction:
The wide use of hemoclips during laparoscopic surgery has led to a variety of unusual complications, among these, there is the migration of Hem-o-Lok clip into the duodenum. We performed a literature review of all cases of Hem-o-Lok clip migration into the duodenum after laparoscopic digestive surgery reported in literature.

Evidence acquisition:
All relevant articles were extracted up to June 2019 based on the results of searches in MEDLINE, PubMed, Scopus, Web of Science and Google Scholar.

Evidence synthesis:
At the time of this review, a total of seven cases have been described. The mean age was 49 years and the majority of these patients were women (57%). Previous laparoscopic surgery was performed for cholecystectomy (four patients), cholecystectomy with common bile duct exploration (one patient), right hemicolectomy (one patient) and distal gastrectomy (one patient). Symptoms occurred from 3 months to 2 years after laparoscopic surgery. The majority of patients developed symptoms of bowel occlusion and abdominal pain. Three patients remained asymptomatic. In many cases the Hem-o-Lok wedged into the wall of the first or second portion of the duodenum. In all cases, esophageal gastroduodenoscopy was the primary modality to make the diagnosis. Initial treatment was conservative with watch-and-wait strategy or proton pump inhibitors followed by endoscopic removal, while surgical treatment was required in two cases.

Conclusions:
The application of Hem-o-Lok clip during laparoscopic surgery is safe and effective. Postoperative Hem-o-Lok migration into the duodenum is rare. The treatment could be conservative in the majority of cases.

Full text

VOLUME 74 . No.6 . DECEMBER 2019

496 MINERVA CHIRURGICA December 2019
REVIEW
Hem-o-Lok clip migration into the duodenum after
laparoscopic digestive surgery: a systematic review
Matteo BARABINO 1, Carmelo LUIGIANO 2 *, Gaetano PICCOLO 1,
Rinaldo PELLICANO 3, Micol POLIZZI 1, Marco GIOVENZANA 1,
Roberto SANTAMBROGIO 1, Andrea PISANI CERETTI 1, Erika ANDREATTA 1,
Maria A. PALAMARA 2, Giuseppa GIACOBBE 4, Pierluigi CONSOLO 4, Enrico OPOCHER 1
1Unit of Hepato-biliopancreatic and Digestive Surgery, Department of Surgery, San Paolo Hospital, University of
Milan, Milan, Italy; 2Unit of Digestive Endoscopy, San Paolo Hospital, Milan, Italy; 3Department of Gastroenterology,
Molinette-S. Giovanni Antica Sede Hospital, Turin, Italy; 4Unit of Digestive Endoscopy, G. Martino Hospital,
University of Messina, Messina, Italy
*Corresponding author: Carmelo Luigiano, Unit of Digestive Endoscopy, San Paolo Hospital, Via A. Di Rudinì 8, 20142 Milan, Italy.
E-mail: carmeluigiano@libero.it
ABSTRACT
INTRODUCTION: The wide use of hemoclips during laparoscopic surgery has led to a variety of unusual complications,
among these, there is the migration of Hem-o-Lok clip into the duodenum. We performed a literature review of all cases
of Hem-o-Lok clip migration into the duodenum after laparoscopic digestive surgery reported in literature.
EVIDENCE ACQUISITION: All relevant articles were extracted up to June 2019 based on the results of searches in
MEDLINE, PubMed, Scopus, Web of Science and Google Scholar.
EVIDENCE SYNTHESIS: At the time of this review, a total of seven cases have been described. The mean age was 49
years and the majority of these patients were women (57%). Previous laparoscopic surgery was performed for cholecys-
tectomy (four patients), cholecystectomy with common bile duct exploration (one patient), right hemicolectomy (one
patient) and distal gastrectomy (one patient). Symptoms occurred from 3 months to 2 years after laparoscopic surgery.
The majority of patients developed symptoms of bowel occlusion and abdominal pain. Three patients remained asymp-
tomatic. In many cases the Hem-o-Lok wedged into the wall of the rst or second portion of the duodenum. In all cases,
esophageal gastroduodenoscopy was the primary modality to make the diagnosis. Initial treatment was conservative
with watch-and-wait strategy or proton pump inhibitors followed by endoscopic removal, while surgical treatment was
required in two cases.
CONCLUSIONS: The application of Hem-o-Lok clip during laparoscopic surgery is safe and effective. Postoperative
Hem-o-Lok migration into the duodenum is rare. The treatment could be conservative in the majority of cases.
(Cite this article as: Barabino M, Luigiano C, Piccolo G, Pellicano R, Polizzi M, Giovenzana M, et al. Hem-o-Lok clip mi-
gration into the duodenum after laparoscopic digestive surgery: a systematic review. Minerva Chir 2019;74:496-500. DOI:
10.23736/S0026-4733.19.08152-5)
Key words: Foreign-body migration; Digestive system endoscopy; Laparoscopy; Duodenum.
Minerva Chirurgica 2019 December;74(6):496-500
DOI: 10.23736/S0026-4733.19.08152-5
© 2019 EDIZIONI MINERVA MEDICA
Online version at http://www.minervamedica.it
Introduction
In the era of the mini-invasive surgery, there
are several methods for ligation of anatomical
structures and vessel (arteries and veins), such as
loops, laparoscopic stitches, endoscopic staplers
and clips. Application of loops and laparoscopic
stitches requires uncommon surgeon’s skills and
training, while the use of endoscopic staplers in-
volves an important economic cost. On the other
hand, the use of hemostatic clips is easy and in-
tuitive. Today the most common laparoscopic
procedure remains laparoscopic cholecystecto-
my (LC) which is the gold standard procedure

HEM-O-LOK CLIP MIGRATION AFTER DIGESTIVE SURGERY BARABINO
Vol. 74 - No. 6 MINERVA CHIRURGICA 497
roscopic surgery,” “Duodenum.” All relevant
articles published in English were retrieved up
to June 2019. Additionally, the references of re-
viewed articles were scrutinized to obtain any
other reference that eluded the primary search.
For studies published in languages other than
those mentioned above, all available information
was taken from their English abstracts. All stud-
ies that contained material applicable to the topic
were considered. Retrieved manuscripts were
reviewed by the authors, and the data were ex-
tracted using a standardized collection tool. Data
were analyzed using descriptive statistics.
Evidence synthesis
At the time of this review, a total of seven cas-
es19-25 have been described (Table I, Figure
1).19-25 The mean age of these patients was 49
years (range: 41 to 65 years) and the majority of
them were women (57%).
Previous laparoscopic surgery was performed
for cholecystectomy (four patients),19-22 chole-
cystectomy with laparoscopic common bile duct
exploration (one patient),23 right hemicolectomy
(one patient),24 and distal gastrectomy (one pa-
tient).25
Symptoms occurred from 3 months to 2 years
after laparoscopic surgery. The majority of pa-
tients developed symptoms of bowel occlusion
(nausea, vomit) and abdominal pain. Three pa-
tients remained asymptomatic and only one devel-
oped melena and anemia. In many cases the Hem-
o-Lok wedged into the wall of the rst or second
portion of the duodenum, induced inammation
and erosion of the mucosa. In all cases esopha-
geal gastroduodenoscopy (EGDS) was the pri-
mary modality to make the diagnosis. Abdominal
computer tomography (CT) scan was performed
to excluded collection in the retroperitoneum or
free air in peritoneum. Initial treatment was con-
servative with watch and wait strategy or proton
pump inhibitors (PPIs) followed by endoscopic
removals. Surgical treatment was performed in
only two cases,21, 22 to avoid further duodenal le-
sions, such as bowel perforation. In one case the
endoscopic removal of the clip was unsuccessful
and was performed a Roux-en-Y gastrojejunos-
tomy for persistent bowel occlusion.22
to treat symptomatic or complicated cholecys-
tolithiasis,1-3 despite the advent of newer mini-
mally invasive approaches, such as robotic or
natural orice transluminal endoscopic surgery
(NOTES).
During LC, surgeons use hemostatic clips for
ligation of the cystic duct and the cystic artery
routinely. Since its introduction metal clips are
generally considered safe and effective. Howev-
er, post-cholecystectomy clip migration is well
recognized.4 Endoclips can migrated into the bile
duct with stricture or resultant stone formation
inside the biliary tree.5 Choledochoduodenal s-
tula, duodenal ulcer or clip embolism have also
been described in literature.6-8 Nevertheless, de-
spite a large number of LC, which are performed
annually worldwide, these complications remain
rare.
Today the Hem-o-Lok clip (WECK Closure
Systems, Research Triangle Park, NC, USA)
represents a useful alternative to metal clips.9
This device has become popular among laparo-
scopic urologists for the ligation of the renal hi-
lum vessels during minimally invasive nephrec-
tomy.10 Since then, many surgeons have used this
clip for other laparoscopic surgical procedures,
including complicated LC and digestive laparo-
scopic surgery.11-13
The Hem-o-Lok clip is a nonabsorbable poly-
mer clip which has a lock engagement feature.
From its rst introduction in 1999, several cases
of Hem-o-Lok migration into the rectum and uri-
nary bladder during radical prostatectomy have
been reported in the literature.14-18 On the other
hand, in 2013 Seyyedmajidi et al.19 reported the
rst case of Hem-o-Lok clip migration into the
duodenum after LC. To evaluate the relevance
of this issue, we performed a review of all cases
of Hem-o-Lok clip migration into the duodenum
reported in literature after laparoscopic digestive
surgery, in order to identify its causes, risk factors
and the correct management of this complication.
Evidence acquisition
This review is based on the results of searches
carried out in MEDLINE, PubMed, Scopus, Web
of Science and Google Scholar. The search terms
used were “Hem-o-Lok clips migration,” “Lapa-

BARABINO HEM-O-LOK CLIP MIGRATION AFTER DIGESTIVE SURGERY
498 MINERVA CHIRURGICA December 2019
Migration of metal clip into the common bile
duct after LC was rst reported in 19924 and a
comprehensive review of less than 100 cases
was published in the year 2010.5 The postulated
mechanisms that led to subsequent biliary com-
plications included: clip invasion into the wall
of the biliary tree with possible biliary stricture
or migration inside the common bile duct with
consequent stone formation. Surgical clips can
migrate also into the duodenum and exception-
ally into the blood vessels with one case of clip
embolization in the pulmonary artery.1
Metallic clips involve a higher risk of dis-
placement than Hem-o-Lok clips, due to lower
friction between surrounding structures and for
a less effective closure mechanism.11 However,
recently several authors reported the migration
of Hem-o-Lok clips after urologic surgery pro-
cedures.14-18, 26
From literature review only twelve reports
were reviewed about Hem-o-Lok migration in
adjacent viscera after laparoscopic digestive sur-
gery, including: 20 cases of Hem-o-Lock clip mi-
gration in common bile duct,23, 27-29 seven cases
of migration into the duodenum,19-25 and two
cases of Hem-o-Lock clips related complications
after colorectal surgery.30
Since many patients remained asymptomatic
for many months or years, today the true inci-
Discussion
Post laparoscopic surgery metal clip migration is
a rare but well-established late complication in
literature;4, 5 rarer is the silent Hem-o-Lok clips
invasion.19, 20
Table I.— Details of the included studies.19-25
Study Year N.
patients Age Sex Type of
surgery
Time from
surgery Symptoms Diagnosis Treatment
Seyyedmajidi et al.19 2013 1 41 F LC 8 months Severe
abdominal
pain
EGDS Endoscopic removal
Soga et al.20 2016 1 66 F LC 13 months Asymptomatic EGDS, CT scan PPI/clip passed
naturally
Padmanabhan et al.21 2016 1 59 F LC 2 years Abdominal
pain,
diarrhea,
melena
EGDS, CT scan Laparoscopic removal
Barabino et al.22 2018 1 65 M LC 3 months Epigastric
pain, bowel
occlusion
CT scan, EGDS Roux-en-Y
gastrojejunostomy
Zheng et al.23 2018 1 NR M LC,
LCBDE
4 months Abdominal
pain
EGDS PPIs/clip passed
naturally
Garrido et al.24 2018 1 56 F LRH 19 months Asymptomatic EGDS, CT scan Endoscopic removal
Park et al.25 2018 1 58 M LADG 6 months Asymptomatic EGDS PPIs/clip passed
naturally
NR: not reported; F: female; M: male; LC: laparoscopic cholecystectomy; LCBDE: laparoscopic common bile duct exploration; LRH:
laparoscopic right hemicolectomy; LADG: laparoscopy-assisted distal gastrectomy; EGDS: esophageal gastroduodenoscopy; CT: computed
tomography; PPI: proton pump inhibitors.
Figure 1.—Flow chart of study selection process.
Potentially relevant articles
indentied and screened (N.=99)
Papers included in the review
(N.=12) (22 cases)
- Hem-o-Lok clip migration in
common bile duct (N.=4) (20
cases)
- Hem-o-Lok clip related
complications after colorectal
surgery (N.=1) (2 cases)
- Hem-o-Lok clip migration into
duodenum (N.=7) (7 cases)
Potentially appropriate papers
about Hem-o-Lok migration
in adjacent viscera after
laparoscopic surgery (N.=23)
(32 cases)
1st step
Computer assisted exclusion:
selection of papers limited to
the English literature and with
available full-text
2nd step
According to the abstracts two
authors (GP and MB) excluded:
not pertinent papers
Papers analyzed (N.=7)
3rd step
Selection of papers fullling
the requisites for analysis

HEM-O-LOK CLIP MIGRATION AFTER DIGESTIVE SURGERY BARABINO
Vol. 74 - No. 6 MINERVA CHIRURGICA 499
Conclusions
The application of Hem-o-Lok clip during LC is
safe and effective. Postoperative Hem-o-Lok mi-
gration into the duodenum is rare. The treatment
could be conservative with only watch and wait
strategy or PPI-based treatment (with the aim to
reduce acid secretion and to heal gastroduode-
nal erosions or ulcers)31 followed by endoscopic
removals. It should be remembered that, due to
some asymptomatic patients, this complication
could be under diagnosed or misdiagnosed.
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o-Lok function such as: meticulous dissection
and thinning of the anatomical structure, choice
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is rare.
Limitations of the study
Our study is subjected to a number of limita-
tions, the most important of which is the rela-
tively small series of cases reported in the lit-
erature.

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Conicts of interest.—The authors certify that there is no conict of interest with any nancial organization regarding the material
discussed in the manuscript.
Manuscript accepted: September 4, 2019. - Manuscript received: July 28, 2019.
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