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

Authors:

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.
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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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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... The use of Hem-o-Lok clips is well described in the adult literature in procedures such as laparoscopic cholecystectomy and laparoscopic or retroperitoneoscopic nephrectomy [9][10][11][12]. There are rare reports of clip migration into surrounding viscera [13,14] which have not been documented in the paediatric population but should remain an important consideration. We acknowledge the short duration of follow-up to date but note that no patients in this study have reported symptoms post-operatively that could be attributable to clip migration. ...
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Background: Nonmetal clip were applied to ligate cystic duct and gall bladder vessels as alternation for metal clip in cholecystectomy (LC) and laparoscopic bile duct exploration (LCBDE). This study aim to explore nonmetal clip migration cases after LC or LCBDE and make literature review. Methods: This study reported six cases of nonmetal clip migration into the gastrointestinal tract or bile duct. Combined with previous literature, it was discussed about the possible risk factors, clinical presentations, outcomes and treatment. Results: Six cases of nonmetal clip migration after LC and LCBDE were found, including 3 cases of Hem-o-lock clips and 3 cases of absorbable clips. The incidence rate of nonmetal clip migration was 1.8% (6/326). Among all complications of 51 cases, the complication rate of clip migration was 11.8%. Four clips migration cases were found after LCBDE T-tube Drainage (66.7%) and two after Primary Closure (33.3%). Five patients with clip migration into CBD (83.3%) and one patients into duodenum (16.7%). Five patients got clips removed and one case just was observated. Literature review showed more cases about nonmetal clip migration. Conclusion: Postoperative nonmetal clip migration was not rare after LC and LCBDE. Migrated clip in CBD may perform stone and lead to severe complication. We should pay more attention to correctly apply clips during LCBDE, make strict follow-up and timely treatment after clip migration.
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The introduction of proton pump inhibitors (PPIs) into clinical practice since about thirty years has greatly improved our therapeutic approach to acid-related diseases for their well recognized efficacy and safety. Accordingly, the role of surgery has been enormously reduced in this field. The main indications for PPI use are universally acknowledged by many scientific societies and are the following: treatment of gastroesophageal reflux disease in its various forms and complications, eradication of H. pylori infection in combination with two or more antibiotics, therapy of H. pylori-negative peptic ulcers, healing and prevention of NSAID-associated gastric ulcers, co-therapy with endoscopic procedures to control upper digestive bleeding and medical treatment of Zollinger Ellison syndrome. Despite the above well defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and this phenomenon poses serious queries about the appropriate prescription of these drugs worldwide. In fact, the endless expansion of PPI market has created important problems for many regulatory authorities for two relevant features : the progressive and irreversible increase of the costs of therapy with this class of drugs and the greater potential harms for the patients. So, there is the need for a reappraisal of PPI correct indications for both general practitioners and various specialists in order to re-establish a correct use of these effective drugs in daily clinical practice, according to the best evidence-based guidelines.
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Introduction: With the development of laparoscopic skills, the laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) has become the standard surgical procedure for choledocholithiasis. We usually use Hem-o-lok clips to control cystic duct and vessels, which is safe on most occasions and has few perioperative complications such as major bleeding, wound infection, bile leakage, and biliary and bowel injury. However, a rare complication of post-cholecystectomy clip migration (PCCM) increases year by year due to the advancement and development of LC, CBD exploration as well as the wide use of surgical ligation clips. Materials and Methods: Six patients whose clips are found dropping into CBD or forming T-tube sinus after laparoscopic surgery in our department. Results: Six patients whose clips are found dropping into CBD (clip-stone) (3/6) or forming T-tube sinus (T clip-sinus) (3/6) after LCBDE or LC. Conclusions: PCCM is a rare but severe complication of LCBDE. A pre-operative understanding of bile duct anatomy, the use of the minimum number of clips and the harmonic scalpel during the surgeries is necessary. Considering clip-stone or clip-sinus in the differential diagnosis of patients with biliary colics or cholangitis after LCBDE even years after surgery, the detailed medical history and pre-operative examination are inevitable, especially for these patients who had undergone LCBDE.
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Migration of metal clips into the duodenum after laparoscopic cholecystectomy is rare. We herein present two cases of migration of metal clips into the duodenum in patients who developed upper quadrant discomfort and a poor appetite after laparoscopic cholecystectomy. Gastroscopy revealed metal clips in the duodenum. In one patient, the clip dropped from the duodenum after 2 months; the other patient went to another institution to undergo duodenotomy. The mechanism underlying migration of a metal clip into the duodenum remains unclear but might be related to chronic inflammation and duodenal peristalsis. In conclusion, clinicians must remember that metal clips can migrate after laparoscopic cholecystectomy and later cause complications.
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A 58-year-old man underwent laparoscopy-assisted distal gastrectomy (LADG) with Billroth I gastroduodenostomy due to early gastric cancer. During surgery, the perigastric vessels were ligated with Hem-o-Lok clips. Esophagogastroduodenoscopy (EGD) 6 months later showed a fungating mass at the anastomosis site. Repeat EGD 1 year after LADG showed a Hem-o-Lok clip at the fungating mass lesion. Because the patient was asymptomatic, with no major abnormalities on clinical examination, and endoscopic removal of the clip would have been difficult due to the presence of adhesions and inflammation, no attempt was made to remove the clip. The patient remained well after the exposed Hem-o-Lok clip was identified. A third EGD 6 months later showed that the clip had disappeared from the anastomosis site, and that this site was covered with normal mucosa surrounding the scar.
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Clip migration into the common bile duct (CBD) is a rare but well-established phenomenon of laparoscopic biliary surgery. The mechanism and exact incidence of clip migration are both poorly understood. Clip migration into the common bile duct can cause recurrent cholangitis and serve as a nidus for stone formation. We present a case, a 54-year-old woman, of clip-induced cholangitis resulting from surgical clip migration 12 months after laparoscopic cholecystectomy and laparoscopic common bile duct exploration (LC+LCBDE) with primary closure.
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Background: The number of surgical operations in elderly patients is increasing due to the aging demographics of western populations. The aim of the present study was to investigate the peri-operative outcome of octogenarian patients undergoing cholecystectomy for acute cholecystitis. Methods: We performed a retrospective analysis including all patients who underwent cholecystectomy for acute cholecystitis from January 2013 to December 2017. Records were collected prospectively from two centers: 1) Unit of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum University, Bologna; 2) "Advanced Surgical Technologies" Department of Surgical Sciences, Umberto I University Hospital, La Sapienza University, Rome. Patients were divided by age (≥ or <80 years) and peri-operative outcomes were compared. Results: During the study period, 464 patients were operated for acute cholecystitis in the two centers. Sixty-three (14%) patients were octogenarians (group 1) and median age was 84.8±3.9 years. Four hundred and one patients (86%) were younger than 80 years (group 2) with median age of 55.3±15.3 years. Forty-four per cent of group-1 patients underwent laparoscopic cholecystectomy versus 81% of the younger group (P<0.01). Elderly patients had a higher percentage of overall complications (25% vs. 9%; P=0.03) and a longer median postoperative length of stay (7.2±6.8 vs. 4.6±7.7; P=0.04). Overall mortality was 1%: two patients died in group-1 and one in group-2 (P=0.50). However, on multivariate analysis age older than 80 years was not found to be an independent risk factor for postoperative morbidity and mortality. Conclusions: The results of this study suggest that cholecystectomy for acute cholecystitis in octogenarians is a relatively safe procedure with an acceptable risk of complications and a postoperative hospital stay comparable to younger ones.
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Hem-o-lok clips have been widely used in laparoscopic or robot-assisted surgery. We report a case of an incidentally discovered Hem-o-lok migration into the bladder after laparoscopic radical prostatectomy. The patient was a 75-year-old man with localized prostate cancer who underwent laparoscopic radical prostatectomy in July 2009. At 3 postoperative years, follow-up ultrasonography revealed a small round mass in the bladder. No lower urinary tract symptoms were reported, and urinalysis results had never indicated hematuria or pyuria. Cystoscopy revealed a Hem-o-lok clip in the bladder, near the vesicourethral anastomotic site. We could not remove it with forceps in the outpatient clinic, so we performed the procedure again under general anesthesia and successfully removed the Hem-o-lok clip. To our knowledge, this is the first report of an asymptomatic Hem-o-lok migration into the bladder.