腹腔鏡下胆管切開切石術後に発生した金属クリップを核とした総胆管結石の1例―クリップレス手術のすすめ―

A case report of surgical clip choledocholithiasis after laparoscopic choledocholithotomy：Encouragement of clipless surgery

症例は84歳，女性．上腹部痛を主訴に近医を受診し，肝機能異常を指摘され，他院を紹介された．諸検査より金属クリップを核とした総胆管結石と診断され，内視鏡的乳頭切開術（endoscopic sphinctecterotomy : EST）により採石が行われた．本例は当院での腹腔鏡下胆管結石治療例であった．金属クリップの迷入は，胆管に接して留置されたクリップの開いた側のedgeが，動脈の拍動などの微細な振動によって脆弱な胆管壁を少しずつ侵食して貫いてくると考えられた．金属クリップによる弊害は徐々にその数を増しており，もはや見逃すことのできない合併症といえる．本例のような合併症を防ぐために，今後胆石症例においてはクリップレス手術とすることが肝要であると考えられた．

　An 84-year-old woman who went to her home doctor for abdominal pain was referred to another local hospital for hepatic dysfunction. Examination revealed surgical clip choledocholithisis, and the patient underwent endoscopic sphincterotomy. She also underwent laparoscopic choledocholithotomy in our hospital 5 years ago. Recently cases of clip migration have increased. We considered that the mechanism of surgical metal clip migration was like the following : the sharp edge of the surgical clip which came in contact with the bile duct encroach upon the fragile wall of the bile duct little by little due to trembling caused by pulsation and peristalsis, and then end up penetrating into the bile duct. We consider that the complication of metal clip shouldn't be overlooked. We recommend that clipless surgery should be performed for cholelithiasis for the prevention of complications due to metal clips.