VCS（vascular closure staple）クリップを用いた腹腔鏡下総胆管直接閉鎖術の長期成績

Evaluation of laparoscopic direct closure of common bile duct using vascular closure staple（VCS）

われわれは一定期間，総胆管結石症にて腹腔鏡下総胆管切開時に血管吻合用クリップであるVCSクリップ（vascular closure staple）を用いた総胆管直接閉鎖術を施行してきた．計16例に本術式を施行し，外来にて定期的に血液検査，MRCPなどを施行した（最長観察期間は6年7か月）．1例に術後1年目に総胆管結石再発を生じたがクリップとの明らかな関連は認めず，この症例以外は再発結石を認めていない．術直後に胆汁瘻と胆管狭窄を認めた症例では，フォローアップのMRCPでは明らかな胆管狭窄はなく，肝胆道系酵素の上昇も認めていない．VCSクリップは腹部X線や超音波検査では胆管閉鎖部に残存し，観察範囲ではクリップの脱落などは認めなかった．VCSを用いた腹腔鏡下総胆管直接閉鎖術は，器具の改良などがなされれば総胆管結石治療の1つの選択肢となりえると思われるが，今後も厳重な経過観察が必要と考える．

　We have performed laparoscopic direct closure of choledochotomy in choledocholithiasis patients using the vascular closure staple （VCS）, a clip for vascular anastomosis. We performed this procedure in a total of 16 patients, and followed them for up to 6 years and 7 months. Only one patient had recurrent common bile duct stones one year after the surgery. However, there was no obvious causal relationship between VCS and the recurrent stones. The remaining patients had no recurrence of common bile duct stones. In one patient who developed biliary fistula and stenosis immediately after the surgery, follow-up MRCP showed no evidence of bile duct stenosis, and there were no elevated levels of biliary tract enzymes. On abdominal Xp and ultrasound, the VCS clip remained at the site of bile duct closure, and no clip detachment was identified.

　With the improvement of instruments, laparoscopic common bile closure using the VCS may become a suture option for laparoscopic closure of choledochotomy, but close follow-up is needed.