腹腔镜胆囊切除术后金属夹体内留置的影响

Influence of retained metal clips in abdomen after celioscopic cholecystectomy

目的 探讨腹腔镜胆囊切除术（ＬＣ）常用的金属夹在体内长期存留对肝胆组织的影响。方法 （１）随访术后４～５ 年的２５４例患者，选其中６０例作Ｂ超、ＣＴ和肝功能酶学检查；（２）家兔３０只分丝线、钛夹和银夹三组行开腹胆囊切除术，分别于术后２、４ 及６个月用常规和电镜形态学方法检查其肝胆局部组织变化。结果 （１）６０ 例Ｂ超、ＣＴ未发现金属夹临近的胆总管有异常改变；肝功能酶学检查结果属于正常范围。（２）实验动物肝胆局部组织一般形态学检查发现，钛夹周围异物反应最轻，银夹次之，丝线结最强；银夹体内留置２个月即出现锈蚀，其附近组织中出现异常棕褐色沉着物，汇管区的枯否细胞增生逐月加重，钛夹无锈蚀，沉着物出现晚而少，丝线组无。超微结构检查发现，两组金属夹动物的肝细胞内高密度次级溶酶体增多，银夹明显重于钛夹。结论 ＬＣ使用的金属夹长期滞留体内，虽未发现对胆管的直接病理损害，但对金属夹周围肝组织有毒性反应，银夹尤其明显，应予重视。

Objective The long term effects on hepatobiliary system due to retained metal clips in laparoscopic cholecystectomy(LC) were studied. Methods Hepatobiliary BUS, CT and enzymology were conducted in 60 patients selected from a series of 254 cases having had LC 4~5 years previously. Silk sutures, Ti and silver metal clips were applied in open cholecystectomies for experimental study on rabbits respectively ( n=30, 10 for each material ). Tissues from animal liver and stump of residual cystic duct were taken after 2, 4, 6 months following surgery for morphological examinations by light and electronic microscopes. Results In patients no abnormality was detected by BUS, CT in the vicinity of clips applied, nor by hepatic enzymology. Foreign body reactions appeared comparatively serious around silk sutures, moderate and mild near silver and Ti clips. Within silver clips rusty spots were seen at 2 month specimens, associated with brown and dark sediments in surrounding tissue and proliferations of Kupffer’s cells in hepato portal area. Ti clips showed rustless and less sediments. With metal clips the ultrastructure of experimental hepatic tissue demonstrated increment of secondary lysosomes with high density, particularly in animals with silver clips. Conclusion Despite no direct pathological impairment was found in sites of metal clips retained for years, toxic effect on hepatic cells did result in by retention of metal clips , in particular the silver ones. This calls for attention.