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Chronic pain from retained Hem-o-lok® clips after pediatric appendectomy: the imperative for surgical removal
Chunhui Gu1,2,3, Lihong Ding1,4, Jian Sun1
1Department of Pediatric Surgery, Huai'an Maternal and Child Health Care Hospital Affiliated to Yangzhou University, Huai'an, China.
Insights
Retained Hem-o-lok clips after pediatric appendectomy are linked to chronic abdominal pain. Surgical clip removal effectively resolved pain in 90.9% of patients, unlike conservative management.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Surgical Materials Science
Background:
- Hem-o-lok clips are commonly used in pediatric laparoscopic appendectomy.
- Rare instances of retained clips have been associated with chronic abdominal pain in children.
- The link between retained clips and persistent pain requires further investigation.
Purpose of the Study:
- To investigate the association between retained Hem-o-lok clips and refractory chronic abdominal pain post-pediatric laparoscopic appendectomy.
- To compare the effectiveness of surgical clip removal versus conservative management for pain resolution.
Main Methods:
- Retrospective cohort study of 11 pediatric patients with persistent right lower quadrant pain after appendectomy.
- Diagnostic evaluation included CT scans, IL-6 measurements, and pain mapping.
- Patients initially received conservative therapy (antibiotics, NSAIDs) followed by surgical clip removal if treatment failed.
Main Results:
- Conservative therapy was ineffective in reducing pain (median ΔVAS = -0.2, P=0.47).
- Surgical clip removal led to complete pain resolution (VAS=0) in 90.9% of patients within 7 days (P<0.001).
- Histopathology confirmed granulomatous inflammation in 81.8% of cases, and IL-6 levels normalized post-removal.
Conclusions:
- Retained Hem-o-lok clips are strongly associated with chronic abdominal pain in children, likely due to foreign body reactions.
- Surgical removal offers rapid symptom resolution, while conservative management is ineffective.
- Further research is needed to confirm causality, but retained clips may contribute to chronic inflammation.
Background:
While Hem-o-lok® clips are widely used and generally safe in children, retained clips have been rarely associated with refractory chronic abdominal pain. This study aimed to investigate the association between retained Hem-o-lok® clips and refractory chronic abdominal pain following pediatric laparoscopic appendectomy and compare therapeutic outcomes between device removal and conservative management.
Methods:
A retrospective cohort study analyzed 11 consecutive pediatric patients who developed persistent right lower quadrant (RLQ) pain [Visual Analog Scale (VAS) ≥3 for >6 weeks] after laparoscopic appendectomy with appendiceal stump closure using Hem-o-lok® clips (2021-2022). Diagnostic evaluation included: contrast-enhanced computed tomography (CT) in 7/11 patients (63.6%), revealing clip-related hypodensities in all 7 cases; Serial interleukin-6 (IL-6) measurements; Quantitative pain mapping. All patients received conservative therapy [ceftriaxone + metronidazole + non-steroidal anti-inflammatory drugs (NSAIDs); mean duration 62.6±14.2 days] prior to surgical intervention. After conservative treatment failure, pain intensity (VAS) was compared between two phases: post-conservative therapy (immediately before surgery). Post-surgical clip removal (7 days postoperatively). Secondary laparoscopic exploration with clip removal and histopathological analysis [International Organization for Standardization (ISO) 10993-6:2016] were performed.
Results:
Conservative therapy failed to reduce pain (median ΔVAS =-0.2, P=0.47).Surgical removal achieved complete pain resolution (VAS =0) in 10/11 patients (90.9%) within 7 days (P<0.001). Histopathology confirmed granulomatous inflammation in 9/11 cases (81.8%). IL-6 levels normalized post-removal (>150 pg/mL vs. <50 pg/mL).
Conclusions:
Retained Hem-o-lok® clips show a strong temporal association with chronic abdominal pain in children, mediated by foreign body reactions. Conservative management was ineffective, while surgical removal rapidly resolved symptoms and restored growth. The observational design and lack of a control group preclude definitive causal inference. The observed association, while supported by histopathology, should be interpreted as generating a hypothesis that retained clips may be a contributor to chronic inflammation in a subset of patients.
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