Can you see filshie clips on ultrasound

CASE CONDENSATIONS GYNECOLOGY

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THE FILSHIE CLIP IN NONSTERILIZATION GYNECOLOGIC LAPAROSCOPY
What happens if a Filshie clip moves?
Do you ovulate with filshie clips?
How long are filshie clips good for?
Can filshie clips come off?

THE FILSHIE CLIP IN NONSTERILIZATION GYNECOLOGIC LAPAROSCOPY

Garcia, Francisco A. R. MD, MPH; Barker, Bel MD; Myloyde, Teressa; Blumenthal, Paul MD, MPH

Department of Obstetrics & Gynecology, the University of Arizona Health Sciences Center, Tucson, Arizona, and the Department of Obstetrics & Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.

Received January 14, 2000, Received in revised form March 30, 2000, Accepted April 20, 2000

This case report may generate many questions about failed sterilisation techniques which need to be discussed, particularly about appropriate usage of dye test/or hysterosalpingography in cases of failed or complicated sterilisation, how important is the consenting for the procedure and how big role can play laparoscopic surgical experience. It is important to emphasise that this patient was under the care of gynaecologist with different level of experience in laparoscopic sterilisation techniques.

Failed sterilisation techniques have been already described in the literature [1]. Some of these cases have been complicated with ectopic pregnancies; other cases needed termination of intrauterine pregnancy or rarely patient decided to keep the pregnancy. Patients can be in great discomfort clinically and psychologically and they need adequate support [2]. However, this case report is in our best knowledge the first one that reports an ectopic tubal unruptured pregnancy after two consecutive sterilisation surgeries with two different techniques [3]. Filshie sterilisation technique is the most popular in UK [4] and following the Royal College of Obstetricians and Gynaecologists guidelines, the failure rate is approximately 1/200. In case of diathermy using bipolar energy for tubal sterilisation, the failure rate is difficult to estimate as there are no published data. In the past, monopolar diathermy on the tubes was used with both higher failure and intraoperative complications rates. In our best knowledge, there are no studies comparing Filshie clip application and bipolar diathermy and their sterilisation failure rates [5].

In our case, the patient needed a diagnostic laparoscopy due to her persistent pelvic pains and three migrated clips (curiously attached all together) were removed successfully. During the first laparoscopic sterilisation, two clips were applied on each tube; however, at the second laparoscopy 4 years later, the remaining proximal end of each tube was very short not allowing any further clip application.

Some will argue that intraoperative dye test should always be done after retrieval of migrated clips in order to obtain macroscopic evidence of tubal blockage and consequently to avoid any surgical interference with the proximal tubes. The potential risk of weak proximal tubal fibrosis in this case with future tubal recanalisation is impossible to evaluate with dye test or hysterosalpingography. A dye test, in these cases of extremely short proximal tubal ends, may not reveal unblocked tubes (as it was confirmed during the third laparoscopy of this patient). Due to the increased intrauterine pressure generated during the dye test, there is a risk of “flush” and partial or complete future desobstruction of the thin fibrotic plug that resulted from the previous migrated Filshie clip. For these reasons in this particular case, it was thought beneficial to diathermise the proximal tubes during the second laparoscopy as the proximal tubal ends were very short from both sides and far away from the tubal clip application point (intermediate part of the tube).

Others will argue that in case of bipolar diathermy the technique needs to secure adequate placement of the bipolar grasper on the surface and periphery of the tubal end. This coagulating consequence of diathermy is difficult to evaluate as the fibrotic effect will depend on the amount of energy applied and how long this was applied for, on the thickness of the proximal tube and also it will depend on the nature of the coagulated tissues and finally the endogenous potential of healing.

Laparoscopic stitching of the uterine cornual end is difficult because needs expertise to avoid uterine trauma and bleeding. The surgical laparoscopic experience and adequate laparoscopic equipment for such operative laparoscopy were not available for the second and third procedure. The consent of this patient did not include conversion to laparotomy for salpingectomy (proximal ends) but only conversion to laparotomy in case of laparoscopic entry technique complications.

With the third laparoscopy, the surgical challenge was first to treat successfully the unruptured tubal ectopic pregnancy with prompt uncomplicated salpingectomies on both remaining distal tubes and secondary to deal with the even shorter cornual tubal ends (remainders) in order to avoid another failure.

A secondary electrocoagulation applied on a larger area at the tubal–cornual origin was performed with the plan to review the patient with a hysterosalpingography 2 months postoperatively in order to demonstrate obstruction. However, even if the hysterosalpingography can show an obstruction it is uncertain for how long this will be maintained and how to follow up the patient.

Hysteroscopic sterilisation is not possible as there is no proximal tubal end long enough to secure permanent and uncomplicated insert placement. Hysteroscopic usage of intrafallopian “glue” for obstruction is not yet available. Further extensive laparoscopic excisions of the uterine cornual ends cannot guarantee complete obstruction either.

The future management options were discussed with the patient in the postroperative follow up and she opted for MIRENA IUS® rather other long-term contraceptive method or further surgery with laparotomy (cornual excision or hysterectomy).

Some questions and uncertainties could be highlighted with this case report. We do not know what could be the physiological healing history of the remaining proximal tube in case of migrated Filshie clips and so whether a recanalisation is a rare but unavoidable risk or whether there is an increased likelihood of recanalisation after usage of diathermy. It could be assumed that all would depend on the length and consistency of the fibrosis which is maintained at the most distal part of the proximal remaining tube. Most of surgeons use currently only one Filshie clip adequately applied on each tube. However in our case, two clips were applied and the ischemia and scar formation could be different than with 1 clip application. In our case, also all four clips migrated. Perhaps the usage of two clips on each tube might have created more tubal ischemia and hence higher risk of clip migration in long term. The ischemic tissue might become weaker in time and clips might not maintain in the appropriate position on the tubal isthmus.

What happens if a Filshie clip moves?

Migrated clips may present as chronic groin sinus, perianal sepsis, or chronic abdominal pain. These symptoms can occur as early as 6 weeks or as late as 21 years after application.

Do you ovulate with filshie clips?

Serial abdominal ultrasonography in women sterilized by Filshie-clips confirmed ovulation in all cycles except in one woman, who had an unruptured follicle in one cycle before and in the sixth cycle after sterilization.

How long are filshie clips good for?

Subsequent research provides data for Filshie clip failure rates up to 24 months, but rigorously designed and executed studies examining failure rates beyond 2 years are lacking.

Can filshie clips come off?

Filshie clips can fall off the tubes commonly. We estimate about 10% of patients have one or both clips fallen off the tube at the time of reversal surgery.