Magnetic compression anastomosis for the stricture of the choledochocholedochostomy after ABO-incompatible living donor liver transplantation

Endoscopic magnetic compression stricturoplasty for congenital esophageal stenosis: A case report

BACKGROUND

Congenital esophageal stenosis (CES) is a rare malformation of the digestive tract. Endoscopic dilation and thoracotomy have been the main treatments for CES. However, there is no well-defined management protocol. Magnetic compression stricturoplasty (MCS) has been used in refractory esophageal stricture in children after esophageal atresia.

CASE SUMMARY

We describe the first case of MCS for CES in one female child patient. The child (aged 3 years and 1 mo) was admitted due to frequent vomiting and choking after eating complementary food since 7 mo old. Esophagography and gastroendoscopy showed that there was stenosis in the lower esophagus, suggesting a diagnosis of CES. The patient did not receive any treatment for esophageal stricture including surgery or endoscopic dilation procedures before MCS. MCS procedure was smoothly conducted without complications. At 24 mo after MCS, durable esophageal patency without dysphagia was achieved.

CONCLUSION

MCS may serve as an alternative and efficient method for patients with CES.

Magnetic Compression Anastomosis Is a Good Treatment Option for Patients with Completely Obstructed Benign Biliary Strictures: A Case Series Study

BACKGROUND

Completely obstructed benign biliary strictures (BBS) is a difficult-to-treat condition. Surgery is the main treatment modality with high morbidity and mortality. Recently, the magnetic compression anastomosis (MCA) technique was employed in such cases with low complication rates.

AIMS

To evaluate the effectiveness of the MCA in completely obstructed BBS.

METHODS

21 MCA procedures were performed in 19 patients with completely obstructed BBS. All patients had percutaneous biliary access. Magnets were located to the proximal side of the obstruction via percutaneous biliary sheath and the distal side endoscopically. The procedure was terminated as the magnets attracted. Either self-expandable fully covered metallic stent and/or a growing number of plastic stents were introduced after recanalization was achieved.

RESULT

A total number of 19 patients with completely obstructed BBS resulting from cholecystectomy or liver transplant underwent 21 MCA procedures. Among those, 19 (90.5%) interventions were successful. The median stricture length that had been measured after magnet attraction was 4 mm (range 1-10 mm). The median magnet coupling time in successful cases was 9 days (range 4-27 days). No correlation was found between magnet coupling time and stricture length (p = 0.27). Complications were observed in 6 (cholangitis:1, magnet migration:2, magnet entrapment:3) of 19 successful MCA procedures. Fifteen of the 19 successful procedures had at least a period of stent-free follow-up. Recurrence of stenosis occurred in 7 procedures, of which 4 remained stent-free with retreatment. Eventually, 12 procedures had stent-free last status.

CONCLUSIONS

MCA is an effective and safe treatment option in completely obstructed BBS. Further studies are required for procedural standardization.

Development of a Magnetic Kissing Guidewire and Animal Experiment: a Preliminary Study

Endovascular therapy has been the first option for many vascular diseases. Due to the increasing development of endovascular devices and techniques in recent decades, endovascular procedures could be applied in treating those cases with complex anatomy. Two or three vascular access routes are required to establish through-and-through access in endovascular therapy for arterial occlusive disease and complex aortic aneurysm. Guidewire snaring with a snare kit is essential but sometimes time-consuming in the establishment of through-and-through access. To simplify the procedure, we design the magnetic kissing guidewire (MKG) with a magnetic tip that attracts each other to establish a guidewire route that meets the needs of clinical practice. We conducted the in vitro test to evaluate its magnetic force and the in vivo test to assess its performance in the arteries of twelve sheep. The results revealed that this novel guidewire significantly simplified the establishment of through-and-through access.

Metal, magnet or transplant: options in primary sclerosing cholangitis with stricture

Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease of the biliary tree of unknown etiology leading to stricturing and dilation. There is currently no effective medical therapy for PSC and liver transplantation (LT) remains the ultimate treatment for severe disease defined as repeated episodes of cholangitis, decompensated biliary cirrhosis or in exceptional cases, cholangiocarcinoma (CCA). Patients often present with a "dominant" stricture and the therapeutic endoscopist plays an important role in management to improve biliary patency using a variety of techniques that involve sampling, balloon dilation and temporary stenting. Newer modalities such as self-expanding metal stents or magnetic compression anastomosis that have been used in other diseases may have a role to play in PSC but should remain investigational. Liver transplantation for PSC is curative in most cases but the optimal timing remains unclear. The lifetime risk of CCA is 10-15% in PSC patients and LT is often not possible at the time of diagnosis. Multiple studies have tried to identify risk factors and to diagnose CCA at an early stage when surgical resection may be possible or LT can be performed. However, deceased donor organs for LT remain in short supply throughout the world so even identifying PSC patients with CCA at an early stage may not be beneficial unless a live donor organ is available.

Magnetic compression anastomosis for the complete dehiscence of hepaticojejunostomy in a patient after living-donor liver transplantation

Background

Magnetic compression anastomosis (MCA) is a minimally invasive method of anastomosis that does not involve a surgical procedure in patients with stricture, obstruction, or dehiscence of anastomosis after surgery. We experienced a case of complete dehiscence of bilioenteric anastomosis that was successfully treated by MCA.

Case presentation

A 55-year-old woman received ABO-incompatible right-lobe living-donor liver transplantation with hepaticojejunostomy for the right anterior duct (RAD) and right posterior duct (RPD). Nineteen days after the operation, bilious and bloody discharge was detected from the abdominal drain. We performed an emergency operation and found that the anastomosis was completely dehiscent. We placed bile drainage catheters into the stumps of the RAD and RPD. She repeatedly experienced cholangitis after the surgery, so we added percutaneous transhepatic cholangial drainage (PTCD) tubes. We decided to treat the complete dehiscence of anastomosis by MCA. One year after the liver transplantation, we performed MCA for the RAD. The bilioenteric fistula was completed 21 days after MCA, and the magnets were retrieved by double-balloon endoscopy. Two months later, MCA for the RPD was also performed by the same procedure. The bilioenteric fistula was not completely established, so we performed double-balloon endoscopy and pulled the magnets down 47 days after MCA for the RAD. The internal/external bile drainage tubes were then left in place to maintain the bilioenteric fistula. Twelve months after MCA for the RAD and 19 months after MCA for the RPD, we removed the tubes without any complications.

Conclusion

Magnetic compression anastomosis for stricture, obstruction, or dehiscence of the anastomosis after living-donor liver transplantation was an effective and safe procedure.

Successful Treatment of Stricture of Duct-to-Duct Biliary Anastomosis After Living-Donor Liver Transplantation of the Left Lobe: A Case Report

Biliary complications, such as stricture or obstruction, after living-donor liver transplantation (LDLT) remain major problems to be solved. Magnetic compression anastomosis (MCA) is a minimally invasive method of biliary anastomosis without surgery in patients with biliary stricture or obstruction. A 66-year-old woman had undergone LDLT for end-stage liver disease for primary biliary cholangitis 20 months previously at another hospital. Computerized tomography showed dilation of the intrahepatic bile duct (B2). Because B2 was invisible with the use of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage (PTBD) was performed for treatment of cholangitis. The rendezvous technique failed because a guidewire could not pass through the biliary stricture. Therefore, we decided to perform MCA. A parent magnet was endoscopically placed distally in the common bile duct of the stricture, and a daughter magnet attached to a guidewire was inserted proximally through the fistula tract of the PTBD. Both magnets were positioned across the stricture, and the 2 magnets were pulled to each other by magnetic power, to sandwich the stricture. By 14 days after MCA, a fistula between B2 and the common bile duct was created. At 28 days after MCA, the magnets were removed distally and a 16-French tube was placed across the fistula. At 7 months after MCA, that tube was removed. In conclusion, when a conventional endoscopic or percutaneous approach including the rendezvous technique fails, MCA is a good technique for biliary stricture after LDLT.