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Gastrointestinal Endoscopy Excellence Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
Gastrointestinal Endoscopy Excellence Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, ThailandRajavithi Surgery Endoscopy Department, Faculty of Medicine, Rajavithi Hospital, Bangkok, Thailand
Gastrointestinal Endoscopy Excellence Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
Gastrointestinal Endoscopy Excellence Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
Magnetic compression anastomosis via EUS-guided hepaticogastrostomy for recanalization of complete common hepatic bile duct transection.
The magnetic compression anastomosis technique provides a minimally invasive method to create an anastomosis by using the attractive force between 2 magnets. Recently, the magnetic compression anastomosis has been applied to both malignant and benign biliary strictures.
We report herein a novel endoscopic technique for the treatment of complete transection of the common hepatic bile duct after liver resection.
A 49-year-old woman who had undergone liver resection (Video 1, segment 5, 6, available online at www.giejournal.org; Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7) for hepatocellular carcinoma 1 year prior presented with progressive painless jaundice. Abdominal CT showed dilated common hepatic and intrahepatic bile ducts. Subsequent ERCP revealed complete common hepatic bile duct transection. EUS-guided hepaticogastrostomy was performed and a 7F, 15-cm double-pigtail plastic stent was inserted into the hepaticogastrostomy tract through segment 2 of the liver. However, the patient developed a liver abscess 2 months later. The hepaticogastric plastic stent was then exchanged for a 10- × 60-mm fully covered self-expandable metal biliary stent to ensure adequate biliary drainage. Cholangiogram again demonstrated a complete transection of the common hepatic bile duct.
Figure 1ERCP revealed complete common hepatic bile duct transection.
Figure 2A custom-made gold-plated neodymium magnet, 3 mm in diameter, was loaded onto a 10F stent pusher. A side hole was created on the pusher using a surgical blade to facilitate over-the-guidewire insertion.
Figure 3The second magnet was placed just below the transection site as close to the first magnet as possible, leaving only a 1.5-cm gap between the magnets.
Figure 4One week later, the 2 magnets were approximated at the transection site. ERCP was then performed with successful passage of a 0.035-inch Jagwire (Boston Scientific, Marlborough, Mass, USA) across the previously transected duct.
Figure 6A 10- × 80-mm fully covered self-expanding metal stent with an interlocking 7F, 15-cm double-pigtail plastic stent was then placed across the stricture site.
Figure 7A cholangiogram after stent removal demonstrated complete recanalization of the common hepatic duct with good bile flow through the transection site.
To internalize biliary drainage via the natural transpapillary route, we decided to use the magnetic compression anastomosis technique. A custom-made gold-plated neodymium magnet, 3 mm in diameter, was loaded onto a 10F stent pusher. A side hole was created on the pusher using a surgical blade to facilitate over-the-guidewire insertion. First, the hepaticogastrostomy tract was cannulated using a swing-tip catheter through the fully covered metal stent. The daughter magnet then was introduced into the hepaticogastrostomy tract and detached using a Savary-Gilliard guidewire (Cook Medical, Bloomington, Ind, USA). Thereafter, the magnet was pushed forward to the transection site by a sphincterotome. Once the magnet was at the desired site just above the transected duct, transpapillary biliary cannulation followed by another 3-mm parent magnet insertion was performed. The second magnet was placed just below the transection site as close to the first magnet as possible, leaving only a 1.5-cm gap between the magnets.
An exploratory abdominal x-ray 1 week later confirmed satisfactory approximation between the 2 magnets. ERCP was then performed with successful passage of a 0.035-inch Jagwire across the previously transected duct. An 8-mm balloon dilator was used over the guidewire to dilate the stricture site. Once the transected bile ducts were recanalized, the 2 magnets were immediately removed as they were spontaneously attracted to the metal tip of the duodenoscope. A 10- × 80-mm fully covered self-expandable metal stent with an interlocking 7F, 15-cm double-pigtail plastic stent was then placed across the stricture site. Both stents were left in place for 8 weeks. A cholangiogram after stent removal demonstrated complete recanalization of the common hepatic duct with good bile flow through the transection site. The patient remained asymptomatic at the 4-month follow-up visit.
The common routes of magnet delivery in the magnetic compression anastomosis technique are percutaneous via percutaneous transhepatic biliary drainage tract and peroral using ERCP. However, percutaneous drain compromises the patient’s quality of life and carries a significant infection risk. Magnetic compression anastomosis via an EUS-guided hepaticogastrostomy tract offers a novel noninvasive incisionless alternate option.
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