Use of a metallic-wall stent in the magnet compression anastomosis technique for bile duct obstruction after liver transplantation

Abstract

Stricture at the biliary anastomosis is the most common surgical complication of living donor liver transplantation (LDLT).1, 2 The magnet compression anastomosis technique (MCT), which was first described in 1998 by Yamanouchi et al.,3 provides a simple treatment alternative for patients with biliary stenosis.4 The clinical feasibility, safety, and usefulness of MCT have been established and demonstrated in various stenoses and occlusions, and this spares the patient from another surgery.5, 6 Furthermore, recent reports of cases with severe biliary stricture after LDLT have described the successful dilatation of the stenotic segment by MCT.7, 8 A key step in this procedure is the delivery of the magnet, especially the parent magnet, through the common bile duct via the papilla of Vater. In fact, some reports have described difficulty in delivering the magnet with this method.9, 10 B5, segment 5 branch; B8, segment 8 branch; CBD, common bile duct; LDLT, living donor liver transplantation; MCT, magnet compression anastomosis technique. We describe here the case of a 34-year-old woman who underwent right-lobe LDLT but subsequently developed complete occlusion of the anastomosis of the segment 5 branch (B5; Fig. 1). MCT was unsuccessful because the magnet was trapped in the cholangiopancreatic bifurcation and could not be advanced into the common bile duct (Fig. 2A). Accordingly, we tried magnet compression anastomosis again after modification of MCT. First, under endoscopy, we inserted a metallic-wall stent (Boston; outer diameter: 10 mm, length: 50 mm; Fig. 2B) into the common bile duct via the papilla of Vater (Fig. 3A). The parent magnet was delivered safely through the stent to the stump of the right bile duct. The daughter magnet was then delivered to the end of the bile duct of B5, and the magnet compression anastomosis was successfully completed (Fig. 3B). After the completion of the magnet compression anastomosis, the stent was pulled out under endoscopy without any difficulty or complication. Three weeks later, a fistula was created between the bile duct of B5 and the stump of the right bile duct. The parent-daughter magnets in the common bile duct were subsequently removed endoscopically through the papilla of Vater (Fig. 4). Xper computed tomography image with percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography. An endoscopic nasal bile duct drainage tube was inserted into the bile duct of the anterior superior segment (B8). The bile duct of the anterior inferior segment (B5) was completely occluded, and the distance between the stump of B5 and the anastomosis was more than 5 mm. Abbreviations: B5, segment 5 branch; B8, segment 8 branch; CBD, common bile duct. (A) The parent-daughter magnet. The parent magnet (diameter: 5 mm, length: 5 mm) is on the left; the daughter magnet (diameter: 4 mm, length: 9 mm) is on the right. (B) The metallic-wall stent (outer diameter: 10 mm, length: 50 mm). Magnetic compression technique. (A) The metallic wall stent was inserted into the common bile duct via the papilla of Vater, and the daughter magnet was inserted into the stump of the segment 5 branch through a 14-Fr sheath tube. (B) The parent magnet was delivered through the wall stent and adhered to the daughter magnet. Creation of a fistula between the bile duct of the segment 5 branch and the stump of the right bile duct at 3 weeks after the magnet compression anastomosis technique. Three days later, the parent-daughter magnets in the common bile duct were removed under endoscopy through the papilla of Vater. The metallic-wall stent is useful especially when difficulties are faced with MCT. It should be noted, however, that the stent insertion/removal from the common bile duct carries some risks. For example, bleeding during extraction is a common complication, although it has been reported that the stent can be safely pulled out under endoscopy several months after the insertion.11, 12 In our case, the stent was removed immediately after delivery of the magnet without any granulation tissue formation around the stent. Therefore, the risk of bleeding was considered low in our case. When it is difficult to deliver the parent magnet through the common bile duct, the wall stent may help us perform magnet compression anastomosis safely.