Magnet compression anastomosis for bile duct stenosis after duct-to-duct biliary reconstruction in living donor liver transplantation (2005)

A 44-year-old woman who had undergone living donor liver transplantation for fulminant hepatic failure presented obstructive jaundice 1 year after transplantation. A right lobe from her husband had been used for the original graft. Intraoperative cholangiography of the donor showed the bile duct of posterior inferior segment (B6) branching from the bile duct of anterior segment (Fig. 1). The bile duct of the donor was transected in the very short segment of the common trunk of the posterior and anterior branches of the right lobe. The orifice of the bile duct of the graft was single, but the shape of it was like the nose of a pig. This single orifice was anastomosed to the stump of the recipient's common hepatic duct. A biliary stent tube (4-French-sized) was inserted into only the bile duct of the posterior segment. Cold- and warm-ischemia time was 42 and 45 minutes, respectively. She initially recovered uneventfully in the early period after liver transplantation. The external stent tube was removed 3 months after the transplantation. Intraoperative cholangiogram of the donor in the initial living donor liver transplantation. Bile duct of posterior inferior segment (B6) branching from the bile duct of the anterior segment Laboratory data at 11 months after the transplantation showed slight elevation of transaminases (aspartate aminotransferase: 80 IU/L, alanine aminotransferase: 100 IU/L) and total bilirubin (1.4 mg/dL). One month later, ultrasonography showed the dilated intrahepatic duct. Endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography disclosed the complete obstruction of the anterior branch (Fig. 2). The dilated duct was drained by the percutaneous transhepatic cholangiography drainage tube. Balloon dilatation was attempted though the percutaneous transhepatic cholangiography drainage tube, but it was not possible because the guidewire could not pass the stenosis. Relaparotomy with choledochojejunostomy was considered, but the patient strongly preferred the nonsurgical procedure. That is why the magnet compression anastomosis was applied. (A) Percutaneous transhepatic cholangiography showed complete biliary obstruction of the anterior branch. (B) Endoscopic retrograde cholangiography could not show the anterior branch. As preparation for the procedure, the percutaneous transhepatic cholangiography drainage tube had been gradually dilated by 2-French-size every week from 8 French to 18 French. The papilla Vateri had been also enlarged by the endoscopic sphincterectomy, A minor tranquilizer (diazepam 10 mg) was given to the patient prior to the procedure. The parent magnet (diameter 4 mm) attached to a guide with a covered tube was inserted into the common bile duct and placed at the common bile duct side of the stricture (Fig. 3). A 16-French-sized sheath tube was inserted through the dilated percutaneous transhepatic cholangiography drainage fistula, and the daughter magnet attached to a guide wire was inserted to the intrahepatic duct (Fig. 4A-B). The 2 magnets were immediately attracted toward each other, sandwiching the stricture (Fig. 4C) (Yamauchi procedure1, 2). The sheath tube was removed and changed to the indwelling porous percutaneous transhepatic cholangiography drainage tube. Establishment of the reanastomosis was assured by day 42 with radiological examinations (Fig. 5). The indwelling drainage tube was pushed and was inserted down to the common bile duct through the anastomosed stoma, as the internal stent tube maintained the patency. The stent tube was removed 3 months later. There has been no recurrence of the stricture in the 15 months of follow-up after the creation of the new stoma. Placing of the parent magnet. (A) A parent magnet (diameter 4 mm) attached to a guide with covered tube was placed endoscopically through the papilla Vateri that was enlarged enough with endoscopic sphincterectomy at supine position. (B) The parent magnet was placed at the stricture point. Placing of the daughter magnet. (A) The daughter magnet attached to a guide wire was inserted through the sheath tube. (B) The daughter magnet was placed into the obstructed intrahepatic duct. (C) The 2 magnets were immediately attracted toward each other. Reanastomosis was established by day 42 after magnets were inserted.