Biliary-duodenal anastomosis using magnetic compression following massive resection of small intestine due to strangulated ileus after living donor liver transplantation: a case report

Abstract

BackgroundDespite the improvements of surgical techniques and postoperative management of patients with liver transplantation, biliary complications are one of the most common and important adverse events. We present a first case of choledochoduodenostomy using magnetic compression following a massive resection of the small intestine due to strangulated ileus after living donor liver transplantation.Case presentationThe 54-year-old female patient had end-stage liver disease, secondary to liver cirrhosis, due to primary sclerosing cholangitis with ulcerative colitis. Five years earlier, she had received living donor liver transplantation using a left lobe graft, with resection of the extrahepatic bile duct and Roux-en-Y anastomosis. The patient experienced sudden onset of intense abdominal pain. An emergency surgery was performed, and the diagnosis was confirmed as strangulated ileus due to twisting of the mesentery. Resection of the massive small intestine, including choledochojejunostomy, was performed. Only 70 cm of the small intestine remained. She was transferred to our hospital with an external drainage tube from the biliary cavity and jejunostomy. We initiated total parenteral nutrition, and percutaneous transhepatic biliary drainage was established to treat the cholangitis. Computed tomography revealed that the biliary duct was close to the duodenum; hence, we planned magnetic compression anastomosis of the biliary duct and the duodenum. The daughter magnet was placed in the biliary drainage tube, and the parent magnet was positioned in the bulbus duodeni using a fiberscope. Anastomosis between the left hepatic duct and the duodenum was accomplished after 25 days, and the biliary drainage stent was placed over the anastomosis to prevent re-stenosis. Contributions to the successful withdrawal of parenteral nutrition were closure of the ileostomy in the adaptive period, preservation of the ileocecal valve, internal drainage of bile, and side-to-side anastomosis.ConclusionsCholedochoduodenostomy with magnet compression could be a less invasive and safer method for treatment of biliary stricture that cannot be accessed by conventional surgery.

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“…According to the report, the length of the time period before removal of the magnets depends upon the distance between the two magnets and their strength. The length of time required for anastomosis by the MCA is 7–10 days with choledochoenterostomy and 10 or more days with enteroenterostomy [ 7 ]. An additional bougie was administered after MCA in three cases, including our own.…”

Endoscopic applications of magnets for the treatment of gastrointestinal diseases

“…Magnetic compression anastomosis is usually used for severe biliary stenosis[31,32] and complete biliary obstruction[33-36] that are difficult to manage using conventional nonsurgical interventions. Based on the specific situation, either biliobiliary anastomosis[31,34,35] or bilioenteral anastomosis[33,37,38] can be conducted. The proximal magnet (mother magnet) is usually inserted through the percutaneous transhepatic biliary drainage (PTBD) tract, while the distal magnet (daughter magnet) can be delivered in three ways: endoscopically (Figure 4), through a second PTBD tract, or through a surgically formed fistula[39].…”

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“…e) Distal common bile duct obstruction caused by malignant tumors of pancreas, duodenum and bile duct, and incarcerated stones. Roux-en-Y choledochojejunostomy has become an important surgical method for the treatment of biliary diseases, which can significantly improve biliary obstruction and relieve symptoms [7].…”