Magnetic compression anastomosis for the treatment of benign biliary strictures: a clinical study from China

Post-cholecystectomy total bile duct strictures: Cases for magnetic compression anastomosis

Bile duct injuries are a serious issue, and their surgical treatment carries the risk of morbidity and mortality. In selected cases, non-surgical treatments are possible, even for total strictures. We outline the technique and results of using magnetic compression anastomosis (MCA) to treat post-cholecystectomy bile duct stricture (PCBDS), in two female patients. Initially, a bilio-cutaneous tract was established via external biliary drainage, followed by the positioning of both endoscopic and percutaneous biliary magnets. After their approximation and subsequent removal, a fully covered self-expandable metal stent (FCSEMS) was deployed across the stricture. The magnet coupling was successfully achieved within the first two weeks of placement. The FCSEMS was maintained for durations of 12 and 16 months. Follow-up durations were 28 and 15 months post-FCSEMS removal. Both patients remain asymptomatic, with normal laboratory and imaging studies, and no adverse events were reported. MCA proves to be a safe and effective method for treating selected cases of total PCBDS. However, further studies and long-term follow-up are required to fully assess the efficacy of this technique.

Combined endoscopic-percutaneous approach for magnetic compression anastomosis in post-transplant anastomotic biliary strictures

OBJECTIVES

To investigate long-term outcomes of combined endoscopic-percutaneous methods for endoscopically unmanageable anastomotic biliary strictures in living donor liver recipients.

MATERIALS AND METHODS

This retrospective single-center study included 144 patients referred for biliary stricture between November 2017 and May 2023. Eighty-eight patients (leak = 8, non-anastomotic stricture = 3, treatment refused = 12, successful ERCP = 65) were excluded. Patients initially underwent percutaneous biliary drainage. Patients for whom percutaneous intervention was successful in traversing stricture were followed up with fully-covered self-expandable metallic stents and/or plastic catheter stents. However, in case of failure, magnetic compression anastomosis (MCA) was performed.

RESULTS

A total of 56 patients (mean age, 59 years ±11; 35 men) comprised the study group. Percutaneous intervention was successful in traversing the stricture in 26/56 patients. Among the remaining 30 patients, 26 were eligible for MCA, which was performed successfully in 24 patients (92%). The mean duration from magnet placement to internalization was 7.71 ± 2.77 days (95% CI: 6.54-8.88). Altogether, in 47 patients (24 of whom underwent MCA), percutaneous drains were removed following biliary stenting. The mean follow-up was 1082.5 ± 668.2 days (95% CI: 907.49-1257.51). In 19 patients (40%), recurrent stricture was evident at ERCP during a median follow-up of 90 (IQR: 60-210) days following stent removal. The recurrent stricture rate following MCA (n = 6/24) was significantly lower compared to patients in whom MCA was not performed (n = 13/23; p = 0.026). Overall, stent type had no significant effect on patency (p = 0.189).

CONCLUSION

Percutaneous biliary procedures are essential for endoscopically unmanageable post-transplant anastomotic biliary strictures. MCA seems to provide higher patency rates even in patients with total biliary occlusion.

KEY POINTS

Question What steps can be taken when endoscopy fails in the treatment of post-transplant anastomotic biliary strictures? Findings Percutaneous biliary access and magnetic compression anastomosis can be applied to increase graft survival in the setting of endoscopically unmanageable post-transplant biliary strictures. Clinical relevance Impassable biliary obstructions are unfortunate complications and not uncommon in liver transplant recipients. Magnetic compression anastomosis is an alternative minimally invasive method of treatment for complete biliary occlusions.

Successful sequential management of traumatic choledochal leak and stenosis in children using ERCP: a case report and literature review

Traumatic Choledochal Leak and Stenosis in Children is a relatively rare bile leakage, and there is no report of endoscopic retrograde cholangiopancreatography [ERCP] bile duct stent treatment in 3 years old, which avoids procedure and biliary tract modifications after the failure of conservative treatment of bile leakage, and solves the previous need for procedure in a minimally invasive or even non-invasive way. At the same time, it can be concluded that identifying the signs of conservative treatment failure is important, and ERCP is superior to CT and MR in diagnosing traumatic biliary leak in young children. Traumatic bile leakage common bile duct inflammatory stenosis, brittle tissue, not suitable for expansion, the choice of 5 Fr to 10 Fr plastic stent sequential treatment is an effective regimen. At the same time, it is necessary to closely monitor the biliary patency after ERCP to understand the long-term postoperative efficacy. Comprehensive evaluation before ERCP and detailed post ERCP monitoring require the participation of pediatricians.

Magnets in action: role of interventional radiologists in magnetic compression anastomosis procedures

Obstructions encountered in biliary, gastrointestinal, and urinary tracts are increasing in number due to successful percutaneous and endoscopic organ-saving procedures. Although functional recovery is established to an extent, failure of traversing an obstruction may end up necessitating invasive surgical procedures. Multidisciplinary collaboration may traverse the limitations of each individual approach, therefore creating the perfect intervention for the patient. Magnetic compression anastomosis is a minimally invasive procedure that can provide a great outcome in select cases with biliary, gastrointestinal, or urinary tract obstructions. CRITICAL RELEVANCE STATEMENT: In this article, various applications of magnetic compression anastomosis are reviewed with illustrative cases of esophageal, biliary, colonic, and urinary obstructions that cannot be traversed with a wire. This method will expand the spectrum of interventions performed in the IR unit. KEY POINTS: Magnets can enable wire access beyond an impassable obstruction. Magnets can create anatomical and non-anatomical anastomosis at an occlusion. Magnetic compression anastomosis is a minimally invasive procedure that can provide great outcomes.

Magnetic anchor technique assisted endoscopic submucosal dissection for early esophageal cancer

BACKGROUND

Esophageal cancer has high incidence globally and is often diagnosed at an advanced stage. With the widespread application of endoscopic technologies, the need for early detection and diagnosis of esophageal cancer has gradually been realized. Endoscopic submucosal dissection (ESD) has become the standard of care for managing early tumors of the esophagus, stomach, and colon. However, due to the steep learning curve, difficult operation, and technically demanding nature of the procedure, ESD has currently been committed to the development of various assistive technologies.

AIM

To explore the feasibility and applicability of magnetic anchor technique (MAT)-assisted ESD for early esophageal cancer.

METHODS

Isolated pig esophagi were used as the experimental model, and the magnetic anchor device was designed by us. The esophagi used were divided into two groups, namely the operational and control groups, and 10 endoscopists completed the procedure. The two groups were evaluated for the following aspects: The total operative time, perforation rate, rate of whole mucosal resection, diameter of the peering mucosa, and scores of endoscopists' feelings with the procedure, including the convenience, mucosal surface exposure degree, and tissue tension. In addition, in the operational group, the soft tissue clip and the target magnet (TM) were connected by a thin wire through a small hole at the tail end of the TM. Under gastroscopic guidance, the soft tissue clip was clamped to the edge of the lesioned mucosa, which was marked in advance. By changing the position of the anchor magnet (AM) outside the esophagus, the pulling force and pulling direction of the TM could be changed, thus exposing the mucosal peeling surface and assisting the ESD.

RESULTS

Herein, each of the two groups comprised 10 isolated esophageal putative mucosal lesions. The diameter of the peering mucosa did not significantly differ between the two groups (2.13 ± 0.06 vs 2.15 ± 0.06, P = 0.882). The total operative time was shorter in the operational group than in the control group (17.04 ± 0.22 min vs 21.94 ± 0.23 min, P < 0.001). During the entire experiment, the TM remained firmly connected with the soft tissue clip and did not affect the opening, closing, and release of the soft tissue clip. The interaction between the TM and AM could provide sufficient tissue tension and completely expose the mucosa, which greatly assists the surgeon with the operation. There was no avulsion of the mucosa, and mucosal lesions were intact when peeled. Therefore, the scores of endoscopists' feelings were higher in the operational group than in the control group in terms of the convenience (9.22 ± 0.19 vs 8.34 ± 0.15, P = 0.002), mucosal surface exposure degree (9.11 ± 0.15 vs 8.25 ± 0.12, P < 0.001), and tissue tension (9.35 ± 0.13 vs 8.02 ± 0.17, P < 0.001). The two groups did not significantly differ in the perforation rate and rate of whole mucosal resection.

CONCLUSION

We found MAT-assisted ESD safe and feasible for early esophageal cancer. It could greatly improve the endoscopic operation experience and showed good clinical application prospects.

Safety and feasibility of a novel recanalization technique using guidewire puncture under cholangioscopy for complete biliary stricture after liver transplantation

Cholangioscopy is reportedly useful for selective guidewire placement across difficult biliary strictures, but few methods are available for complete stricture of biliary anastomosis. This study aimed to propose a guidewire puncture technique to recanalize totally obstructed anastomosis and discuss its safety and feasibility. From January 2015 to December 2021, a total of 11 patients with complete biliary anastomotic stricture after liver transplantation were enrolled. These patients underwent peroral single operator cholangioscopy (SpyGlass), whereas two failed cases on SpyGlass finally underwent percutaneous transhepatic cholangioscopy (PTCS). The steps of the recanalization technique were as follows: the stricture was viewed carefully to detect the closure point (CP) of the scar endoscopically, then the CP was targeted by the hard tip of the guidewire and broke through under guidance of the cholangioscope and fluoroscope. Complete occlusions were confirmed by SpyGlass in all cases. A total of 13 hard-tip guidewire punctures were performed under cholangioscopy, and ten punctures were successful (technical success rate, 76.9% [10/13]). After recanalization of the occluded anastomosis, plastic stent or metallic stent was deployed in three and seven patients, respectively. No procedure-related complications occurred during or after the cholangioscopy-assisted guidewire puncture. After a mean follow-up of 12 months, stents had been removed in five patients. The other six patients were still receiving stent treatment. This study demonstrated that the guidewire puncture technique under cholangioscopy is safe and feasible for complete stricture of biliary anastomosis, and the success rate is satisfactory.

An experimental study of magnetic compression technique for ureterovesical anastomosis in rabbits

This study aimed to explore the feasibility of the magnetic compression technique (MCT) for ureterovesical anastomosis in a rabbit model with ureteral obstruction. The distal ureteral obstruction model using female New Zealand rabbits was induced by ligating the distal end of the right ureter with silk thread for four weeks. A pair of cylindrical NdFeB magnets (daughter magnet and parent magnet) with a hole in the center was used for the ureterovesical anastomosis. The daughter magnet and the parent magnet were respectively placed close to the obstruction site through the dilated proximal ureter and urethra, and then the daughter-parent magnets pair was attracted together automatically. Postoperative X-rays were taken to confirm the position of the magnets. The anastomotic stoma specimens were obtained two weeks postoperatively, and the anastomotic stoma formation was observed by the naked eye and histological staining. The operation time and the anastomotic burst pressure were measured. The ureter was significantly dilated in the fourth week after ligation, which satisfied the placement of the daughter magnet. The ureterovesical magnet placements were successfully performed in ten experimental rabbits, with an operation time of 36.5 ± 6.09 min. The parent and daughter magnets attracted each other well and were subsequently removed through the urethra two weeks postoperatively, resulting in the establishment of ureterovesical anastomosis. The anastomotic burst pressure was 147.5 ± 14.59 mmHg. Gross specimens and histological examination of the anastomotic stoma showed that the anastomotic stoma healed well. MCT is feasible and simple for ureterovesical anastomosis.

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.

A novel micromagnetic ring used for biliary-enteric anastomosis in rats

BACKGROUND

To explore the feasibility of micromagnetic ring in establishing biliary-enteric anastomosis in a rat model.

METHODS

A new micromagnetic ring suitable for rat biliary-enteric anastomosis model was designed and fabricated. The common bile ducts of 20 Sprague-Dawley albino rats were ligated and dilated after 2 weeks. Surgery for biliary-enteric anastomosis was completed by using micromagnetic ring. The anastomosis time, postoperative survival rate, liver function, liver histopathology, and complications were recorded. After 28 days, anastomotic specimens were obtained to observe healing with the naked eye and light microscopy.

RESULTS

Among the 20 Sprague-Dawley albino rats, one rat showed bile leakage and died one week after ligation of the common bile duct and another rat was removed from the experiment because there was no obvious dilatation of the common bile duct. The remaining 18 rats successfully underwent surgery for biliary-enteric anastomosis using micromagnetic ring, with an average anastomosis time of 7.10 ± 1.15 min (range, 5.17-9.50 min). The expulsion time of micromagnetic anastomosis rings was 11.94 ± 2.48 days (range, 8-17 days). The bilirubin level dropped to normal 1 week after surgery. Biliary-enteric anastomotic specimens were obtained 28 days after surgery, and microscopic observation showed that the mucosal layer of the anastomosis had good continuity and the anastomosis was smooth.

CONCLUSION

A micromagnetic ring can be used to construct a rat biliary-enteric anastomosis model, and it offers advantages, such as simple operation and reliable anastomosis effect.

Role of ERCP in Benign Biliary Strictures

Benign biliary strictures (BBS) can be associated with several causes, with postoperative and inflammatory strictures representing the most common ones. Endoscopy represents nowadays the first-line treatment in the management of BBS. Endoscopic balloon dilatation, plastic stents placement, fully covered metal stent placement, and magnetic compression anastomosis are the endoscopic techniques available for the treatment of BBS. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the management of BBS and to evaluate the application of the different procedures in the different clinical settings.

Magnetic Guiding with Permanent Magnets: Concept, Realization and Applications to Nanoparticles and Cells

The idea of remote magnetic guiding is developed from the underlying physics of a concept that allows for bijective force generation over the inner volume of magnet systems. This concept can equally be implemented by electro- or permanent magnets. Here, permanent magnets are in the focus because they offer many advantages. The equations of magnetic fields and forces as well as velocities are derived in detail and physical limits are discussed. The special hydrodynamics of nanoparticle dispersions under these circumstances is reviewed and related to technical constraints. The possibility of 3D guiding and magnetic imaging techniques are discussed. Finally, the first results in guiding macroscopic objects, superparamagnetic nanoparticles, and cells with incorporated nanoparticles are presented. The constructed magnet systems allow for orientation, movement, and acceleration of magnetic objects and, in principle, can be scaled up to human size.

Percutaneous Management of Benign Biliary Strictures

Benign biliary strictures are often due to a variety of etiologies, most of which are iatrogenic. Clinical presentation can vary from asymptomatic disease with elevated liver enzymes to obstructive jaundice and recurrent cholangitis. Diagnostic imaging methods, such as ultrasound, multidetector computed tomography, and magnetic resonance imaging (cholangiopancreatography), are used to identify stricture location, extent, and possible source of biliary obstruction. The management of benign biliary strictures requires a multidisciplinary team approach and include endoscopic, percutaneous, and surgical interventions. Percutaneous biliary interventions provide an alternative diagnostic and therapeutic approach, especially in patients who are not amenable to endoscopic evaluation. This review provides an overview of benign biliary strictures and percutaneous management by interventional radiologists. Diagnostic evaluation with percutaneous transhepatic cholangiography and treatment options, including biliary drainage, balloon dilation, retrievable/biodegradable stents, and other innovative minimally invasive options, are discussed.

Magnetic compression anastomosis via EUS-guided hepaticogastrostomy for recanalization of complete common hepatic bile duct transection

Video 1Magnetic compression anastomosis via EUS-guided hepaticogastrostomy for recanalization of complete common hepatic bile duct transection.

Cholangiojejunostomy Using a Novel Magnamosis Device: Initial Clinical Results

BACKGROUND

Cholangiojejunostomy (CJ) is a popular operation; however, no specific anastomotic device is available. A novel magnamosis device for CJ was developed in 2017; here, we evaluated the feasibility and safety of the device.

METHODS

Between January 2017 and December 2019, 23 patients who underwent CJ using a novel magnamosis device were enrolled. For the CJ: the parent magnet was placed in the proximal duct, and the purse-string suture was tightened over the rod of the parent magnet. The magnamosis device was introduced into the jejunum, and the mandrel penetrated the jejunum at the anastomotic site, before insertion into the rod of the parent magnet. After rotating the knob, the distance between two magnets was shortened enough to achieve coupling.

RESULTS

Sixteen patients (69.6%) underwent open CJ, while 7 (30.4%) underwent laparoscopic CJ; 21 patients (91.3%) underwent choledochojejunostomy, and 2 (8.7%) underwent right or left hepatic duct jejunostomy. The mean time for completion of CJ was 9.2±2.5 min; it was significantly shorter for open CJ than for the laparoscopic way (8±1.2 min vs. 11.8±2.5 min, P<0.05). Only one patient (4.3%) suffered bile leakage after operation and was cured by conservative treatment. The magnets were discharged with a postoperative duration of 66.7±47.2 days, with a 100% expulsion rate. After a median follow-up of 15 months, only one patient (4.3%) developed inflammatory anastomotic stricture.

CONCLUSION

The novel magnamosis device is a simple, safe, and effective modality for CJ.

Telemedicine for Follow-up Management of Patients After Liver Transplantation: Cohort Study

BACKGROUND

Technical capabilities for performing liver transplantation have developed rapidly; however, the lack of available livers has prompted the utilization of edge donor grafts, including those donated after circulatory death, older donors, and hepatic steatosis, thereby rendering it difficult to define optimal clinical outcomes.

OBJECTIVE

We aimed to investigate the efficacy of telemedicine for follow-up management after liver transplantation.

METHODS

To determine the efficacy of telemedicine for follow-up after liver transplantation, we performed a clinical observation cohort study to evaluate the rate of recovery, readmission rate within 30 days after discharge, mortality, and morbidity. Patients (n=110) who underwent liver transplantation (with livers from organ donation after citizen's death) were randomly assigned to receive either telemedicine-based follow-up management for 2 weeks in addition to the usual care or usual care follow-up only. Patients in the telemedicine group were given a robot free-of-charge for 2 weeks of follow-up. Using the robot, patients interacted daily, for approximately 20 minutes, with transplant specialists who assessed respiratory rate, electrocardiogram, blood pressure, oxygen saturation, and blood glucose level; asked patients about immunosuppressant medication use, diet, sleep, gastrointestinal function, exercise, and T-tube drainage; and recommended rehabilitation exercises.

RESULTS

No differences were detected between patients in the telemedicine group (n=52) and those in the usual care group (n=50) regarding age (P=.17), the model for end-stage liver disease score (MELD, P=.14), operation time (P=.51), blood loss (P=.07), and transfusion volume (P=.13). The length and expenses of the initial hospitalization (P=.03 and P=.049) were lower in the telemedicine group than they were in the usual care follow-up group. The number of patients with MELD score ≥30 before liver transplantation was greater in the usual care follow-up group than that in the telemedicine group. Furthermore, the readmission rate within 30 days after discharge was markedly lower in the telemedicine group than in the usual care follow-up group (P=.02). The postoperative survival rates at 12 months in the telemedicine group and the usual care follow-up group were 94.2% and 90.0% (P=.65), respectively. Warning signs of complications were detected early and treated in time in the telemedicine group. Furthermore, no significant difference was detected in the long-term visit cumulative survival rate between the two groups (P=.50).

CONCLUSIONS

Rapid recovery and markedly lower readmission rates within 30 days after discharge were evident for telemedicine follow-up management of patients post-liver transplantation, which might be due to high-efficiency in perioperative and follow-up management. Moreover, telemedicine follow-up management promotes the self-management and medication adherence, which improves patients' health-related quality of life and facilitates achieving optimal clinical outcomes in post-liver transplantation.

One-step Percutaneous Transhepatic Cholangioscopy Combined With High-frequency Needle-knife Electrotomy in Biliary Strictures After Liver Transplantation

BACKGROUND

Endoscopic management is the mainstay for biliary strictures after liver transplantation. However, this method is often failed in cases associated with hepatolithiasis or refractory strictures. The aim of this study is to investigate whether 1-step percutaneous transhepatic biliary cholangiography (PTC) combined with high-frequency needle-knife electrotomy can be an alternative method in biliary strictures after liver transplantation that could not be treated by endoscopic management.

METHODS

Clinical data of 14 patients suffering from biliary strictures after liver transplantation from June 2014 to January 2018 were retrospectively analyzed. One-step PTC combined with high-frequency needle-knife electrotomy was used to resolve the strictures.

RESULTS

One-step PTC was successfully performed in all 14 patients. In 10 of 12 (83.3%) patients with hepatolithiasis, the stones were removed completely. Stricture resolution was detected in 13 of 14 (92.9%) patients at first postoperative choledochoscopy. Three mild adverse events occurred (cholangitis, 2 patients; delayed hemobilia, 1 patient), but were resolved with conservative treatment. The follow-up after supporting catheter removal was 15.7±4.5 months. Only 1 patient (8.3%) had stone recurrence and no stenosis occurred during supporting-catheter-free follow-up.

CONCLUSIONS

One-step PTC combined with high-frequency needle-knife electrotomy seems to be a useful for treating biliary strictures after liver transplantation.

Biliary complications after liver transplantation: current perspectives and future strategies

Importance

Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation.

Objective

The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT.

Evidence Review

a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment.

Findings

Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks.

Conclusions and Relevance

BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.

Fedora-type magnetic compression anastomosis device for intestinal anastomosis

BACKGROUND

Although previous studies have confirmed the feasibility of magnetic compression anastomosis (MCA), there is still a risk of long-term anastomotic stenosis. For traditional MCA devices, a large device is associated with great pressure, and eventually increased leakage.

AIM

To develop a novel MCA device to simultaneously meet the requirements of pressure and size.

METHODS

Traditional nummular MCA devices of all possible sizes were used to conduct ileac anastomosis in rats. The mean (± SD) circumference of the ileum was 13.34 ± 0.12 mm. Based on short- and long-term follow-up results, we determined the appropriate pressure range and minimum size. Thereafter, we introduced a novel "fedora-type" MCA device, which entailed the use of a nummular magnet with a larger sheet metal.

RESULTS

With traditional MCA devices, the anastomoses experienced stenosis and even closure during the long-term follow-up when the anastomat was smaller than Φ5 mm. However, the risk of leakage increased when it was larger than Φ4 mm. On comparison of the different designs, it was found that the "fedora-type" MCA device should be composed of a Φ4-mm nummular magnet with a Φ6-mm sheet metal.

CONCLUSION

The diameter of the MCA device should be greater than 120% of the enteric diameter. The novel "fedora-type" MCA device controls the pressure and optimizes the size.

Magnetic Compression Anastomosis in Laparoscopic Pancreatoduodenectomy: A Preliminary Study

BACKGROUND

Laparoscopic pancreatoduodenectomy (LPD) is a minimally invasive technique widely developed in the last few decades. Although magnetic compression anastomosis (magnamosis) is used during cholangiojejunostomy, its applicability in LPD has not yet been reported. Herein, we evaluated the feasibility and effectiveness of magnamosis in LPD.

METHODS

Between January 2018 and December 2019, seven patients who underwent laparoscopic magnetic compression choledochojejunostomy (LMC-CJ) or laparoscopic magnetic compression pancreatojejunostomy (LMC-PJ) in LPD were enrolled. After LPD, a parent magnet with or without a drainage tube was placed in the proximal bile duct and pancreatic duct of each patient. Daughter magnets were introduced to couple with the parent magnets at the desired sites. A close postoperative surveillance of magnet movements was performed. Various relevant data were collected, and all patients were followed up until February 2020.

RESULTS

LPD was successfully completed in all seven patients, of which seven underwent LMC-CJ and two received LMC-PJ. The median time needed for completion of LMC-CJ was 11 min (range, 8-16). The cost time for the two cases of LMC-PJ was 12 and 15 min, respectively. After a median time of 50 d (range, 40-170) postoperation, all magnets were expelled. No leakages of LMC-CJ or LMC-PJ were observed after operation. After a median follow-up period of 11 mo (range, 4-18), there was no incidence of anastomotic stricture.

Magnetic compression anastomosis for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction: a case report

BACKGROUND

Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction.

CASE PRESENTATION

A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society.

CONCLUSIONS

Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.

Magnetic Compression Anastomosis for the Treatment of Post-Transplant Biliary Stricture

A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.