Left hepaticogastrostomy for biliary obstruction: long-term results

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

Background

Despite 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 presentation

The 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.

Conclusions

Choledochoduodenostomy with magnet compression could be a less invasive and safer method for treatment of biliary stricture that cannot be accessed by conventional surgery.

Endoscopic ultrasonography-guided hepaticogastrostomy

To date, percutaneous transhepatic biliary drainage (PTBD) has been considered as the usual biliary access after failed endoscopic retrograde cholangiopancreatography (ERCP). Since endoscopic ultrasonography (EUS)-guided bile duct puncture was first described in 1996, sporadic case reports of EUS-guided biliary drainage (EUS-BD) have suggested it as an alternative to PTBD after failed ERCP. The potential benefits of EUS-BD include internal drainage, thus avoiding long-term external drainage in cases where external PTBD drainage catheters cannot be internalized. EUS-guided hepaticogastrostomy (EUS-HG) is one form of EUS-BD. This article describes the indications, techniques, and outcomes of published data on EUS-HG.

Endoscopic ultrasound of the upper gastrointestinal tract and mediastinum: diagnosis and therapy

Endoscopic ultrasound (EUS) has developed significantly over the last two decades and has had a considerable impact on the imaging and staging of mass lesions within or in close proximity to the gastrointestinal (GI) tract. In conjunction with conventional imaging such as helical computed tomography and magnetic resonance imaging, the indications for EUS include (1) differentiating between benign and malignant lesions of the mediastinum and upper GI tract, (2) staging malignant tumors of the lung, esophagus, stomach, and pancreas prior to surgery or oncological treatment, (3) excluding common bile duct stones before laparoscopic cholecystectomy, thereby avoiding the need for endoscopic retrograde cholangiopancreatography (ERCP) in some patients, and (4) assessing suspected lesions that are either equivocal or not seen on conventional imaging. In recent years, EUS has charted a course similar to that taken by ERCP, evolving from a purely diagnostic modality to one that is interventional and therapeutic. These indications include (5) obtaining a tissue diagnosis by EUS-guided fine-needle aspiration or trucut-type needle biopsy and (6) providing therapy such as coeliac plexus neurolysis and pancreatic pseudocyst drainage--in many cases, more accurately and safely than conventional techniques. Emerging investigational techniques include EUS-guided enteric anastomosis formation and fine-needle injection therapy for malignant disease.

Percutaneous Transhepatic Biliary Drainage in the Management of Postsurgical Biliary Leaks in Patients with Nondilated Intrahepatic Bile Ducts

PURPOSE

To assess the feasibility of percutaneous transhepatic biliary drainage (PTBD) for the treatment of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts, its efficacy in restoring the integrity of bile ducts, and technical procedures to reduce morbidity.

METHODS

Seventeen patients out of 936 undergoing PTBD over a 20-year period had a noncholestatic liver and were retrospectively reviewed. All patients underwent surgery for cancer and suffered a postsurgical biliary leak of 345 ml/day on average; 71% were in poor condition and required permanent nutritional support. An endoscopic approach failed or was excluded due to inaccessibility of the bile ducts.

RESULTS

Established biliary leaks and site of origin were diagnosed an average of 21 days (range 1-90 days) after surgery. In all cases percutaneous access to the biliary tree was achieved. An external (preleakage) drain was applied in 7 cases, 9 patients had an external-internal fistula bridging catheter, and 1 patient had a percutaneous hepatogastrostomy. Fistulas healed in an average of 31 days (range 3-118 days ) in 15 of 17 patients (88%) following PTBD. No major complications occurred after drainage. Post-PTBD cholangitis was observed in 6 of 17 patients (35%) and was related to biliary sludge formation occurring mostly when drainage lasted >30 days and was of the external-internal type. Median patient survival was 17.7 months and in all cases the repaired biliary leaks remained healed.

CONCLUSIONS

PTBD is a feasible, effective, and safe procedure for the treatment of postsurgical biliary leaks. It is therefore a reliable alternative to surgical repair, which entails longer hospitalization and higher costs.

Interventional applications of endoscopic ultrasound

Endoscopic ultrasound, which was developed more than 20 years ago, is currently a valuable investigative tool for endoscopists. It began as a diagnostic instrument and in the short span of a decade made a clinical impact as a therapeutic tool with a promising potential for various interventional applications. The introduction of the curved linear array echoendoscope in the 1990s enabled a whole range of interventional applications of endoscopic ultrasound ranging from fine needle aspiration of lesions surrounding the gastrointestinal tract to celiac plexus block and drainage of pancreatic pseudocyst. This review article outlines the current interventional applications of endoscopic ultrasound and discusses potential future procedures. These procedures include endoscopic ultrasound guided creation of communication between the gastrointestinal tract and adjacent organs, such as hepaticogastrostomy and choledochoduodenostomy.

Initial experience with laparoscopic bypass for upper gastrointestinal malignancy: a new option for palliation of patients with advanced upper gastrointestinal tumors

BACKGROUND

The majority of patients with upper gastrointestinal (UGI) tract malignancy present at a stage where cure of disease is not possible. The aim of treatment in these patients is effective palliation. Various interventions have been described for the palliation of biliary and gastric outlet obstruction including open surgery, endoscopic and transparietal stent placement. Laparoscopic bypass appears to have the advantage of decreased postoperative pain and shorter hospital stay as well as offer effective palliation. The aim of this study was to assess the safety and efficacy of laparoscopic bypass in patients with incurable UGI tract malignancy.

PATIENTS AND METHODS

Between August 2000 and April 2002 laparoscopic gastric and biliary bypass concurrently or alone was attempted in 19 consecutive patients with unresectable carcinoma of the head of the pancreas, adenocarcinoma of the stomach, cholangiocarcinoma of the distal common bile duct, or adenocarcinoma of the duodenum. The operative time, length of postoperative stay, complications, and the effectiveness of the procedure in terms of the ability to sustain oral nutrition and or the relief of obstructive jaundice were recorded and used as outcome measures.

RESULTS

Laparoscopic bypass was successful in 18 out of 19 cases. The mean operative time for a single bypass was 164 minutes while the average postoperative hospital stay was 11 days. All patients were able to sustain oral nutrition during the course of their hospital stay and or had effective relief from their obstructive jaundice. Two patients died from procedure unrelated causes within 30 days of the operation.

CONCLUSION

Laparoscopic bypass appears to be a safe and effective means of palliation for patients with unresectable UGI tract tumors and should replace open surgical palliation in this group of patients.

Percutaneous Hepaticogastrostomy in a Patient with Complete Common Duct Obstruction after Right Hepatectomy

Complete bile duct obstruction that cannot be traversed by a guide wire can be challenging for the interventional radiologist. Although hepaticogastrostomy, which can be an alternative for such cases, has been performed under fluoroscopic and endoscopic guidance previously, this technique can be simplified by using only fluoroscopy. This technique was used in a patient who had complete common bile duct obstruction after hepatic resection. The patient initially had a good clinical outcome and stayed symptom-free for 5 months but eventually developed biliary epithelial hyperplasia and required placement of another metallic stent.

Therapeutic endoscopic retrograde cholangiopancreatography: what the future holds

These are exciting times for interventional endoscopists performing ERCP. The advent of noninvasive, diagnostic techniques of the pancreaticobiliary tree has resulted in a shift toward more therapeutic procedures. The combination of major technologic advances together with endoscopists' growing comfort with invasive procedures has helped to push the boundaries of endoscopic therapy. These therapies, however, should always be sanctioned by sound science and well-controlled clinical trials.

Alternative technique of laparoscopic hepaticojejunostomy for advanced pancreatic head cancer

Only 20% of patients with pancreatic cancer can undergo curative resection. Therefore, palliative treatment of pancreatic cancer assumes the utmost clinical importance. The aim of the palliative treatment of pancreatic head carcinoma is to relieve the jaundice and/or duodenal obstruction. Endoscopic or transparietal decompression of the obstructed bile duct can be accomplished in most cases, but the durability of these techniques is not as great as that of a surgically created bypass. On the other hand, hepaticojejunostomy carries higher morbidity and mortality rates than the former nonsurgical methods. In order to promote long lasting palliation with low morbidity and mortality rates, minimally invasive techniques of biliary and gastric bypass have been described. However, laparoscopic Roux-en-Y hepaticojejunostomy seems to be a complex surgical procedure. With an aim to simplify the construction of a laparoscopic hepaticojejunostomy, the authors suggest an alternative technique.