A 41-year-old man developed an iatrogenic benign biliary stricture. Magnetic resonance cholangiopancreatography (MRCP) showed a 23-mm transverse stenosis of the common hepatic duct ([Fig. 1]). The patient had undergone two endoscopic retrograde cholangiopancreatographies (ERCPs) in other hospitals, but both attempts had failed as the guidewire could not be passed through the stricture. We decided to try the magnetic compression technique (MCT).
Fig. 1 Magnetic resonance image showing transverse stenosis of the hilar bile duct.
First, we used percutaneous transhepatic biliary drainage (PTBD), and the sinus was gradually dilated once a week to 16 Fr. We then performed the MCT. Using ERCP and PTBD, we delivered a magnet ([Fig. 2]) to each end of the stricture, but the wave phenomenon did not occur ([Fig. 3]). To increase the magnetic force, two magnets were superimposed at each end of the stricture and, this time, the wave phenomenon was observed. The magnets were adjusted to align with the bile duct axis and released once they were stable ([Fig. 4]
a). The PTBD was continued.
Fig. 2 Photograph of the hollow magnetic beads used for anastomosis compression (diameter 3 mm, length 6 mm), which can be fixed in place using silk thread.
Fig. 3 Fluoroscopic image showing the effect of a single magnetic bead on anastomosis compression, with the magnetic force being insufficient, so the wave phenomenon is not observed.
Fig. 4 Fluoroscopic images showing the double magnetic beads: a immediately after placement; b 3 weeks after placement, by which time they have fitted together.
The bile duct stenosis was compressed by the continuous magnetic force, causing local ischemia and necrosis, resulting in sinus formation. After 3 weeks, the dual magnets had fitted together ([Fig. 4]
b) and were removed. ERCP showed residual membranous stenosis and it was still not possible to pass a guidewire. We next used the rendezvous technique, combining ERCP and PTBD. We dilated the stenotic area with a bougie and placed a plastic biliary stent. A month later, angiography showed linear stenosis (Bismuth II type). After balloon dilation, we placed bilateral biliary stents ([Fig. 5]).
Fig. 5 Stenting of a benign biliary stricture after magnetic compression of the anastomosis, with implantation of bilateral (side-by-side) biliary stents: a fully covered metal biliary stent (Cook) in the right hepatic duct and a plastic stent (7 Fr, 10 cm; Cook) in the left hepatic duct.
An ERCP performed 6 months later showed that the original stenosis had disappeared and the inner diameter of the intrahepatic bile duct was normal, indicating that the treatment had been successful ([Video 1]).
A benign biliary stricture is treated with the magnetic compression anastomosis technique.Video 1
Most previous studies describing MCT have treated strictures <15 mm in length [1]
[2]
[3]. Our patient’s stricture was 23 mm, so we believe it is the longest treated in this way to have been reported.
Endoscopy_UCTN_Code_TTT_1AR_2AG
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