Magnetic Compression Anastomosis for Treatment of Post-cholecystectomy Bile Duct Injury Related Biliary Strictures

Abstract

The management of post-cholecystectomy biliary strictures remains challenging. While endoscopic and percutaneous biliary procedures have shown high success rates in treating these benign biliary strictures, sometimes the guidewire cannot be negotiated across the stricture, making the stricture refractory to management by the endoscopic or percutaneous route. Magnetic compression anastomosis is a nonsurgical alternative used on the endoscopic and percutaneous biliary platform to create a passage across the refractory biliary stricture. We report three cases of uncrossable bile duct strictures managed with magnetic compression anastomosis. This report highlights the utility of a relatively simple technique for managing complex problems.

Keywords

bile duct injury - benign biliary stricture - magnetic compression anastomosis

Introduction

Bile duct injury (BDI) and stricture are rare but dreaded complications of cholecystectomy. Prompt recognition and appropriate multidisciplinary management are critical to prevent complications such as cholangitis, portal hypertension, and biliary cirrhosis. While surgery is the gold standard for treating biliary stricture, endoscopic and percutaneous biliary stenting procedures are increasingly used with high success rates in managing biliary injuries and strictures. Failure to negotiate a guidewire across the stricture makes it refractory to endoscopic or percutaneous stenting. Magnetic compression anastomosis (MCA) is a combined percutaneous and endoscopic technique that facilitates guidewire passage and subsequent stent placement across the uncrossable bile duct stricture. We report three cases of refractory postcholecystectomy strictures successfully treated with MCA.

Case 1

A 28-year-old woman presented with jaundice 3 weeks following open cholecystectomy for gallbladder stones. On abdominal ultrasound, the bile ducts were prominent, with an apparent cutoff at the level of the common hepatic duct suggesting stricture. During the endoscopic retrograde cholangiopancreatography (ERCP), the common bile duct (CBD) showed a complete cutoff at the proximal level, and the occlusion could not be crossed. On percutaneous transhepatic cholangiogram, there was complete occlusion of the common hepatic duct with patent right and left duct confluence ([Fig. 1(A)]). The stricture could not be crossed. A diagnosis of complete CBD transection with a 1.5-cm-long bile duct stricture was made on both ERCP and percutaneous cholangiogram.

Fig. 1 (A) Cholangiogram showing complete block. (B) Magnet placed through percutaneous transhepatic biliary drainage. (C, D) Magnet placed through endoscopic retrograde cholangiopancreatography. (E) Magnet approximation at day 3. (F–H) Fistula formation by magnet approximation at days 3 to 8. (I) Multiple stents in situ at 7 months.

We used the MCA technique to resolve the refractory bile duct stricture. A rare-earth magnet 3 mm in diameter and 10 mm in length was used. Percutaneous transhepatic biliary drainage (PTBD) was performed using the standard technique under combined ultrasound and fluoroscopic guidance, and a 10-Fr catheter was placed through the right duct approach for 1 week. One week later, the PTBD catheter was exchanged for a 12-Fr sheath, and one magnet was delivered using a plastic stent pusher tube ([Fig. 1(B)]). The magnet was placed at the peripheral end of the obstruction and is called the “daughter magnet.” Another magnet called the “parent magnet” was placed via an endoscopic route at the central end of the obstruction after checking the attracting poles of the magnet ([Fig. 1(C, D)]). A fluoroscopy check was performed every day to check magnet approximation. After 7 days, the magnets successfully approximated ([Fig. 1(H)]). On check cholangiogram on day 7, a fistulous tract had formed between the transected ends ([Fig. 1(F)]). A guidewire was successfully negotiated across the fistula and into the duodenum. A 7-Fr plastic stent was placed through the percutaneous route, and another 10-Fr plastic stent was placed through the endoscopic route to maintain the fistulous tract.

Both the magnets were retrieved using rat tooth forceps through the percutaneous and endoscopic routes. The patient was followed up every 2 months with liver function tests (LFTs). Additional plastic stents were placed monthly via the endoscopic route for six stents [Fig. 1(I)]. A cholangiogram in the seventh month showed complete resolution of the biliary stricture. All six stents were removed ([Fig. 2(A, B)]). The patient is under outpatient follow-up and reported no specific symptoms or recurrence, and LFTs are normal.

Fig. 2 (A) Stents removed at 7 months. (B) Cholangiogram after stent removal shows normal common bile duct continuity without any stricture.

Case 2

A 45-year-old woman, 4 weeks after open cholecystectomy for gallbladder stones, had uncrossable CBD stricture by both endoscopic and percutaneous routes. A similar procedure was followed as in the first case, where magnets were placed at the proximal and distal ends of the stricture ([Fig. 3]). After 7 days, the magnets came nearer. Still, to strengthen the approximation, two more magnets were added via the endoscopic route ([Fig. 3C, D]). The magnets successfully approximated on the 15th day. A guidewire was successfully negotiated into the duodenum ([Fig. 3D]). The stricture was dilated with a balloon ([Fig. 3E, F]). Magnets were retrieved, and plastic stents were placed ([Fig. 3G–I]). The patient is under serial follow-up to date.

Fig. 3 (A) Cholangiogram showing complete block at common hepatic duct (CHD). (B) Magnets placed for a 2-cm stricture. (C) Magnets approximated. (D) Wire negotiated. (E) Stricture at transection site. (F) Balloon dilatation at stricture. (G) Magnet retrieval by rat tooth forceps by endoscopic retrograde cholangiopancreatography. (H) Magnet retrieval percutaneously. (I) Two plastic stents placed.

Case 3

A 30-year-old woman who had undergone open cholecystectomy 3 weeks earlier for gallbladder stones was referred to our hospital. ERCP failed due to a complete cutoff of distal CBD. MCA was performed to recanalize the stricture by a similar method ([Fig. 4]). On fluoroscopy check the next day, all three magnets were found to lie in the duodenum ([Fig. 4E]), suggesting fistula formation. The structure was crossed ([Fig. 4G]), and two plastic stents of 10 and 7 Fr were placed percutaneously to maintain the fistulous tract ([Fig. 4H, I]). The magnets were retrieved via the endoscopy approach as they were in the duodenum. The patient is under a 3-month follow-up with normal LFTs and no specific symptoms.

Fig. 4 (A) Stricture at common bile duct (CBD) transection. (B) Magnet placed percutaneously and endoscopic retrograde cholangiopancreatography (ERCP) cholangiogram. (C) ERCP magnet placed. (D) Distance between magnets: 2.25 cm. (E) All magnets in duodenum at day 2. (F) Recanalized CBD stricture by magnet. (G) Wire negotiation through the tract. (H) Two wires placed. (I) Two plastic stents placed percutaneously.

Discussion

BDIs are serious complications of cholecystectomy, occurring more often since the introduction and widespread adoption of laparoscopy (0.4–1.5% of cases) compared to open cholecystectomy (0.2–0.3% of cases).[1] These injuries may be treated surgically, but more often, the resulting strictures are often managed endoscopically or via a percutaneous route. When the strictures are non-negotiable, additional methods are required. MCA is one of the methods employed in this study.

In all three cases described, magnet-assisted recanalization was achieved with the restoration of CBD continuity. The stricture was less than 2 cm long in all three cases, and the magnets aligned correctly. The method uses magnets to compress the stricture transmurally, causing gradual ischemic necrosis of the stricture. This ischemic necrosis creates an anastomosis between the two magnets.[2] The bile duct anastomosis following MCA is clinically similar to that of an anastomosis formed by conventional surgery. In an animal model, the anastomosis site exhibited continuity of the serosal, submucosal, and mucosal layers. Ischemia and necrosis were absent, and the burst strengths of anastomosis formed by MCA equaled or exceeded those of a surgical approach.[3] [4]

Many factors affect the success of MCA ([Table 1]), including the length of the stricture, shape of the bile duct, power of the magnets, and axis of the bile duct. MCA may fail when the stricture is long, and the bile duct is tapered or twisted in shape.[5] [6] The longer the stricture, the weaker the magnetic power between the two magnets. If the magnetic force is too weak, tissue necrosis due to magnetic compression cannot occur, and a new fistula will not form. Therefore, an exact evaluation of the length of the stricture is essential for a successful approximation of magnets before MCA. Evaluating the axis and shape of the bile duct is also crucial to the success of MCA. Even if the stricture is relatively short, the magnet cannot fully reach the stricture if the bile duct is tapered and rotated. Moreover, the axis of the bile ducts is important to determine the direction of magnet alignment. If the magnets are aligned parallel, MCA fails owing to weak magnetic power.[6] [7] The age of the stricture may impact the success as retraction of bile ducts may preclude MCA.

Table 1 Outcome of MCA for bile duct recanalization in recent studies

Author and journal	Year	Type of report	Mean stricture length (mm)	Days for recanalization	No. of patients	Technical success (%)	Cause of failure in unsuccessful patients	Complications
Jang Endoscopy 2014;46(1):70–74	2014	Original article	8.43	37	7	71.4 (5/7)	Parallel alignment of magnets Long stricture length	None
Jang et al Clinical endoscopy 2017; 85(5):1057–1066	2017	Original article	NA	57.8	39	89.7 (37/39)	Greater distance between two magnets (1) Tapered ducts (1)	Cholangitis (1), Recurrence of stricture (1) Restenosis (1)
Jang et al Scandanavian journal of gastroenterology 2018; 53(10–11)	2018	Original article	NA	63.8	49	100	–	Sludge formation, cholangitis, pericatheter leak, intrahepatic stone formation, re-stricture
Li et al Surgical endoscopy 2019; 34:2541–2550	2020	Original article	3 ± 1.7	16.33	9	100	–	Cholangitis (1) Biliary bleeding (1)
Ödemiş et al Digestive diseases and sciences 2022; 67:4906–4918	2022	Original article	4 (1–10)	9	19	90.5% (19/21)	NA	Magnet entrapment: 3 Magnet migration: 2 Cholangitis: 1
Tringali et al Endoscopy 2022; 54 (8): E411–E412	2022	Case	NA	24	–	100%	–	Magnet migration
Sung Ill Jang Gastrointestinal endoscopy 2024 (online May 16)	2023	Original article	NA	NA	10	100%	–	Partial restenosis (2)

Abbreviations: MCA, magnetic compression anastomosis; NA, not applicable.

The reported clinical success rate of 87.5% and a recurrence rate of 7.1% with MCA are superior to those of other conventional endoscopic or percutaneous methods.[5] It is difficult to compare the success rate of MCA with the conventional methods, as MCA is applied only when endoscopic or percutaneous methods fail.[5] MCA creates a new fistula tract through tissue necrosis instead of simple dilation of fibrotic tissue in benign biliary strictures; thus, the recurrence rate seems lower than other conventional treatments. The possibility of elastic recoiling in the fistula formed by MCA may be lower.[8]

There were no major adverse events in our patients except for mild fever. In previous studies, the only adverse event reported after MCA was a slight fever. No adverse events from the procedure itself or devices have been reported. Magnet-related adverse events are not thought to occur. MCA does not induce inflammation or immune reaction in the bile duct.[5] The MCA procedure has also been described as a successful method of recanalization of hepaticojejunostomy strictures by many studies.[7] [9]

Conclusion

MCA represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods. It can be utilized to perform bilio-biliary anastomosis in postcholecystectomy BDI without a major surgery. Further long-term studies are required to establish its durability.

Conflict of Interest

None declared.

• References

• 1 de'Angelis N, Catena F, Memeo R. et al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16 (01) 30
• 2 Muraoka N, Uematsu H, Yamanouchi E. et al. Yamanouchi magnetic compression anastomosis for bilioenteric anastomotic stricture after living-donor liver transplantation. J Vasc Interv Radiol 2005; 16 (09) 1263-1267
• 3 Pichakron KO, Jelin EB, Hirose S. et al. Magnamosis II: magnetic compression anastomosis for minimally invasive gastrojejunostomy and jejunojejunostomy. J Am Coll Surg 2011; 212 (01) 42-49
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• 6 Jang SI, Kim JH, Won JY. et al. Magnetic compression anastomosis is useful in biliary anastomotic strictures after living donor liver transplantation. Gastrointest Endosc 2011; 74 (05) 1040-1048
• 7 Jang SI, Rhee K, Kim H. et al. Recanalization of refractory benign biliary stricture using magnetic compression anastomosis. Endoscopy 2014; 46 (01) 70-74
• 8 Jang SI, Cho JH, Lee DK. Magnetic compression anastomosis for the treatment of post-transplant biliary stricture. Clin Endosc 2020; 53 (03) 266-275
• 9 Zhang G, Liang Z, Zhao G, Zhang S. Endoscopic application of magnetic compression anastomosis: a review. J Gastroenterol Hepatol 2024; 39 (07) 1256-1266

Publication History

Article published online:
02 December 2024