Biliary - Biliary Recanalization Using a Magnetic Compression Device
Comments: Magnetic Compression asastomosis (MCA) used two magnets in conjunction with an interventional radiologic technique to create a non-surgical, sutureless enteric anastomosis. The clinical feasibility, safety, and usefulliness of the MCA technique has been demonstrated for making anastomoses without surgery.
The MCA technique makes it possible to perform the canalization in patients with difficult biliary strictures using ERCP and percutaneous transhepatic technique. We first set to evaluate the clinical utility of the MCA technique for choledochocholedochostomy.
Before the MCA procedure, we first have to prepare two magnets for both the transpapillary route is 3 or 4 mm in diameter and 9 mm in thickness with a nylon wire 30 cm long attached, In contrast the magnet inserted via the percutaneous route is 3 to 5 mm in diameter with a nylon loop attached.
Here you can see choledochocholedochostomy using the MCA technique. Procedure is conducted with the patient in a supine position.
At first a 14 Fr sheath catheter is placed percutaneously.
Next the nylon loop of magnet is grasped with a polypectomy snare. Then, the magnet is pulled firmly against the polypectomy snare sheath inserted through the working channel.
Then, the endoscope is advanced into the duodenum and the snare with magnet is cannulated into the bile duct via the papilla of Vater where endoscopic shincterotomy had been performed.
Then we positioned the magnet in the superior bile duct.
Finally another magnet is advanced to the stricture via a percutaneous transhepatic route.
After confirming that the two magnets were attracting each other, the polypectomy snare wire is pulled completely within the sheath, releasing the magnet. Eventually, the choledochocholedochostomy is completed. Next I'd like to show you 3 clinical cases.
Case 1. This patient had severe biliary stricture due to intraoperative injury. Although we tried recanalization via the percutaneous transhepatic and transpapillary route, we couldn't. Then, we performed the MCA technique.
A snare with a magnet was inserted into the common bile duct via the papilla. This is the x-ray just after MCA technique. There was a little space between the two magnets, but their attraction to each other was confirmed. The magnets were attached to each other the following day. At 20 days after procedure, a guidewire was easily passed alongside the attached magnets and through the distal common bile duct to the duodenum. The distal magnet was pulled out through the papilla by using biopsy forceps. The proximal magnet was removed via the PTBD route. Finally, choledochocholedochostomy was completed.
In the next case, The patient had undergone right 3 segmental and S3 partial resection of the liver for metastastic liver tumors from colonic cancer. You can see a severe biliary stricture here, Although we tried recanalization via the percutaneous transhepatic and transpapillary route, we couldn't So, we tried MCA technique.
After placement of a 14 F sheath catheter percutaneously, a magnet was advanced into the sheath to the proximal portion of the stricture. Then a snare with a magnet was inserted into the common bile duct via the papilla up to the distal portion of the the stricture. There was a comparatively large space between two magnets, but we felt that the two magnets were faintly attracted.
The X-ray just after the MCA technique is on the left. At 7 days the procedure, the magnets were attracted to each other closely.
At 30 days after the procedure, the magnets were attached to each other completely. Then, we performed recanalization.
This is out last case. This patient underwent extraabdominal and intraluminal radiotherapy, we tried to conduct internal drainage of all intrahepatic bile ducts, but we couldn't. Then, we performed the MCA technique.
At first the transpapillart route was dilated using 7-Fr and 10-Fr plastic stents.
After placement of a 14 F sheath catheter percutaneously, a snare with a magnet was inserted into the common bile duct via the papilla up to the portion. Then, percutaneously, a magnet was advanced into the sheath. Eventually, we could confirm the attraction of both magnets.
X-ray just after MCA technique is on the left. The magnets were attached to each other the following day.
At 10 days after the procedure, a guidewire was easily passed alongside the attached magnets and through the distal common bile duct to the duodenum.
Eventually, recanalization could be achieved.
We need to perform further investigations, but we believe that in certain patients with severe bile duct strictures that cannot be canalized by conventional means the MCA technique will prove to be great value for recanalization.
| Contributed by: |
Takao Itoi, MD, PhD Physician Tokyo Medical University |
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Citation: Itoi, T. (May 19 2008). Biliary - Biliary Recanalization Using a Magnetic Compression Device. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=760 Times viewed since Feb 2006: 3711 |
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