Saito Ryusuke, Tahara Hiroyuki, Shimizu Seiichi, Ohira Masahiro, Ide Kentaro, Ishiyama Kohei, Kobayashi Tsuyoshi, Ohdan Hideki
Department of Gastroenterological and Transplant Surgery, Hiroshima University, 1-2-3 Kasumi, Minamiku, Hiroshima, Hiroshima, 734-8551, Japan.
Surg Case Rep. 2017 Dec;3(1):73. doi: 10.1186/s40792-017-0349-4. Epub 2017 May 25.
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.
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.
Choledochoduodenostomy with magnet compression could be a less invasive and safer method for treatment of biliary stricture that cannot be accessed by conventional surgery.
尽管肝移植患者的手术技术和术后管理有所改进，但胆道并发症仍是最常见且重要的不良事件之一。我们报告首例活体肝移植术后因绞窄性肠梗阻行小肠大部切除术后采用磁压榨法行胆总管十二指肠吻合术的病例。
该54岁女性患者因原发性硬化性胆管炎合并溃疡性结肠炎继发肝硬化，患有终末期肝病。5年前，她接受了活体肝移植，采用左叶供肝，同时切除肝外胆管并进行了Roux-en-Y吻合术。患者突发剧烈腹痛。急诊手术确诊为肠系膜扭转导致的绞窄性肠梗阻。行小肠大部切除术，包括胆总管空肠吻合术。仅剩余70cm小肠。患者带着胆管腔外引流管和空肠造口管转入我院。我们开始全肠外营养，并建立经皮经肝胆道引流以治疗胆管炎。计算机断层扫描显示胆管靠近十二指肠；因此，我们计划对胆管和十二指肠进行磁压榨吻合术。将子磁体置于胆管引流管内，通过纤维内镜将母磁体置于十二指肠球部。25天后完成左肝管与十二指肠的吻合，并在吻合口上方放置胆管引流支架以防止再狭窄。在适应期关闭回肠造口、保留回盲瓣、胆汁内引流以及侧侧吻合术对成功停用肠外营养起到了作用。
磁压榨胆总管十二指肠吻合术可能是一种治疗传统手术无法处理的胆道狭窄的侵入性较小且更安全的方法。
