Successful Treatment of Stricture of Duct-to-Duct Biliary Anastomosis After Living-Donor Liver Transplantation of the Left Lobe: A Case Report.

Biliary complications, such as stricture or obstruction, after living-donor liver transplantation (LDLT) remain major problems to be solved. Magnetic compression anastomosis (MCA) is a minimally invasive method of biliary anastomosis without surgery in patients with biliary stricture or obstruction. A 66-year-old woman had undergone LDLT for end-stage liver disease for primary biliary cholangitis 20 months previously at another hospital. Computerized tomography showed dilation of the intrahepatic bile duct (B2). Because B2 was invisible with the use of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage (PTBD) was performed for treatment of cholangitis. The rendezvous technique failed because a guidewire could not pass through the biliary stricture. Therefore, we decided to perform MCA. A parent magnet was endoscopically placed distally in the common bile duct of the stricture, and a daughter magnet attached to a guidewire was inserted proximally through the fistula tract of the PTBD. Both magnets were positioned across the stricture, and the 2 magnets were pulled to each other by magnetic power, to sandwich the stricture. By 14 days after MCA, a fistula between B2 and the common bile duct was created. At 28 days after MCA, the magnets were removed distally and a 16-French tube was placed across the fistula. At 7 months after MCA, that tube was removed. In conclusion, when a conventional endoscopic or percutaneous approach including the rendezvous technique fails, MCA is a good technique for biliary stricture after LDLT.

Magnetic compression anastomosis for bile duct stenosis after donor left hepatectomy: a case report.

Magnetic compression anastomosis (MCA) provides a minimally invasive treatment creating a nonsurgical, sutureless enteric anastomosis in conjunction with an interventional radiologic technique by using 2 high-power magnets. Recently, the MCA technique has been applied to bile duct strictures after living donor liver transplantation or major hepatectomy. Herein we described use of MCA for bile duct stenosis 5 months after donor left hepatectomy in a 24-year-old man who presented with a stricture at the porta hepatis and intrahepatic bile duct dilatation. Unsuccessful transpapillary biliary drainage and balloon dilatation through a percutaneous transhepatic biliary drainage (PTBD) route led to the MCA. A 4-mm-diameter cylindrical samarium-cobalt (Sm-Co) daughter magnet with a long nylon wire was placed at the superior site of the obstruction through the PTBD route. A 5-mm-diameter Sm-Co parent magnet with an attached nylon handle was endoscopically inserted into the common bile duct and placed at the inferior site of obstruction. The 2 magnets were attracted, sandwiching the stricture and establishing a reanastomosis. In conclusion, the MCA technique was a unique procedure for choledochocholedochostomy in a patient with bile duct stenosis after donor hepatectomy.

Magnetic compression anastomosis for benign obstruction of the common bile duct.

Advances in interventional radiology have made possible magnetic compression anastomosis between the bile duct and the small intestine as a novel treatment. A 70-year-old man who had undergone subtotal gastrectomy for gastric cancer 2 years previously experienced recurring cholangitis with high fever and jaundice. Diagnostic evaluation subsequently demonstrated complete obstruction of the common bile duct which was attributed to recurrent cholangitis. A parent magnet was placed endoscopically into the afferent loop of the duodenum through the gastrojejunostomy with Billroth II reconstruction. The daughter magnet attached to a guide wire was placed in the obstructed common bile duct through a percutaneous transhepatic cholangiographic drainage tube. Two magnets were immediately attracted towards each other transmurally, and anastomosis was established on day 32 after the procedure. This novel method of magnetic compression anastomosis has the advantages of noninvasiveness and simplicity, as well as being a well-tolerated procedure for indications such as biliary obstruction.

[Effectiveness of 3 ways method in intra-arterial infusion chemotherapy for advanced or recurrent cervical cancer with or without radiotherapy].

We analyzed 58 cases of advanced or recurrent cervical cancer treated with intra-arterial infusion chemotherapy (IAIC) with or without radiotherapy. Two separate IAIC regimens were administered since 1985: group I consisted of 5-FU + MMC +/- ADR (30 patients) and group II consisted of CDDP + MMC +/- 5-FU (28 patients). The tip of a catheter was placed in the bifurcation of the abdominal aorta (1 way method: 45 patients regimen II: 15) between 1977-1984. We have used selective catheterization (2 ways method: 9) since 1995 in order to get good drug distribution. However we experienced grade 4 toxic effect of cutaneous and pain with this method, so we have used a 3 ways method (4 patients) since 1998. The two-year survival rete was 60% with the 1 way method, and 67% with the 2 ways method and regimen II. Severe adverse effects (grade 3 + 4) were found in 53, 56, 0%, respectively, by each of the three methods (1, 2, 3 ways) hematologically, 13, 22, 0% in gastrointestinally, 0, 44, 0% in cutaneously and 0, 56, 0% in pain or neurotoxicity. These data suggest that IAIC by the 3 ways method is a useful treatment for advanced or recurrent cervical cancer. However, one should check the blood flow distribution periodically, and control concentration of drugs.

Transcatheter arterial embolization for impending rupture of an isolated internal iliac artery aneurysm complicated with disseminated intravascular coagulation.

A 90-year-old male, with impending rupture of an isolated internal iliac artery aneurysm (IIAA) complicated with disseminated intravascular coagulation (DIC) was successfully treated with transcatheter arterial embolization (TAE). After TAE, enlargement of the aneurysm was arrested and coagulation-fibrinolytic abnormalities induced by DIC improved without severe complications. Although IIAA is relatively rare, the post-operative mortality of patients with ruptures is reportedly high. We assessed the usefulness of this procedure for impending rupture of IIAA, especially for patients in high risk groups.

Lower leg ischemia associated with aortic dissection.

Lower leg ischemia associated with aortic dissection is a potentially life-threatening condition requiring immediate treatment. To better understand the diagnostic factors and improve the treatment strategy of this serious complication, we analyzed our experience regarding the radiographic findings, treatment, and outcome in eight patients (aged 28-72 years, six men and two women). CT revealed type A aortic dissection in seven patients and type B in one. The obstructed site was in the iliac artery in five patients and in the abdominal aorta below the renal arteries in three. Surgical procedures included five ascending aortic graft replacements, three femoro-femoral bypasses, and one each of surgical fenestration, aorto-iliac bypass, and axillo-femoral bypass with thrombectomy. Endovascular treatment was performed in two patients, iliac stent placement in one, and thrombolysis of the iliac artery in one. Five patients survived and three died due to myonephrotic metabolic syndrome in two and postoperative bleeding in one. Treatment strategy depends on several issues regarding aortic dissection including ascending aortic involvement, patent false lumen, entry site, renal artery involvement, and thrombosis in a true or false lumen. CT and angiography are the most important methods for deciding upon appropriate therapy in each individual.

Indication of chemoembolization therapy without gelatin sponge for hepatocellular carcinoma.

This study evaluated the effect of chemoembolization (C-LIP) consisting of ethiodized oil (Lipiodol Ultra Fluid; André Guerbet, Aulnay-sous-Bois, France) and epirubicin, without gelatin sponge on hepatocellular carcinoma (HCC), administered by hepatic arterial infusion. We analyzed the cases from two points of view: the local recurrence rate for hypervascular solitary small HCC (tumor size: < or =3 cm in diameter) and the cumulative survival rate for advanced HCC (stage VI according to the criteria of Liver Cancer Group of Japan) following C-LIP therapy. The C-LIP also was compared with transcather arterial embolization (TAE; C-LIP followed by gelatin sponge) and percutaneous ethanol injection therapy (PEIT). In the small HCC cases, the recurrence rate at 1 year after C-LIP was 77% (10 of 13 patients), while the local recurrence rate was 46% (six of 13 patients) at 6 months and 61% (eight of 13 patients) at 1 year. The local recurrence rate at 1 year was 29% (four of 14 patients) after TAE and 20% (three of 15 patients) after PEIT. These results showed that the effect of local anticancer therapy by C-LIP was not as potent as that of TAE or PEIT. In advanced HCC cases, the cumulative survival rate for 13 patients treated by C-LIP was 72% at 6 months, 36% at 1 year, and 14% at 2 years. However, the survival rates for 13 patients at 6 months, 1 year, and 2 years after TAE were 46%, 23%, and 8%, respectively. There was no difference between the C-LIP patients and TAE patients with regard to the pretreatment liver function. Three patients died within 2 months after the initial TAE. These deaths were mainly due to damage to the noncancerous liver parenchyma. Therapy with C-LIP alone was not appropriate for hypervascular solitary small HCCs, and additional treatment was necessary. We think C-LIP therapy should be selected instead of TAE for advanced HCCs to avoid severe parenchymal damage.

[Biliary lithotripsy using super fine cholangioscopy with the deviced bended sheath].

Percutaneous transhepatic cholangioscopy (PTCS) is an useful technique to evaluate or treat biliary diseases, although PTCS is an invasive method for the patients. We used 5 F or 7 F of super fine cholangioscopy to treat two cases of choledocholithiasis after surgery without dilatation of drainage tract. We developed different types of bended sheath for supplement of lack of angle system in this cholangioscope. Furthermore, by using bended sheath, cholangioscopic view improved, because saline was injected at the same time via the sheath. We emphasize that super fine cholangioscope with bended sheath is a safe and useful modality for evaluation of biliary disease.

Pathophysiology of hypertension following coronary artery bypass surgery: an experimental dog model for postoperative hypertension.

Immediate postoperative hypertension has been reported to occur during the first 3-6 h in 30%-75% of patients who have undergone aortocoronary bypass operations. Although some causes and potential predisposing factors of this type of hypertension have been cited, the mechanisms involved still remain unclear. Some studies have implicated the involvement of nerve reflexes originating from the heart, great vessels, and coronary arteries, but they do not explain the exact role of such impulses. The paucity of data in humans is, needless to say, due primarily to the invasive nature of the experimental procedure. To further our knowledge on the involvement of nerve reflexes as a factor in initiating immediate postoperative hypertension, we used a dog model and devised a modified form of surgery by inserting a soft catheter into the left coronary artery to form a stenosis; we measured several factors usually involved in hypertension. We succeeded in performing this modified form of surgery in 10 of 81 dogs. Our model showed that the mean aortic pressure significantly increased from 81 +/- 5.5 to 102 +/- 7.0 mmHg (P less than 0.05), systemic vascular resistance from 7604 +/- 833 to 9648 +/- 1101 dyn.s.cm-5 (P less than 0.05), and plasma noradrenaline levels from 0.45 +/- 0.092 to 0.51 +/- 0.087 ng/ml (P less than 0.01) immediately after restoration of blood flow to the distal area behind the stenosis. These dynamic and humoral characteristics are similar to ones documented in current clinical reports. To our knowledge, this is the first experimental animal model of hypertension after coronary artery bypass graft surgery.