Percutaneous portal venoplasty and stenting for anastomotic stenosis after liver transplantation

AIM:To review percutaneous transhepatic portal venoplasty and stenting(PTPVS)for portal vein anastomotic stenosis(PVAS)after liver transplantation (LT). METHODS:From April 2004 to June 2008,16 of 18 consecutive patients(11 male and 5 female;aged 17-66 years,mean age 40.4 years)underwent PTPVS for PVAS.PVAS occurred 2-10 mo after LT(mean 5.0 mo). Three asymptomatic patients were detected on routine screening color Doppler ultrasonography(CDUS). Fifteen patients who also had typical clinical signs of portal hypertension(PHT)were identified by contrastenhanced computerized tomography(CT)or magnetic resonance imaging.All procedures were performed under local anesthesia.If there was a PVAS<75%, the portal pressure was measured.Portal venoplasty was performed with an undersized balloon and slowly inflated.All stents were deployed immediately following the predilation.Follow-ups,including clinical course, stenosis recurrence and stent patency which were evaluated by CDUS and CT,were performed. RESULTS:Technical success was achieved in all patients.No procedure-related complications occurred. Liver function was normalized gradually and the symptoms of PHT also improved following PTPVS.In 2 of 3 asymptomatic patients,portal venoplasty and stenting were not performed because of pressure gradients<5 mmHg.They were observed with periodic CDUS or CT.PTPVS was performed in 16 patients.In 2 patients,the mean pressure gradients decreased from 15.5 mmHg to 3.0 mmHg.In the remaining 14 patients,a pressure gradient was not obtained because of>75%stenosis and typical clinical signs of PHT.In a 51-year-old woman,who suffered from massive ascites and severe bilateral lower limb edema after secondary LT,PVAS complicated hepatic vein stenosis and inferior vena cava(IVC)stenosis. Before PTPVS,a self-expandable and a balloonexpandable metallic stent were deployed in the IVC and right hepatic vein respectively.The ascites and edema resolved gradually after treatment.The portosystemic collateral vessels resulting from PHT were visualized in 14 patients.Gastroesophageal varices became invisible on poststenting portography in 9 patients.In a 28-yearold man with hepatic encephalopathy,a pre-existing meso-caval shunt was detected due to visualization of IVC on portography.After stenting,contrast agents flowed mainly into IVC via the shunt and little flowed into the portal vein.A covered stent was deployed into the superior mesenteric vein to occlude the shunt. Portal hepatopetal flow was restored and the IVC became invisible.The patient recovered from hepatic encephalopathy.A balloon-expandable Palmaz stent was deployed into hepatic artery for anastomotic stenosis before PTPVS.Percutaneous transhepatic internal-external biliary drainage was performed in 2 patients with obstructive jaundice.Portal venous patency was maintained for 3.3-56.6 mo(mean 33.0 mo) and all patients remained asymptomatic.CONCLUSION:With technical refinements,early detection and prompt treatment of complications,and advances in immunotherapy,excellent results can be achieved in LT.

Y–Z deformable magnetic ring for the treatment of rectal stricture: A case report and review of literature

BACKGROUND Treatment of postoperative anastomotic stenosis for colorectal cancer is often challenging,especially for patients who do not respond well to endoscopy.In cases where patients have undergone an enterostomy,the stenosis can be easily resolved through magnetic compression.However,common magnetic compre-ssion techniques cannot be performed on those without enterostomy.We design-ed a novel Y–Z deformable magnetic ring(Y–Z DMR)and successfully applied it to a patient with a stenosis rectal anastomosis and without enterostomy after rectal cancer surgery.CASE SUMMARY We here report the case of a 57-year-old woman who had undergone a laparo-scopic radical rectum resection(Dixon)for rectal cancer.However,she started facing difficulty in defecation 6 months after surgery.Her colonoscopy indicated stenosis of the rectal anastomosis.Endoscopic balloon dilation was performed six times on her.However,the stenosis still showed a trend of gradual aggravation.Because the patient did not undergo an enterostomy,the conventional endoscopic magnetic compression technique could not be performed.Hence,we imple-mented a Y–Z DMR implemented through the anus under single channel.The magnetic ring fell off nine days after the operation and the rectal stenosis was relieved.The patient was followed up for six months and reported good defeca-tion.CONCLUSION The Y–Z DMR deformable magnetic ring is an excellent treatment strategy for patients with rectal stenosis and without enterostomy.

Management of venous stenosis in living donor liver transplant recipients

AIM:To retrospectively evaluate the management and outcome of venous obstruction after living donor liver transplantation(LDLT).METHODS:From February 1999 to May 2009,1 intraoperative hepatic vein(HV) tension induced HV obstruction and 5 postoperative HV anastomotic stenosis occurred in 6 adult male LDLT recipients.Postoperative portal vein(PV) anastomotic stenosis occurred in 1 pediatric left lobe LDLT.Patients ranged in age from 9 to 56 years(median,44 years).An air balloon was used to correct the intraoperative HV tension.Emergent surgical reoperation,transjugular HV balloon dilatation with stent placement and transfemoral venous HV balloon dilatation was performed for HV stenosis on days 3,15,50,55,and 270 after LDLT,respectively.Balloon dilatation followed with stent placement via superior mesenteric vein was performed for the pediatric PV stenosis 168 d after LDLT.RESULTS:The intraoperative HV tension was corrected with an air balloon.The recipient who underwent emergent reoperation for hepatic stenosis died of hemorrhagic shock and renal failure 2 d later.HV balloon dilatation via the transjugular and transfemoral venous approach was technically successful in all patients.The patient with early-onset HV stenosis receiving transjugular balloon dilatation and stent placement on the 15th postoperative day left hospital 1 wk later and disappeared,while the patient receiving the same interventional procedures on the 50th postoperative day died of graft failure and renal failure 2 wk later.Two patients with late-onset HV stenosis receiving balloon dilatation have survived for 8 and 4 mo without recurrent stenosis and ascites,respectively.Balloon dilatation and stent placement via the superior mesenteric venous approach was technically successful in the pediatric left lobe LDLT,and this patient has survived for 9 mo without recurrent PV stenosis and ascites.CONCLUSION:Intraoperative balloon placement,emergent reoperation,proper interventional balloon dilatation and stent placement can be effective as a way to manage hepatic and PV stenosis during and after LDLT.

Fedora-type magnetic compression anastomosis device for intestinal anastomosis

BACKGROUND Although previous studies have confirmed the feasibility of magnetic compression anastomosis(MCA),there is still a risk of long-term anastomotic stenosis.For traditional MCA devices,a large device is associated with great pressure,and eventually increased leakage.AIM To develop a novel MCA device to simultaneously meet the requirements of pressure and size.METHODS Traditional nummular MCA devices of all possible sizes were used to conduct ileac anastomosis in rats.The mean(±SD)circumference of the ileum was 13.34±0.12 mm.Based on short-and long-term follow-up results,we determined the appropriate pressure range and minimum size.Thereafter,we introduced a novel“fedora-type”MCA device,which entailed the use of a nummular magnet with a larger sheet metal.RESULTS With traditional MCA devices,the anastomoses experienced stenosis and even closure during the long-term follow-up when the anastomat was smaller thanΦ5 mm.However,the risk of leakage increased when it was larger thanΦ4 mm.On comparison of the different designs,it was found that the“fedora-type”MCA device should be composed of aΦ4-mm nummular magnet with aΦ6-mm sheet metal.CONCLUSION The diameter of the MCA device should be greater than 120%of the enteric diameter.The novel“fedora-type”MCA device controls the pressure and optimizes the size.

COMPARATIVE STUDY OF RADICAL TREATMENT OF ESOPHAGEAL CARDIAC CANCER BY ESOPHAGOGASTROSTOMY

Digestive tract reconstruction could be completed with s anastomotic methods as anti-reflux method,manual end-to-end method or instrumental method.The patients were checked 2 weeal and 1 year postoperatively. The first method achieved the best result in preventing anastomotic leakage, stenosis or renux esophagitis.

Disturbed passage of jejunal limb near esophageal hiatus after overlapped esophagojejunostomy following laparoscopic total gastrectomy

BACKGROUND Overlapped esophagojejunostomy(OEJ) is a secure purely laparoscopic reconstruction after laparoscopic total gastrectomy(LTG). However, long-term surgical results have not been documented well.AIM In this paper, we report unusual patients who manifested jejunal limb stricture near the esophageal hiatus without anastomotic stenosis during long-term observation after surgery.METHODS From April 2009 until May 2020, we retrospectively reviewed 211 patients underwent LTG following by OEJ for gastric carcinoma and took a standard surveillance program. We aimed to characterize a novel complicated disorder observed in these patients to assist treatment and prevention.RESULTS Five patients(2.4%) had unusual jejunal limb stricture after LTG and OEJ,occurring at a mean of 10 mo after initial radical LTG. All five patients had disturbed oral intake and marked weight loss, and two had aspiration pneumonia.Various diagnostic modalities and intraoperative findings in each patient revealed an intact anastomosis, bent or tortuous jejunal limb resulting from loose fibrous adhesions on the left crus at the esophageal hiatus and no cancer recurrence. All five patients were successfully treated by reoperation for adhesiolysis, division of the left crus and rearrangement of the jejunal limb.CONCLUSION Disturbed passage through the jejunal limb near the hiatus can occur after some types of OEJ following LTG. We speculate that it may result from a short remnant esophagus, excessive mobilization of the jejunal limb that permits bending or tortuosity and adhesions on the left crus at the hiatus. Prevention for this complication is possible during the original LTG procedure.