Superior mesenteric artery syndrome managed laparoscopically: a case report.

BACKGROUND: Superior mesenteric artery syndrome is a rare condition that has only around 400 reported cases so far. Typically, the superior mesenteric artery branches off the abdominal aorta at 45° to create an aortomesenteric distance of 10-28 mm, with the duodenum passing through. However, if this aortomesenteric angle reduces to less than 25°, the third portion of the duodenum becomes compressed between the SMA and aorta, causing mechanical obstruction. CASE PRESENTATION: This case report aims to demonstrate the diagnostic difficulties and the laparoscopic management of a 52-year-old Indian male presenting with abdominal pain and vomiting, with associated weight loss. Imaging was further suggestive of high intestinal obstruction, and he was later found to have superior mesenteric artery syndrome. CONCLUSION: Taking into account a significant reduction in morbidity, we propose laparoscopic duodenojejunostomy to be the new procedure of choice for superior mesenteric artery syndrome.

Changes in microcirculation of small intestine end-to-end anastomoses in an experimental model.

INTRODUCTION: Sufficient perfusion is essential for a safe intestinal anastomosis. Impaired microcirculation may lead to increased bacterial translocation and anastomosis insufficiency. Thus, it is important to estimate well the optimal distance of the anastomosis line from the last mesenterial vessel. However, it is still empiric. In this experiment the aim was to investigate the intestinal microcirculation at various distances from the anastomosis in a pig model. MATERIALS AND METHODS: On 8 anesthetized pigs paramedian laparotomy and end-to-end jejuno-jejunostomy were performed. Using Cytocam-IDF camera, microcirculatory recordings were taken before surgery at the planned suture line, and 1 to 3 mesenterial vessel mural trunk distance from it, and at the same sites 15 and 120 min after anastomosis completion. After the microcirculation monitoring, anastomosed and intact bowel segments were removed to test tensile strength. RESULTS: The proportion and the density of the perfused vessels decreased significantly after anastomosis completion. The perfusion rate increased gradually distal from the anastomosis, and after 120 min these values seemed to be normalized. Anastomosed bowels had significantly lower maximal tensile strength and higher slope of tensile strength curves than intact controls. CONCLUSION: Alterations in microcirculation and tensile strength were observed. After completing the anastomosis, the improvement in perfusion increased gradually away from the wound edge. The IDF device was useful to monitor intestinal microcirculation providing data to estimate better the optimal distance of the anastomosis from the last order mesenteric vessel.

Benign hepaticojejunostomy strictures after pancreatoduodenectomy.

PURPOSE: To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs. METHODS: A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined. RESULTS: BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029-18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75-52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients. CONCLUSIONS: Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients.

Endoscopic Ultrasound-guided Jejunocolostomy for Management of Refractory Severe Obesity in a Post-gastric Bypass Patient.

Obesity is a complex disease process, which often requires multifactorial, patient-tailored strategies for effective management. Treatment options include lifestyle optimization, pharmacotherapy, endobariatrics, and bariatric metabolic endoscopy. Obesity-based interventions can be challenging in patient populations with severe obesity, particularly post-gastric bypass. We report the case of a non-surgical patient with a failed remote open gastric bypass, who underwent an endoscopic small bowel diversion procedure, resulting in partial caloric diversion, via the creation of an EUS-guided jejunocolostomy (EUS-JC). The procedure is an extension of prior reported EUS-guided and magnet-based small bowel bypass procedures, in this case, for the purposes of weight loss (Kahaleh et al., 1; Jonica et al. Gastrointest Endosc. 97(5):927-933, 2; Machytka et al. Gastrointest Endosc. 86(5):904-912, 3;). The procedure was performed without peri-procedural complications, with effective weight loss during follow-up. Endoscopic bariatric interventions that target the small bowel, such as EUS-JC, offer promising tools for obesity management and should be studied further. Numerous factors including lifestyle, psychosocial, genetic, behavioral, and secondary disease processes contribute to obesity. Severe obesity (defined as a BMI > 50 kg/m2) is associated with increased morbidity and mortality with a significantly reduced response to treatment (Flegal et al. JAMA. 309(1):71-82, 4;). Weight regain can be noted in up to 50% of patients post-RYGB. In populations with severe obesity, there is an associated 5-year surgical failure rate of 18% (Magro et al. Obesity Surg. 18(6):648-51, 5;). These patients may not be surgical candidates for revision or can develop post-revision chronic protein-caloric malnutrition (Shin et al. Obes Surg. 29(3):811-818, 6;). Lifestyle, modification, pharmacotherapy, or endoscopic transoral reduction (TORe) can be effective generally; however, in patients with severe obesity, the total desired excess body weight loss may not likely be accomplished solely by these strategies. An endoscopic small bowel intervention that diverts a portion of caloric intake from small bowel absorption can potentially promote weight loss similar to a surgical lengthening of the Roux limb (Shah et al. Obes Surg. 33(1):293-302, 7; Hamed et al. Annal Surg. 274(2):271-280, 8;), in the sense that there is a reduction in the total small bowel surface area for absorption. Roux limb distalization can be effective for weight regain for post bypass patients. The EUS-JC technique aims to work similarly by reducing the total small bowel surface area utilized for absorption. Since this patient was deemed a non-surgical candidate, an EUS-guided jejunocolostomy was offered. Prior to the procedure, the patient established longitudinal care with our bariatric nutritionist and obesity medicine services. Extensive pre-bariatric labs were screened to rule out confounders for recurrent severe obesity. Intra-procedure, the patient received one dose of 500 mg intravenous levofloxacin. Post-procedure, loperamide was prescribed every 8 h as needed for post-procedure diarrhea. Within 2 weeks, the patient was no longer taking anti-diarrheals. The post-procedure diet consisted of a liquid diet for 2 days before advancement to a low-residue diet for 1 month, and then a regular diet.

Robotic hepaticojejunostomy training in novices using robotic simulation and dry-lab suturing (ROSIM): randomized controlled crossover trial.

BACKGROUND: Robotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking. METHODS: This was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences. RESULTS: Overall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2-8.0] vs 3.8 [2.3-12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training. CONCLUSION: Surgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.

Robot-assisted resection of choledochal cyst in neonates.

OBJECTIVE: Laparoscopic choledochectomy and hepatojejunostomy have been reported in children since 1995, but this procedure is technically demanding. Robotic surgical systems can simplify complex minimally invasive procedures. Currently, few reports have been made on neonates. We present the experience of 6 cases of neonatal CC(choledochal cysts). STUDY DESIGN: Between January 2022 and December 2023, 6 neonates underwent robotic resection of choledochal cyst and hepaticojejunostomy using the Da Vinci surgical system at Children's Hospital, Zhejiang University School of Medicine, a high-volume hepatobiliary disease center. demographic data of the patients and surgical outcomes were collected and analyzed. RESULTS: All 6 patients were successfully treated by robotic cystectomy and hepaticojejunostomy. The mean age was 17.3 days (range 4-25) and the mean weight was 3.6 kg (range 2.55-4.4). 5 cysts were type Ia and 1 was type Iva. The mean diameter of the cysts was 3.8 cm (range 1.25-5). The mean time to establish feeding was 4.83 days (range 4-6), and patients were discharged after a median time of 16.83 days (range 7-42) without postoperative complications. CONCLUSIONS: This procedure is safe and effective for neonates. The authors found that the use of robot-assisted surgery has ergonomic advantages in this delicate, minimally invasive procedure.

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer.

BACKGROUND: Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus. MATERIALS AND METHODS: This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up. RESULTS: In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001). CONCLUSION: Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Comparison of the clinical effectiveness of hepaticojejunostomy and self-expanding metal stents for bypassing the bile ducts in patients with unresectable pancreatic head cancer complicated by obstructive jaundice.

OBJECTIVE: Aim: To improve treatment outcomes of patients with unresectable pancreatic head cancer complicated by obstructive jaundice by improving the tactics and techniques of surgical interventions. PATIENTS AND METHODS: Materials and Methods: Depending on the treatment tactics, patients were randomised to the main group (53 people) or the comparison group (54 people). The results of correction of obstructive jaundice by Roux-en-Y end to side hepaticojejunostomy (main group) and common bile duct prosthetics with self-expanding metal stents (comparison group) were compared. RESULTS: Results: The use of self-expanding metal stents for internal drainage of the biliary system compared to hepaticojejunostomy operations reduced the incidence of postoperative complications by 29.9% (χ2=13.7, 95% CI 14.38-44.08, p=0.0002) and mortality by 7.5% (χ2=4.16, 95% CI -0.05-17.79, p=0.04). Within 8-10 months after biliary stenting, 11.1% (6/54) of patients developed recurrent jaundice and cholangitis, and another 7.4% (4/54) of patients developed duodenal stenosis with a tumour. These complications led to repeated hospitalisation and biliary restentation in 4 (7.4%) cases, and duodenal stenting by self-expanding metal stents in 4 (7.4%) patients. CONCLUSION: Conclusions: The choice of biliodigestive shunting method should be selected depending on the expected survival time of patients. If the prognosis of survival is up to 8 months, it is advisable to perform prosthetics of the common bile duct with self-expanding metal stents, if more than 8 months, it is advisable to perform hepaticojejunal anastomosis with prophylactic gastrojejunal anastomosis.

Towards a 'step-up approach' for the treatment of recurrent non-stenotic cholangitis after hepaticojejunostomy: systematic review.

BACKGROUND: Recurrent non-stenotic cholangitis (NSC) is a difficult-to-treat complication after hepaticojejunostomy (HJ) leading to multiple hospital admissions. The optimal treatment strategy is unclear as a systematic review is lacking. METHODS: A systematic review was performed including studies detailing treatment strategies and outcomes for recurrent NSC in patients with a surgical HJ in PubMed, Embase, and Cochrane Library (inception - September 2023). Primary outcome was resolution of NSC as defined by the included studies. RESULTS: Overall, 72 patients with recurrent NSC after HJ were included from seven retrospective studies. The rate of recurrent NSC (specified in five studies) was 4% (46/1143 HJs). Diagnosis of NSC was mostly made after excluding HJ stenosis and assessing bile reflux. Initial treatment consisted of short-course antibiotics for all patients. Second step treatment consisted of prolonged antibiotic therapy (n = 10, 13.8%). Third step treatment consisted of surgery (n = 9, n = 12.5%); mostly lengthening of the biliary loop. Together, the overall reported resolution-rate of recurrent NSC was 66.6% (n = 48). CONCLUSION: A 'step-up approach' may be effective in two-thirds of patients with recurrent NSC after HJ, starting with short-course antibiotics, and eventually adding prolonged antibiotic therapy and, ultimately, surgery aimed at preventing intestinal content and food reflux. Prospective studies are needed.

Top Tips for Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement.

Direct percutaneous endoscopic jejunostomy (DPEJ) provides post-pyloric enteral access in patients unable to meet long-term nutritional needs per os in situations where gastric feeding is neither tolerated nor feasible. Specific conditions associated with feeding intolerance due to due to nausea, vomiting, or ileus include gastric outlet obstruction, gastroparesis, or complications of acute or chronic pancreatitis; infeasibility may be due to high aspiration risk or prior gastric surgery. Since performing DPEJ is not an ACGME requirement for GI fellows or early career gastroenterologists, not all trainees are taught this technique. Hence, provider expertise for teaching and performing this technique varies widely across centers. In this article, we provide top tips for successful performance of DPEJ.

[Necrosis and intestinal perforation associated with feeding by jejunostomy]. / Necrosis y perforación intestinal asociada a alimentación por yeyunostomía.

Enteral nutrition through jejunostomy is a common practice in any general surgery service; it carries a low risk of complications and morbidity and mortality. We present the case of a patient with an immediate history of subtotal gastrectomy that began nutrition through jejunostomy and complicated with intestinal necrosis due to non-occlusive ischemia in the short period. The purpose of this work is to report on this complication, its pathophysiology and risk factors to take it into account and be able to take appropriate therapeutic action early.

La nutrición enteral por yeyunostomía es una práctica frecuente en cualquier servicio de cirugía general, esta conlleva bajo riesgo de complicaciones y morbimortalidad. Presentamos el caso de una paciente con antecedente inmediato de gastrectomía subtotal que inició nutrición por yeyunostomía y complicó con necrosis intestinal por isquemia no oclusiva en el corto lapso. La finalidad de este trabajo es informar sobre esta complicación, su fisiopatología y factores de riesgo para tenerla en cuenta y poder tomar precozmente una conducta terapéutica adecuada.

Minor hepatectomy combined with cholangioplasty and cholangiojejunostomy for Bismuth II hilar cholangiocarcinoma: A propensity score matching analysis.

BACKGROUND: The optimal surgical approach for Bismuth II hilar cholangiocarcinoma (HCCA) remains controversial. This study compared perioperative and oncological outcomes between minor and major hepatectomy. MATERIALS AND METHODS: One hundred and seventeen patients with Bismuth II HCCA who underwent hepatectomy and cholangiojejunostomy between January 2018 and December 2022 were retrospectively investigated. Propensity score matching created a cohort of 62 patients who underwent minor (n = 31) or major (n = 31) hepatectomy. Perioperative outcomes, complications, quality of life, and survival outcomes were compared between the groups. Continuous data are expressed as the mean ± standard deviation, categorical variables are presented as n (%). RESULTS: Minor hepatectomy had a significantly shorter operation time (245.42 ± 54.31 vs. 282.16 ± 66.65 min; P = 0.023), less intraoperative blood loss (194.19 ± 149.17 vs. 315.81 ± 256.80 mL; P = 0.022), a lower transfusion rate (4 vs. 11 patients; P = 0.038), more rapid bowel recovery (17.77 ± 10.00 vs. 24.94 ± 9.82 h; P = 0.005), and a lower incidence of liver failure (1 vs. 6 patients; P = 0.045). There were no significant between-group differences in wound infection, bile leak, bleeding, pulmonary infection, intra-abdominal fluid collection, and complication rates. Postoperative laboratory values, length of hospital stay, quality of life scores, 3-year overall survival (25.8 % vs. 22.6 %; P = 0.648), and 3-year disease-free survival (12.9 % vs. 16.1 %; P = 0.989) were comparable between the groups. CONCLUSION: In this propensity score-matched analysis, overall survival and disease-free survival were comparable between minor and major hepatectomy in selected patients with Bismuth II HCCA. Minor hepatectomy was associated with a shorter operation time, less intraoperative blood loss, less need for transfusion, more rapid bowel recovery, and a lower incidence of liver failure. Besides, this findings need confirmation in a large-scale, multicenter, prospective randomized controlled trial with longer-term follow-up.

Robotic Left Hepatectomy with En Bloc Biliary Resection and Roux-en-Y Hepaticojejunostomy: A Technique of Portal Venous Tangential Vascular Reconstruction.

BACKGROUND: Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach. METHODS: The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis. RESULTS: The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses. CONCLUSION: The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

Detection of residual stones by peroral direct cholangioscopy in patients with intrahepatic stones after hepaticojejunostomy: a prospective study (with video).

BACKGROUND AND AIMS: The difficulty in radiographic confirmation of the presence of stones remains challenging in the treatment of intrahepatic bile duct (IHBD) stones in patients after hepaticojejunostomy (HJ). Peroral direct cholangioscopy (PDCS) enables direct observation of the bile duct and is useful for detecting and removing residual stones; however, its effectiveness is not clearly established in this clinical context. METHODS: This single-center, single-arm, prospective study included 44 patients with IHBD who underwent bowel reconstruction with HJ during the study period. Stone removal was performed by using short-type double-balloon enteroscopy. After balloon-occluded cholangiography, the double-balloon enteroscopy was exchanged for an ultra-slim endoscope through the balloon overtube for PDCS. The primary end point was the rate of residual stones detected by PDCS. Secondary end points were success rate of PDCS, residual stone removal with PDCS, procedure time for PDCS, procedure-related adverse events, and stone recurrence rate. RESULTS: PDCS was successful in 39 (89%) of 44 patients, among whom residual stones were detected in 16 (41%) (95% CI, 28%-54%). Twelve patients (75%) had residual stones <5 mm. Stone removal was successful in 15 (94%) patients, and median procedure time for PDCS was 16 minutes (interquartile range, 10-26 minutes). The rate of procedure-related adverse events was 7% (3 of 44); all adverse events improved with conservative treatment. During the median follow-up of 2.1 years (interquartile range, 1.4-3.3 years), the overall probability of recurrence-free status at 1, 2, and 3 years was 100%, 92%, and 86%, respectively. CONCLUSIONS: PDCS is a safe and effective procedure for complete stone removal in patients with IHBD stones after HJ.

Robotic Biliary Stricturoplasty and Roux-en-Y Hepaticojejunostomy After Hepatic Artery Infusion Pump Injury.

BACKGROUND: Hepatic artery infusion pump (HAIP) with floxuridine/dexamethasone and systemic chemotherapy is an established treatment regimen, which had been reported about converting 47% of patients with stage 4 colorectal liver metastasis from unresectable to resectable.1,2 To this effect, HAIP chemotherapy contributes to prolonged survival of many patients, which otherwise may not have other treatment options. Biliary sclerosis, however, is a known complication of the HAIP treatment, which occurs in approximately 5.5% of patients receiving this modality as an adjuvant therapy after hepatectomy and in 2% of patients receiving HAIP treatment for unresectable disease.3 While biliary sclerosis diffusely affects the perihilar and intrahepatic biliary tree, a dominant stricture maybe found in select cases, which gives an opportunity for a local surgical treatment after failure of endoscopic stenting/dilations. While the use of minimally invasive approach to biliary surgery is gradually increasing,4 there have been no descriptions of its application in this scenario. In this video, we demonstrate the use of minimally invasive robotic technique for biliary stricturoplasty and Roux-en-Y (RY) hepaticojejunostomy to treat persistent right hepatic duct stricture after HAIP chemotherapy. PATIENT: A 68-year-old woman with history of multifocal bilobar stage 4 colorectal liver metastasis presented to our office with obstructive jaundice and recurrent cholangitis that required nine endoscopic retrograde cholangiopancreatographies (ERCPs) and a placement of internal-external percutaneous transhepatic biliary drain (PTBD) by interventional radiology within the past 2 years. Her past surgical history was consistent with laparoscopic right hemicolectomy 3 years prior, followed by a left lateral sectorectomy with placement of an HAIP for adjuvant treatment. The patient had more than ten metastatic liver lesions within the right and left lobe, ranging from 2 to 3 cm in size at the time of HAIP placement. The patient had a histologically normal background liver parenchyma before the HAIP chemotherapy treatment. The patient did not have any history of alcohol use, diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, or other underlying intrinsic liver disorders, which are known to contribute to the development of hepatic fibrosis. Despite a radiologically disease-free status, the patient started to have episodes of acute cholangitis 1 year after the placement of HAIP that required multiple admissions to a local hospital. The HAIP was subsequently removed once the diagnosis of biliary sclerosis was made despite dose reductions and treatment with intrahepatic dexamethasone for almost 1 year. In addition to this finding, the known liver metastases have shown complete radiological resolution. Therefore further treatment with HAIP was deemed unnecessary, and pump removal was undertaken. Magnetic resonance imaging showed a dominant stricture at the junction of the right anterior and right posterior sectoral hepatic duct. The location of the dominant stricture was confirmed by an ERCP and cholangioscopy. Absence of neoplasia was confirmed with multiple cholangioscopic biopsies. Multiple endoscopic and percutaneous attempts with stent placement failed to dilate the area of stricture. Postprocedural cholangiographies showed a persistent significant narrowing, which led to multiple recurrent obstructive jaundice and severe cholangitis. While the use of surgical approach is rarely needed in the treatment of biliary sclerosis, a decision was made after extensive multidisciplinary discussions to perform a robotic stricturoplasty and RY hepaticojejunostomy with preservation of the native common bile duct. TECHNIQUE: The operation began with a laparoscopic adhesiolysis to allow for identification of HAIP tubing (which was later removed) and placement of robotic ports. A peripheral liver biopsy was obtained to evaluate the degree of hepatic parenchymal fibrosis. Porta hepatic area was carefully exposed without causing an inadvertent injury to the surrounding hollow organs. Biopsy of perihepatic soft tissues was taken as appropriate to rule out any extrahepatic disease. The common bile duct and common hepatic duct with ERCP stents within it were identified with the use of ultrasonography. Anterior wall of the common hepatic duct was then opened, exposing the two plastic stents. Cephalad extension of the choledochotomy was made toward the biliary bifurcation and the right hepatic duct. The distal common bile duct was preserved for future endoscopic access to the biliary tree. After lowering the right-sided hilar plate, dense fibrosis around the right hepatic duct was divided sharply with robotic scissors, achieving a mechanical release of the dominant stricture. An intraoperative cholangioscopy was performed to confirm adequate openings of the right hepatic duct secondary and tertiary radicles, as well as patency of the left hepatic duct. A 4-Fr Fogarty catheter was used to sweep the potential biliary debris from within the right and left hepatic lobe. Finally, a confirmatory choledochoscopy was performed to ensure patency and clearance of the right-sided intrahepatic biliary ducts and the left hepatic duct before fashioning the hepaticojejunostomy. A 40-cm antecolic roux limb was next prepared for the RY hepaticojejunostomy. A side-to-side double staple technique was utilized to create the jejunojejunostomy. The common enterotomy was closed in a running watertight fashion. Once the roux limb was transposed to the porta hepatic in a tension-free manner, a side-to-side hepaticojejunostomy was constructed in a running fashion by using absorbable barbed sutures. The index suture was placed at 9 o'clock location, and the posterior wall of the anastomosis was run toward 3 o'clock location. This stabilized the roux limb to the bile duct. The anterior wall of the anastomosis was next fashioned by using a running technique from both corners of the anastomosis toward the middle (12 o'clock), where both sutures were tied together. This completed a wide side-to-side hepaticojejunostomy anastomosis encompassing the upper common hepatic duct, biliary bifurcation, and the right hepatic duct. A closed suction drain was placed before closing.5 RESULTS: The operative time was approximately 4 hr with 60 ml of blood loss. The postoperative course was uneventful. The patient was discharged home on postoperative Day 5 after removal of the closed suction drain, confirming the absence of bile leak. The patient had developed periportal/periductal fibrosis, cholestasis, and moderate-severe parenchymal fibrosis (F3-F4) based on liver biopsy, often seen in patients treated with a long course of floxuridine HAIP chemotherapy. The patient is clinically doing well at 1 year outpatient follow-up without any evidence of recurrent cholangitis at the time of this manuscript preparation. CONCLUSIONS: Robotic biliary stricturoplasty with RY hepaticojejunostomy for treatment of biliary sclerosis after HAIP chemotherapy is safe and feasible. Appropriate experience in minimally invasive hepatobiliary surgery is necessary to achieve this goal.