Abstract：
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.
METHODS: 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.
METHODS: 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.
METHODS: 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.
METHODS: 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.
摘要：
背景：肝动脉输液泵（HAIP）联合氟尿苷/地塞米松和全身化疗是一种既定的治疗方案，据报道，47%的4期结直肠癌肝转移患者从不可切除转变为可切除.HAIP化疗有助于延长许多患者的生存期，否则可能没有其他治疗选择。胆道硬化症,然而,是HAIP治疗的已知并发症，这发生在大约5.5％的患者接受这种方式作为肝切除术后的辅助治疗和2％的患者接受HAIP治疗不可切除的疾病.3虽然胆道硬化弥漫性影响肝门周和肝内胆管树,在某些情况下可能会发现显性狭窄，这为内窥镜支架置入/扩张失败后的局部手术治疗提供了机会。而微创方法在胆道手术中的应用逐渐增多,在图4中,没有关于其在该场景中的应用的描述。在这个视频中,我们展示了使用微创机器人技术进行胆道狭窄成形术和Roux-en-Y（RY）肝空肠吻合术来治疗HAIP化疗后持续的右肝管狭窄。
方法：一名68岁的女性，有多灶性双叶4期结直肠肝转移病史，她因梗阻性黄疸和复发性胆管炎出现在我们的办公室，在过去2年内需要进行9次内镜逆行胰胆管造影（ERCPs），并通过介入放射学进行内外经皮肝穿刺胆管引流（PTBD）。她过去的手术史与3年前的腹腔镜右半结肠切除术一致，然后进行左外侧切片切除术，并放置HAIP进行辅助治疗。患者右叶和左叶有十多个转移性肝脏病变，范围从2到3厘米的大小在HAIP放置的时间。在HAIP化疗治疗之前，患者的组织学背景肝实质正常。患者没有饮酒史，糖尿病,代谢综合征,非酒精性脂肪性肝炎,或其他潜在的内在肝脏疾病，已知有助于肝纤维化的发展。尽管放射学上没有疾病，患者在接受HAIP治疗1年后开始出现急性胆管炎发作,需要多次入院当地医院.尽管剂量减少并使用肝内地塞米松治疗近1年，但一旦诊断为胆管硬化，随后就删除了HAIP。除了这个发现,已知的肝转移已显示出完整的放射学分辨率。因此，用HAIP进一步治疗被认为是不必要的，并进行了泵的拆卸。磁共振成像显示右前和右后扇形肝管的交界处有明显的狭窄。通过ERCP和胆道镜检查确认了显性狭窄的位置。多次胆管活检证实没有瘤形成。多次内窥镜和经皮支架置入尝试均未能扩大狭窄区域。术后胆管造影显示持续显著狭窄，导致多次复发性梗阻性黄疸和严重胆管炎。虽然在治疗胆管硬化时很少需要使用手术方法，经过广泛的多学科讨论，决定进行机器人狭窄成形术和RY肝空肠吻合术，同时保留天然胆总管。
方法：手术开始于腹腔镜下粘连松解术，以识别HAIP管（后来被移除）并放置机器人端口。获得外周肝活检以评估肝实质纤维化的程度。小心地暴露肝门区域，而不会对周围的中空器官造成意外伤害。酌情对肝周软组织进行活检以排除任何肝外疾病。使用超声检查确定胆总管和肝总管内装有ERCP支架。然后打开肝总管的前壁，暴露两个塑料支架。胆总管切开术的头颅向胆管分叉和右肝管延伸。保留了远端胆总管，以备将来内镜进入胆道树。降低右侧门板后，右肝管周围的致密纤维化用机器人剪刀急剧分割，实现主导狭窄的机械释放。术中进行了胆道镜检查，以确认右肝导管二级和三级神经根的开口足够。以及左肝管的通畅。使用4-FrFogarty导管从左右肝叶内清除潜在的胆道碎片。最后,在进行肝空肠吻合术之前，进行了确诊的胆道镜检查，以确保右侧肝内胆管和左肝管的通畅和清除。接下来为RY肝空肠吻合术准备了40厘米的前肢。使用侧面双缝合技术来创建空肠空肠造口术。常见的肠切开术以水密的方式关闭。一旦以无张力的方式将母肢转移到肝门，通过使用可吸收的倒刺缝线以跑步方式构建了并排的肝空肠吻合术。索引缝合线放置在9点的位置，吻合口的后壁向3点位置移动。这稳定了胆总管的外肢。接下来，通过使用从吻合口的两个角落向中间（12点）的运行技术来形成吻合口的前壁，两条缝线都绑在一起。这完成了宽的一侧到一侧的肝空肠吻合术，包括上总肝管，胆道分叉,和右肝导管.闭合前放置封闭的抽吸引流管。5结果：手术时间约为4小时，失血60ml。术后病程顺利。患者于术后第5天在移除封闭的抽吸引流器后出院回家,确认没有胆漏.患者出现门静脉/导管周围纤维化，胆汁淤积,和中重度实质纤维化（F3-F4）基于肝活检，常见于长期接受氟尿苷HAIP化疗的患者。在1年的门诊随访中，患者的临床状况良好，在本手稿准备时没有任何复发性胆管炎的证据。
结论：机器人胆管狭窄成形术联合肝肝空肠RY吻合术治疗HAIP化疗后胆管硬化是安全可行的。要实现这一目标，必须有适当的微创肝胆手术经验。
方法：一名68岁的女性，有多灶性双叶4期结直肠肝转移病史，她因梗阻性黄疸和复发性胆管炎出现在我们的办公室，在过去2年内需要进行9次内镜逆行胰胆管造影（ERCPs），并通过介入放射学进行内外经皮肝穿刺胆管引流（PTBD）。她过去的手术史与3年前的腹腔镜右半结肠切除术一致，然后进行左外侧切片切除术，并放置HAIP进行辅助治疗。患者右叶和左叶有十多个转移性肝脏病变，范围从2到3厘米的大小在HAIP放置的时间。在HAIP化疗治疗之前，患者的组织学背景肝实质正常。患者没有饮酒史，糖尿病,代谢综合征,非酒精性脂肪性肝炎,或其他潜在的内在肝脏疾病，已知有助于肝纤维化的发展。尽管放射学上没有疾病，患者在接受HAIP治疗1年后开始出现急性胆管炎发作,需要多次入院当地医院.尽管剂量减少并使用肝内地塞米松治疗近1年，但一旦诊断为胆管硬化，随后就删除了HAIP。除了这个发现,已知的肝转移已显示出完整的放射学分辨率。因此，用HAIP进一步治疗被认为是不必要的，并进行了泵的拆卸。磁共振成像显示右前和右后扇形肝管的交界处有明显的狭窄。通过ERCP和胆道镜检查确认了显性狭窄的位置。多次胆管活检证实没有瘤形成。多次内窥镜和经皮支架置入尝试均未能扩大狭窄区域。术后胆管造影显示持续显著狭窄，导致多次复发性梗阻性黄疸和严重胆管炎。虽然在治疗胆管硬化时很少需要使用手术方法，经过广泛的多学科讨论，决定进行机器人狭窄成形术和RY肝空肠吻合术，同时保留天然胆总管。
方法：手术开始于腹腔镜下粘连松解术，以识别HAIP管（后来被移除）并放置机器人端口。获得外周肝活检以评估肝实质纤维化的程度。小心地暴露肝门区域，而不会对周围的中空器官造成意外伤害。酌情对肝周软组织进行活检以排除任何肝外疾病。使用超声检查确定胆总管和肝总管内装有ERCP支架。然后打开肝总管的前壁，暴露两个塑料支架。胆总管切开术的头颅向胆管分叉和右肝管延伸。保留了远端胆总管，以备将来内镜进入胆道树。降低右侧门板后，右肝管周围的致密纤维化用机器人剪刀急剧分割，实现主导狭窄的机械释放。术中进行了胆道镜检查，以确认右肝导管二级和三级神经根的开口足够。以及左肝管的通畅。使用4-FrFogarty导管从左右肝叶内清除潜在的胆道碎片。最后,在进行肝空肠吻合术之前，进行了确诊的胆道镜检查，以确保右侧肝内胆管和左肝管的通畅和清除。接下来为RY肝空肠吻合术准备了40厘米的前肢。使用侧面双缝合技术来创建空肠空肠造口术。常见的肠切开术以水密的方式关闭。一旦以无张力的方式将母肢转移到肝门，通过使用可吸收的倒刺缝线以跑步方式构建了并排的肝空肠吻合术。索引缝合线放置在9点的位置，吻合口的后壁向3点位置移动。这稳定了胆总管的外肢。接下来，通过使用从吻合口的两个角落向中间（12点）的运行技术来形成吻合口的前壁，两条缝线都绑在一起。这完成了宽的一侧到一侧的肝空肠吻合术，包括上总肝管，胆道分叉,和右肝导管.闭合前放置封闭的抽吸引流管。5结果：手术时间约为4小时，失血60ml。术后病程顺利。患者于术后第5天在移除封闭的抽吸引流器后出院回家,确认没有胆漏.患者出现门静脉/导管周围纤维化，胆汁淤积,和中重度实质纤维化（F3-F4）基于肝活检，常见于长期接受氟尿苷HAIP化疗的患者。在1年的门诊随访中，患者的临床状况良好，在本手稿准备时没有任何复发性胆管炎的证据。
结论：机器人胆管狭窄成形术联合肝肝空肠RY吻合术治疗HAIP化疗后胆管硬化是安全可行的。要实现这一目标，必须有适当的微创肝胆手术经验。
