Robotic Anterior Rectal Resection for Rectal Cancer with Partial Pelvic Peritonectomy for Carcinosis from Pancreatic Cancer

Abstract

Introduction: Advanced robotic technology enhances a total mesorectal excision for rectal cancer and may overcome challenges associated with difficult pelvic anatomy.1,2 Moreover, minimally invasive approach may be used to address several common complications of solid organ malignancies.3,4 This video shows a patient with rectal cancer who underwent neoadjuvant therapy with a new finding of a primary pancreatic cancer at postneoadjuvant re-evaluation. The patient underwent a palliative robotic anterior rectal resection for a bleeding adenocarcinoma of the rectum. Materials and Methods: A 70-year-old patient presented to the outpatient clinic with diarrhea and rectal bleeding. Diagnostic work-up included a colonoscopy that showed an adenocarcinoma of the rectum at 8–9 cm from the anal verge. A CT scan revealed no pulmonary disease and no carcinosis, and a pelvic MRI confirmed a substenotic, full thickness infiltrating tumor of the rectum. Multidisciplinary tumor board recommended neoadjuvant treatment based on capecitabine and RT (total dose 55 Gy/25 fractions). Postneoadjuvant re-evaluation included a pelvic MRI that showed a partial response of the rectal tumor. A CT scan identified a new finding of a neoplasm at the level of the pancreatic body. Endoscopic ultrasonography showed a mesopancreatic tumor with splenic vessel involvement. Histologic examination documented an adenocarcinoma and magnetic resonance cholangiopancreatography confirmed the tumor. Multidisciplinary tumor board recommended gemcitabine but it was halted for rectal bleeding after 1 week. A rectoscopy confirmed the bleeding from the rectal lesion. Palliative rectal surgery was recommended, and the patient underwent an anterior rectal resection with S3 metastasectomy and partial pelvic peritonectomy for carcinosis with an end-to-end colorectal anastomosis according to the Knight & Griffen technique and a diverting ileostomy (S3 metastasis and carcinosis were intraoperative findings). Results: The patient was discharged on postoperative day 6. The postoperative course was uneventful and afterward systemic treatment with gemcitabine and paclitaxel was resumed. At re-evaluation by CT and MRI, no pelvic recurrence was diagnosed, whereas the volume of the pancreatic lesion was reduced. A stereotactic ablation was performed on the pancreatic lesion. The patient underwent ileostomy closure, but after 1 year from the primary surgery, the patient referred was admitted with an intestinal obstruction. An explorative laparoscopy revealed diffuse carcinosis from the pancreatic lesion. The patient died a few months later. Conclusion: Robotic technique is a safe and an efficacious tool for palliative surgery. In complex cases, a robotic technique provides a fast recovery and a quick reprise for further oncologic treatments. Palliative surgery, however, must be delivered as part of an interdisciplinary team and should be attempted through a minimally invasive approach to reduce pain and adverse effects of surgical intervention.5 No competing financial interests exist. Runtime of video: 10 mins