Robotic reoperative pancreatectomy for recurrent disease after pancreaticoduodenectomy, with conversion of pancreaticojejunostomy to pancreaticogastrostomy: approach and outcomes

Abstract

Presenter: Krishnaraj Mahendraraj MD | Cedars-Sinai Medical Center Background: We describe here the rare case of a reoperative pancreatectomy following pancreaticoduodenectomy with conversion of the pancreaticojejunostomy to a pancreaticogastrostomy. This is a 74yo woman who underwent a pancreaticoduodenectomy one year prior for pancreatic neuroendocrine tumor. On surveillance she was found to have a focal area of recurrence right at the pancreaticojejunostomy anastomosis, which progressed despite somatostatin analog therapy. Given that this was the sole site of recurrence and that she had 50-60% of native pancreas volume left, we opted for reoperative pancreatectomy. Methods: Case review Results: Four robotic ports were placed across the lower abdomen along with a suprapubic assist port. The pancreatic remnant was densely adherent to the underlying portal vein and superior mesenteric vein. Robotic exploration revealed a 3 cm mass of the proximal pancreatic remnant, right at the prior pancreaticojejunostomy. We traced the previous pancreaticobiliary limb to find a point between pancreas and the biliary anastomosis where this could be divided. We opened up the jejunum right at the pancreaticojejunostomy to allow full mobility. We used a linear stapler and divided the jejunum proximal to the biliary limb, preserving the hepaticojejunostomy. We were able to separate the pancreatic mass off the splenic artery as well as celiac artery and vein. Distally, fine branches were taken with clips and vessel sealer. We eventually got to the point where we were completely free of the underlying structures and the mass was completely mobilized. We used ultrasound to confirm our margin before dividing the pancreas down with cautery. The specimen was passed off the field in an Endobag and pathology confirmed negative margin at the point of transection. We now turned our attention to reconstruction. The stomach laid over the pancreatic remnant roughly at the body-tail junction of pancreas, which was well to the left of midline, placing it in an ideal location for tension-free anastomosis without the need for extensive mobilization. Her Whipple had been pylorus preserving, giving us a complete stomach to work with. We made a gastrotomy at the posterior gastric wall and the pancreatic anastomosis was performed by an invaginating technique. We used 4-0 Monocryl with interrupted horizontal mattress sutures to invaginate the gland into the back wall of the stomach. This anastomosis was tested with methylene blue into the stomach and we saw no leak. Her largest skin incision at the end of the operation was the 4 cm suprapubic assist post which was also used to deliver the specimen. The patient made an excellent recovery and was subsequently discharged on Postoperative Day 4 with normal vitals, ambulating, with good pain control, and tolerating food. She resumed somatostatin analog therapy and close surveillance is maintained due to her risk for recurrence. Pathology and subsequent imaging show her to be disease-free. Conclusion: The robotic approach allowed for precise navigation in narrow spaces, such as maneuvering the pancreatic remnant under the stomach. It allowed us to perform a complex oncologic resection through small incisions resulting in expedited recovery, as well as avoid her prior incision thereby reducing hernia risk.