D Brock Hewitt, MD, MPH
Assistant Professor
NYU Langone Health
New York, New York, United States
Anthony Sorrentino, MD
Resident
NYULMC
New York, New York, United States
Robotic pancreaticoduodenectomy (RPD) is associated with shorter hospital length of stay and quicker return to functional recovery with comparable oncologic and major morbidity outcomes to open PD. At high-volume centers, RPD is being offered to highly selected patients with locally advanced pancreatic cancer (LAPC). Here, we report a case of a RPD in a patient with LAPC and aberrant anatomy to highlight notable technical considerations.
Methods:
Video record of a RPD for a patient with LAPC.
Results:
A 60-year-old male diagnosed with LAPC after workup for abdominal pain and unintentional weight loss. Imaging demonstrated a head of pancreas mass with encasement of the common hepatic artery and 180-degree involvement of the portal vein. Of note, he had a completely replaced right hepatic artery from the SMA and a partially replaced left hepatic artery (segment 2 and 3 branches) from the left gastric artery with termination of the common hepatic artery in the GDA and a segment 4 branch. After 12 cycles of neoadjuvant chemotherapy, he was taken for a RPD. The mass was invading the common hepatic artery, requiring en bloc resection, but was successfully dissected away from the portal confluence with negative intraoperative margins. The replaced right hepatic artery was divested from the pancreas. The segment 4 branch had pulsatile back bleeding; an arterial reconstruction was not performed. After the extended RPD, a diminutive pancreatic remnant remained. To avoid a high-risk anastomosis to a small duct and atrophic pancreas, the remnant pancreas was stapled without the creation of a pancreaticojejunostomy. The patient did not develop a pancreatic fistula and did not require a change in his diabetic medication at discharge. He remains on pancreatic enzymes. Final pathology revealed moderately to poorly differentiated PDAC, negative margins, 1/19 lymph nodes involved, and a partial neoadjuvant response score of 2.
Conclusions:
This case highlights the technical feasibility of a RPB in a patient with LAPC, including overcoming challenges related to aberrant arterial anatomy, arterial encasement, and a small pancreatic remnant. Highly selected patients with LAPC and favorable biology can be safely managed with RPD at high volume centers.