Anneliese Hierl, MD (she/her/hers)
Research Resident
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Brian Badgwell, MD, MS
Professor
University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Paul F. Mansfield, MD
Professor
Department of Surgical Oncology, University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Naruhiko Ikoma, MD, MS
Associate Professor
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Locally advanced gastroesophageal junction (GEJ) tumors require a balance between achieving R0 resection and preserving postoperative quality of life. Proximal gastrectomy with double tract reconstruction (PG-DTR) has emerged as an oncologically safe alternative to total gastrectomy, offering improved functional outcomes and reduced reflux symptoms. This video demonstrates a robotic PG-DTR with en-bloc distal pancreatectomy and splenectomy (DPS) for Siewert Type II GEJ adenocarcinoma with direct pancreatic invasion.
Methods:
We report a single case of a 70-year-old male with locally advanced GEJ adenocarcinoma (Siewert II) who underwent robotic PG-DTR with en-bloc DPS following neoadjuvant FOLFOX chemotherapy. Operative steps included meticulous mediastinal and oncologic lymph node dissection, hand-sewn esophagojejunostomy, adequate spacing between the esophagojejunostomy and gastrojejunostomy, upright fixation of the remnant stomach, and closure of hiatal, mesenteric, and Petersen defects.
Results:
The operation was completed in under six hours with 100 mL estimated blood loss. Pathology revealed a 6.3 cm moderately differentiated T4bN2 adenocarcinoma. Despite advanced stage disease and focal peritoneal deposits, the patient had an uncomplicated postoperative recovery, tolerated early diet advancement, and was discharged on postoperative day 4. At three-month follow-up, he reported good appetite, diet tolerance, and improved energy levels. Key technical considerations included careful patient selection with preoperative chemotherapy for downstaging, achievement of R0 resection with an oncologic lymph node dissection, and optimization of functional outcomes through anastomotic spacing and defect closure.
Conclusions:
Robotic PG-DTR with en-bloc DPS is technically feasible and may offer functional advantages for select patients with locally advanced GEJ tumors involving the pancreas. The robotic approach facilitates precise dissection and may enhance recovery thereby supporting timely resumption of systemic therapy.