Robotic radical antegrade modular pancreatosplenectomy after laparotomy biopsy and neoadjuvant therapy

Abstract

Study objective

To demonstrate a case of robotic radical antegrade modular pancreatosplenectomy (R-RAMPS) after laparotomy biopsy and neoadjuvant chemoradiotherapy.

Design

Stepwise demonstration and description with video footage.

Setting

The Pancreatic Disease Center, Ruijin Hospital affiliated with Shanghai JiaoTong University School of Medicine, Shanghai (China).

Case presentation

A 58-year-old male patient was diagnosed with borderline resectable pancreatic cancer, receiving 4 courses of neoadjuvant therapy. Examination revealed pancreatic body and tail mass on Oct. 20, 2022. Laparotomy exploration and biopsy was conducted by local hospital, giving the pathology result of poorly differentiated adenocarcinoma. Neoadjuvant therapy was carried out with AG chemotherapy (nab-paclitaxel plus gemcitabine) and immunotherapy (Tirelizumab) 4 courses from Dec. 1, 2022 to Mar. 9, 2023, and stereotactic body radiotherapy 10 times from Feb. 14, 2023 to Feb. 27, 2023. Effective evaluation of neoadjuvant therapy relied on a comprehensive assessment, including tumor markers, RECIST 1.1 criteria (evaluated through CT scans), PET/CT imaging, and detailed surgical observations.

Intervention

Distal pancreatectomy (DP) was the gold-standard radical surgery for the left-sided pancreatic adenocarcinoma. Radical antegrade modular pancreatosplenectomy (RAMPS) is an upgradation of DP to achieve thorough retroperitoneal dissection.¹ The first robotic DP was reported by Melvin et al.² in 2003. In 2012, Choi et al.³ first reported R-RAMPS for the treatment of distal pancreatic adenocarcinoma. Neoadjuvant chemotherapy has been slowly adopted in borderline resectable, locally advanced and even resectable pancreatic cancers.⁴ The role of adjuvant chemoradiation has been controversial due to conflicting results reported.^5,6 Neoadjuvant radiotherapy was considered to increase the chances of complete tumor resection with the advantages in efficacy and tolerance.⁷ However, there were limited reports on robotic pancreatic radical operation after neoadjuvant therapy. Moreover, laparotomy and neoadjuvant radiotherapy greatly increased the difficulty of minimally invasive surgery due to the local tissue destruction and severe abdomen adhesion (Fig. 1)(Table. 1).

During the operation, the patient was placed in a supine position with legs apart in the 30-degree reverse Trendelenburg position. The trocar layout was shown in Fig. 2. Adhesiolysis was conducted by the ultrasonic dissector. Exposure of the distal pancreas and tumor was carried out by division of gastrocolic ligament and mobilization of the splenic flexure of the colon. Stapler (2.5mm) was used in management of the pancreatic stump. We completely removed the pancreatic body and tail, spleen, and left adrenal gland. Number 14, 7, 8a, 8p, 9, 16a lymph nodes were dissected outside the arterial sheath. Frozen section of pancreatic margin, SV margin, and SA margin were all reported negative.

The results were as follows. The procedure was successfully performed with a 5 cm incision at the site of the previous incision. The postoperative pathology showed a very small amount of residual cancer with a treatment effect of Grade 1. No lymph node metastasis was detected. The patient developed a biochemical leak, began drinking water on postoperative day 3, transitioned to a liquid diet on day 5, had the splenic fossa drain removed on day 7, the stump drain removed on day 10 and was discharged on day 11. The patient's pain score was 2/10 on day 1, and decreased to to 0/10 on day 3. No recurrence was observed by September 2023.

Conclusion

Robotic radical antegrade modular pancreatosplenectomy can be successfully conducted in patients with pancreatic adenocarcinoma experiencing laparotomy and neoadjuvant therapy.