Robotic-assisted trans-mesocolic side-to-side duodenojejunostomy for palliative management of malignant distal duodenal obstruction

Introduction

Background

Malignant duodenal obstruction is a clinical condition in which the duodenum is mechanically obstructed due to the presence of a mass preventing the flow of gastric and duodenal contents. It affects up to 20% of patients with advanced gastrointestinal malignancies (1,2). When the obstruction is in the distal segments of the duodenum (D3 or D4), it is referred to as a distal duodenal obstruction (DDO). DDO typically presents with symptoms such as early satiety, epigastric pain, abdominal distension, intermittent bilious vomiting, and weight loss. These symptoms can greatly reduce a patient’s quality of life. Treatment involves resection of the obstructing mass if indicated. For patients with unresectable cancer, palliative bypass procedures can be performed to relieve symptoms related to obstruction and restore oral intake (3).

Rationale

Malignant duodenal obstruction is a challenge to treat, with no established consensus in patients with unresectable cancer (3). Historically, open gastrojejunostomy has been the surgical treatment of choice with a 70% efficacy (3). Gastrojejunostomy involves the creation of an anastomosis between the stomach and jejunum in a side-to-side or end-to-side fashion. Laparoscopic gastrojejunostomy has gained traction as a potentially less morbid alternative to the traditional open method.

A major limitation of gastrojejunostomy is that the duodenum itself is not drained because the anastomosis is proximal to the duodenum and the pylorus preventing adequate refluxing of duodenal contents into the stomach. To circumvent this, Roux-en-Y duodenojejunostomy, a surgical technique introduced in 1908, was proposed as another treatment alternative (4). This procedure is done by anastomosing the proximal jejunum to the second part of the duodenum (D2) in a Roux-en-Y fashion. However, the relatively increased complexity of this procedure and additional risks such as potential to compromise the papilla resulted in limited adoption of this approach, especially when is the goal is palliation (5). Thus, the less technically complicated gastrojejunostomy remained the favored treatment for palliating malignant DDO despite its limitations.

Objective

We present a novel case of robotic-assisted trans-mesocolic side-to-side duodenojejunostomy in a 75-year-old female patient with metastatic duodenal adenocarcinoma of D4 complicated by recurrent malignant obstruction. Our objective for this report was to demonstrate the feasibility and effectiveness of duodenojejunostomy as a palliative treatment for DDO when performed robotically with a trans-mesocolic approach. We present this article in accordance with the SUPER reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-24-87/rc).

Preoperative preparations and requirements

The patient was a 75-year-old female with metastatic duodenal adenocarcinoma. She initially presented to an outside hospital with syncope and was found to have a 5.3 cm duodenal mass on imaging, which was subsequently diagnosed as duodenal adenocarcinoma. Two months later, the patient developed intractable vomiting and imaging findings of dilation of the proximal duodenum measuring up to 7.4 cm (Figure 1), indicative of malignant DDO. At that time, a gastrojejunostomy stent was placed by an outside hospital which alleviated her symptoms. A year later, routine imaging revealed interval growth of the duodenal mass, and recurrent duodenal dilation. Her chemotherapy was stopped because of the obstruction. Shortly after these imaging findings, the patient again developed symptoms of malignant DDO and was admitted to our institution for urgent treatment. During this admission, the patient was initially decompressed via nasogastric tube and esophagogastroduodenoscopy (EGD), performed by the gastroenterology team. EGD revealed a partially patent stent with worsening obstruction. Subsequently, a larger gastrojejunal stent was placed by the gastroenterology team. After a multidisciplinary discussion with the gastroenterology and surgical oncology teams, the patient was offered the choice to undergo robotic-assisted duodenojejunostomy as a possibly more effective procedure to palliate the duodenal obstruction. After a detailed discussion about the risks and benefits of the procedure, the patient elected to undergo palliative robotic-assisted trans-mesocolic side-to-side duodenojejunostomy. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this article, accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 CT scan of the patient showing massive dilation of the stomach and the duodenum (yellow arrows). CT, computed tomography.

The surgeon (M.A.A.) is a board-certified, fellowship-trained surgical oncologist with extensive experience in minimally invasive and robotic surgery. The team also consisted of a bedside assistant, anesthesiologist, circulating nurse, and a surgical technologist. The da Vinci Xi Surgical System (Intuitive Surgical, Mountain View, CA, USA) was utilized. General anesthesia was administered, and the airway was secured with an endotracheal tube. Preoperative antibiotics were administered. The patient was positioned supine, and the abdomen was then prepped and draped in the standard fashion.

Step-by-step description

Insufflation was achieved using a Veress needle at Palmer’s point, an optical separator trocar was used to gain entry into the abdominal cavity under direct visual guidance. A 5 mm laparoscope was subsequently inserted. Four 8-mm robotic ports were placed in the peritoneal space in a horizontal row along the umbilicus and were spaced a minimum of 8 cm apart to prevent collisions (Figure 2). The ports were placed in the right midclavicular line, left midclavicular line, and additional placements in the right anterior axillary line and left anterior axillary line, all situated at the umbilicus.

Figure 2 Port placement for performing minimally invasive robotic-assisted trans-mesocolic gastrojejunostomy.

The transverse colon was identified and retracted cephalad, exposing the mesocolon. The robot was then docked and the mesocolon was incised to the right of the middle colic artery, allowing optimal exposure of the third part of the duodenum (D3) while preserving the colonic blood supply and the superior mesenteric vessels. A window created in the mesocolon. A loop of proximal jejunum was then identified 20 cm from the ligament of Treitz. A two-layer handsewn loop duodenojejunostomy was fashioned between the proximal loop of jejunum and D3 through the mesenteric defect. The decision was made to perform a handsewn anastomosis to avoid the need for a 12 mm port for a stapler. The handsewn anastomosis consisted of a two-layered approach, with the posterior layer consisting of interrupted 3-0 silk sutures, followed by two running 3-0 V-lock sutures for the inner layer. Finally, the anterior layer was reinforced with Lembert sutures using 3-0 silk sutures. The anastomosis was then covered using the cut edge of the mesocolon as a vascularized flap, and indocyanine green (ICG) was injected to evaluate the viability of the anastomosis and the transverse colon. The skin incisions were closed in the standard fashion. The entire procedure is covered in detail in Video 1.

Postoperative considerations and tasks

The patient had an uncomplicated postoperative course. She was started on a clear liquid diet on postoperative day (POD) 1 and progressed to a regular diet on POD 2. Notably, her pain was well-controlled without the need for narcotics, and she was ultimately discharged on POD 3. The patient resumed chemotherapy 3 weeks postoperatively. On outpatient follow-up, she continued to tolerate solid diet and gaining weight. A follow-up EGD conducted 3 months postoperatively for removal of the failed gastrojejunostomy stent, which also demonstrated a patent and well-healed surgical duodenojejunostomy anastomosis. The patient did not experience recurrence of malignant duodenal obstruction before she passed away 8 months later due to progression of her liver metastases.

Although this patient had an uneventful postoperative course, some potential complications that providers may encounter include those relevant to all procedures, such as surgical site infection or bleeding, as well as those specific to this surgery, such as anastomotic leak. The former should be managed per standard of care, such as source control and/or antibiotics for infection and monitoring, transfusion, and/or invasive intervention for bleeding. Regarding anastomotic leak, drainage, and endoscopic interventions can be used.

Tips and pearls

There are several tips and pearls to be noted from this case. The creation of a mesenteric window requires dissection to the right middle colic artery and great care should be taken to understand location of the superior mesenteric vessels and the duodenum throughout the dissection. Thus, caution should be taken when working in the D3 area due to proximity to the superior mesenteric artery and vein. Instead of using a larger 12 mm port for stapler-assisted anastomosis, a handsewn approach with an 8 mm incision can be used instead, which may be more hemostatic and may lessen the risk of staple line bleeding. Finally, ICG dye can be used intraoperatively to ensure viability of the transverse colon.

Discussion

Surgical highlights

Opting for a side-to-side duodenojejunostomy between the proximal jejunum and D3 helps to steer clear of the potential complications associated with D2 anastomosis. These potential complications include duodenal enterotomies or compromising the ampulla and/or delayed emptying. Our proposed approach was made possible through the robotic assistance for the trans-mesocolic duodenojejunostomy, which facilitates navigation around the complex surgical anatomy around the duodenum and its surrounding structures. Similarly, by avoiding the use of metal stents, complications such as stent migration and occlusion are effectively eliminated, reducing the need for repeat interventions.

Strengths and limitations

This procedure has several notable strengths, namely the trans-mesocolic access of D3 and its minimally invasive nature. The trans-mesocolic method is advantageous because it allows one to access D3 through the avascular window to the right of the middle colic artery. This obviates the need to perform an extended Kocher maneuver and minimizes the chances of a major papilla/ampullary injury or duodenal tears from the robotic graspers. Furthermore, it may decrease the risk of anastomotic bleeding and other complications associated with extensive dissection.

The minimally invasive aspect of this procedure also yielded numerous benefits in the postoperative setting. We were able to avoid an open procedure, which allowed for early initiation and tolerance of oral intake on POD 1, and the patient was safely discharged from the hospital only 3 days after surgery. We performed a handsewn anastomosis, which negated the need for a larger 12 mm port placement to accommodate the stapler. As a result, the largest incision was 8 mm which caused the patient less pain postoperatively and allowed the patient achieved adequate pain control without the need for narcotics. Importantly, due to her uncomplicated and swift recovery, she was able to resume chemotherapy just 3 weeks after surgery.

Finally, the robotic platform itself offers several technical advantages over the traditional laparoscopic approach in this case. The three-dimensional (3D) high-definition vision system provides enhanced visualization of the mesocolon and its mesenteric vasculature, while the robotic instruments enable smoother and more precise movements. Although trans-mesocolic duodenojejunostomy has been safely performed laparoscopically, for this patient, we believe that leveraging the advancements of the robotic approach allowed us to perform this challenging procedure more effectively.

There are limitations associated with this technique. This procedure does not work to treat proximal duodenal obstruction in D1 or D2 as the anastomosis needs to be into D3 for it to line up well with the mesocolic window. In this case, a gastrojejunostomy may be more appropriate. In addition, robotic surgery is associated with a higher learning curve (5) and thus surgeons who are not already proficient in robotic-assisted procedures would likely need additional experience (5,6).

It is important to acknowledge the increased cost of robotic procedures. Whether or not the increased cost is justified for a palliative procedure must carefully be considered and depends on a variety of patient factors such as life expectancy and viability of other alternatives. For this patient, we believe the procedure justifies the increased cost as the patient had already failed treatment via stenting and was experiencing massive duodenal dilation. Shorter length of stay (LOS) could also balance the increased cost of a robotic surgery. Our patient had a LOS of only 3 days, which is notably shorter than the average LOS of 8 days [6–13] reported in a nationwide review of outcomes in patients undergoing surgery for malignant small bowel obstruction (7). Reduced pain with this approach is also critical consideration given the palliative nature of the procedure. Our patient had moderate (5/10) immediately post-op which quickly subsided to mild (3/10) and no pain (0/10) upon discharge without the use of opioid analgesics.

Comparison with other surgical techniques and research

Surgical techniques that have been used to treat malignant DDO include gastrojejunostomy, open duodenojejunostomy, or duodenal stents (3). The literature is sparse on which of these is the optimal approach for obstruction beyond the second part of duodenum. Gastrojejunostomy has conventionally been the preferred procedure for managing duodenal obstruction (8), but its efficacy in relieving DDO may need to be evaluated. There are also concerns for bile reflux and/or marginal ulcers with gastrojejunal anastomoses (8-10).

Palliative endoscopic duodenal stent placement has been developed to serve as an alternative approach to surgical gastrojejunostomy. Previous studies have shown that patients who underwent stenting had improved diet tolerance and experienced a shorter hospital stay compared to those who underwent bypass surgery (11-15). However, these stents have higher risk of recurrence and may not be appropriate for patients with longer life expectancies.

One study comparing different surgical techniques for gastric outlet obstruction (GOO) which can include duodenal obstruction, including duodenal self-expanding metal stents (SEMS), endoscopic ultrasound-guided gastroenterostomy, and surgical gastrojejunostomy, revealed comparable clinical efficacy of each technique (16). While the endoscopic approach is suitable for gastric/D1 or D2/D3 obstruction, especially in patients with a hostile abdomen or those needing to resume chemotherapy (17), surgical approaches are better reserved for cases requiring long-term bypass or those with benign disease (14,18,19).

For masses arising in D4, duodenojejunostomy is more appropriate. By creating an anastomosis between the proximal jejunum and D3 duodenum, duodenojejunostomy not only effectively decompresses the proximal duodenum but also prevents biliary reflux into the stomach. If the goal of the procedure is palliative, a robotic-assisted trans-mesocolic approach with a side-to-side anastomosis at D3—as we have presented in this report—may be a superior approach because of increased technical feasibility and shorter recovery time compared to open duodenojejustomy.

Of note, a similar robotic trans-mesocolic approach to the distal duodenum has been recently described to in the setting of sleeve duodenectomy for resection of non-malignant lesions (20). However, only one other report of robotic-assisted duodenojejunostomy for the treatment of malignant DDO was found in our search (21). In this report, the patient has invasive pancreatic cancer leading to DDO. While this report used the same trans-mesocolic approach, the authors performed a handsewn single layer side-to-side anastomosis between D3 and a loop of proximal jejunum instead of a handsewn double layer anastomosis. Like our patient, this patient was able to resume oral intake on POD 1. However, their patient had a longer LOS of 5 days compared to three in our study—although a variety of patient-specific factors could be contributing to this difference. Notably, they had similar outcomes to our patient 3 months post-procedure.

Implications and actions recommended

This novel application of this surgical technique for DDO has several important implications for clinical practice and future research. This report demonstrates that this approach can address the limitations associated with conventional gastrojejunostomy or endoscopic stent placement for patients with distal obstruction with a life expectancy of greater than the relatively shorter recovery from this procedure. It offers the potential for symptom relief, improved postoperative outcomes, and early resumption of solid diet and systemic chemotherapy. This has significant implications for the palliative management of advanced malignant duodenal obstruction (21).

Conclusions

In summary, we present the case of a 75-year-old female patient with metastatic duodenal adenocarcinoma and recurrent DDO who underwent palliative minimally invasive robotic-assisted trans-mesocolic side-to-side duodenojejunostomy. Notably, the patient had a swift recovery and resumed solid diet on POD 2, and systemic chemotherapy regimen just 3 weeks following the operation. She did not experience recurrent obstruction until her passing 8 months later from liver metastasis progression. Overall, this report demonstrates that robotic-assisted trans-mesocolic duodenojejunostomy is a reasonable and effective method for palliating malignant DDO.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://cco.amegroups.com/article/view/10.21037/cco-24-87/rc

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-24-87/prf

Funding: This work was supported by the University of California, San Francisco, Noyce Initiative Computational Innovator Postdoctoral Fellowship Award (to J.J.W.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-24-87/coif). J.J.W. reported that this work was supported by the University of California, San Francisco, Noyce Initiative Computational Innovator Postdoctoral Fellowship Award. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article, accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Chiu KW, Razack A, Maraveyas A. Self-expandable metal stent placement for malignant duodenal obstruction distal to the bulb. Eur J Gastroenterol Hepatol 2015;27:1466-72. [Crossref] [PubMed]
2. Park JM, Min BH, Lee SH, et al. Feasibility of self-expandable metal stent placement with side-viewing endoscope for malignant distal duodenal obstruction. Dig Dis Sci 2015;60:524-30. [Crossref] [PubMed]
3. Manuel-Vázquez A, Latorre-Fragua R, Ramiro-Pérez C, et al. Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature. World J Gastroenterol 2018;24:1978-88. [Crossref] [PubMed]
4. Sharma H, Marwah S, Singla P, et al. Roux-en-Y duodenojejunostomy for surgical management of isolated duodenal obstruction due to chronic pancreatitis. Int J Surg Case Rep 2017;31:209-13. [Crossref] [PubMed]
5. Seman M, Kasereka-Kisenge F, Taieb A, et al. Resection of the third and four portions of the duodenum. J Visc Surg 2019;156:45-9. [Crossref] [PubMed]
6. Jiménez-Rodríguez RM, Díaz-Pavón JM, de la Portilla de Juan F, et al. Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int J Colorectal Dis 2013;28:815-21. [Crossref] [PubMed]
7. Song Y, Metzger DA, Bruce AN, et al. Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study. Ann Surg 2022;275:e198-205. [Crossref] [PubMed]
8. Bradley EL 3rd, Clements JL Jr. Idiopathic duodenal obstruction: an unappreciated complication of pancreatitis. Ann Surg 1981;193:638-48. [Crossref] [PubMed]
9. Uravić M, Stimac D, Rubinić M, et al. Duodenal obstruction from chronic pancreatitis. Minerva Chir 1997;52:885-9. [PubMed]
10. Vijungco JD, Prinz RA. Management of biliary and duodenal complications of chronic pancreatitis. World J Surg 2003;27:1258-70. [Crossref] [PubMed]
11. Jeurnink SM, van Eijck CH, Steyerberg EW, et al. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol 2007;7:18. [Crossref] [PubMed]
12. Zheng B, Wang X, Ma B, et al. Endoscopic stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Dig Endosc 2012;24:71-8. [Crossref] [PubMed]
13. Nagaraja V, Eslick GD, Cox MR. Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials. J Gastrointest Oncol 2014;5:92-8. [PubMed]
14. Upchurch E, Ragusa M, Cirocchi R. Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction. Cochrane Database Syst Rev 2018;5:CD012506. [Crossref] [PubMed]
15. Ly J, O'Grady G, Mittal A, et al. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc 2010;24:290-7. [Crossref] [PubMed]
16. Krishnamoorthi R, Bomman S, Benias P, et al. Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis. Endosc Int Open 2022;10:E874-97. [Crossref] [PubMed]
17. Azemoto N, Ueno M, Yanagimoto H, et al. Endoscopic duodenal stent placement versus gastrojejunostomy for unresectable pancreatic cancer patients with duodenal stenosis before introduction of initial chemotherapy (GASPACHO study): a multicenter retrospective study. Jpn J Clin Oncol 2022;52:134-42. [Crossref] [PubMed]
18. Zhang LP, Tabrizian P, Nguyen S, et al. Laparoscopic gastrojejunostomy for the treatment of gastric outlet obstruction. JSLS 2011;15:169-73. [Crossref] [PubMed]
19. Siu WT, Tang CN, Law BK, et al. Vagotomy and gastrojejunostomy for benign gastric outlet obstruction. J Laparoendosc Adv Surg Tech A 2004;14:266-9. [Crossref] [PubMed]
20. Yoshino O, Vrochides D, Martinie JB. Robotic distal pancreas-sparing duodenectomy (duodenal sleeve resection) with transmesenteric approach: robotic approach for tumors in the third and fourth parts of the duodenum. Surg Endosc 2023;37:3246-52. [Crossref] [PubMed]
21. Hirata Y, Katz MHG, Ikoma N. Robotic Duodenojejunostomy Bypass for Metastatic Pancreatic Body Cancer. J Gastrointest Surg 2022;26:1115-6. [Crossref] [PubMed]