Robot-Assisted Resection of a Pyloric Pancreatic Rest with Peroral Endoscopic Removal and Reconstruction by Partial Gastroduodenostomy

Abstract

Background:

Gastric pancreatic rests consist of ectopic pancreatic tissue within the stomach wall and exhibit a typical endoscopic appearance. They are frequently asymptomatic, but can cause pain, erosions, and depending on their location, gastric outlet obstruction. Symptomatic pancreatic rests should be resected surgically.

Objective:

We report the first robot-assisted resection of a pyloric pancreatic rest with endoscopic removal of the tumor through the pharynx and subsequent reconstruction of the gastric outflow tract by partial gastroduodenostomy.

Case:

A 10-year-old girl presented with several months of worsening abdominal pain and nonbilious emesis. An upper gastrointestinal endoscopy showed a large pancreatic rest adjacent to and obstructing the pylorus, confirmed by endoscopic ultrasound. The patient was scheduled for robot-assisted resection of the tumor. Intraoperatively, resection of the mass with part of the pylorus was performed. To avoid augmenting one of the robotic trocar sites for removal of the tumor, the mass was pushed into the stomach and retrieved endoscopically through the esophagus and pharynx. The pylorus was reconstructed robotically by transverse gastroduodenostomy using interrupted sutures in two layers. The operative time was 320 minutes.

Results:

The patient tolerated the procedure well, advanced on her diet without difficulties, and discharged home on postoperative day 3. Histopathology confirmed the diagnosis. She remained asymptomatic, and an upper gastrointestinal contrast study 3 months later showed normal passage of contrast from the stomach into the duodenum. She remains asymptomatic at 8 months follow-up.

Conclusions:

Symptomatic pyloric pancreatic rests require careful excision with precise reconstruction of the gastric outflow tract, and therefore lend themselves to a robot-assisted approach. Endoscopic removal through the mouth as a natural orifice allows for removal without augmenting one of the trocar sites and thereby minimizes visible scars. If careful resection and reconstruction are achieved, the outcome is excellent.

No competing financial interests exist.

Runtime of video: 4 mins 50 secs

This video was presented at the International Pediatric Endosurgery Group's 23rd Annual Congress, July 2014, in Edinburgh, Scotland.