Total Robotic Resection of Ascending Duodenal Gastrointestinal Stromal Tumor using Tubular Stapler Anastomosis: A Case Report

An obese patient was admitted to the Department of Gastrointestinal Surgery at Xiangyang Central Hospital, an affiliated hospital of Hubei University of Arts and Sciences, in June 2024 due to a gastrointestinal stromal tumor (gastrointestinal mesothelioma) of the ascending duodenum. Complete robotic excision of the gastrointestinal stromal tumor and tubular stapler insertion into the ascending duodenum were carried out. The surgeries took 190 minutes (the docking time was 30 minutes), there were approximately 10 milliliters of intraoperative hemorrhage, and there was no duodenal stenosis or contrast agent leak on the upper gastrointestinal tract. The outcomes demonstrated the technical safety and viability of using a tubular stapler to treat ascending duodenums under a total robot, as well as offering some experience in the selection of surgical techniques for GIST in specific segments.

Introduction

Gastrointestinal Stromal Tumor (GIST) is the most common sarcoma of the Gastrointestinal tract, with a global incidence of approximately 12 per 1 million per year [1]. The most common anatomic location of primary tumors was the stomach (55.6%), followed by the small intestine (31.8%), the colorectal (6.0%), various other locations (5.5%), and the esophagus (0.7%) [2], of which only 3% -5% of GIST occurs in the duodenum [3], while duodenal GIST occurs mostly in the descending segment, ascending gastrointestinal stromal tumors (d 4) are rare. The clinical manifestations of gastrointestinal stromal tumors vary, including bleeding, obstruction, perforation, or abdominal mass [4]. This patient's tumor was located in the ascending duodenum. Gastrointestinal bleeding was the first symptom. Radical surgical resection is the first-line cornerstone and mainstay for the treatment of localized primary GIST and is the only potential cure [5,6]. The use of surgical robots in clinical settings since the start of the twenty-first century heralded the arrival of the robotic surgery era in minimally invasive surgery. Initially utilized for the treatment of colorectal and gastric cancers [7,8], their use in gastrointestinal surgery has grown significantly. Currently, robotic surgery has been progressively expanded to treat gastrointestinal stromal tumors due to the ongoing development of robotic surgical systems' functionalities and the ongoing improvement of surgeons' operational skills. However, there are still few relevant research reports available because of the high operational difficulty and the absence of a comprehensive quality control system. The use of standard tubular staplers in robotically assisted duodenojejunostomy has not been documented. On June 20, 2024, our center performed a robotically assisted resection of a tumor in the ascending part of the duodenum along with the use of a tubular stapler for a duodenojejunostomy, based on prior experience with robotic surgery. The details are reported as follows.

Case presentation

Patient, female, 70 years old, admitted to hospital for 5 days due to dizziness, fatigue, black stool, blood pressure 125/65 mmHg, pulse rate 90 times/min, BMI: 28 kg/m2, blood routine: red blood cell count: 2.33 × 10 ^ 12/L к, hemoglobin assay: 63 g/L ≠ , no abnormal findings were found in the rest of the examinations, and no special history was found. An enhanced CT scan of the abdomen showed soft tissue shadow in the ascending part of the duodenum, part of it protruded out of the lumen and grew out of the lumen, and the largest diameter was about 4.5 mm * 5 mm (Figure 1). The initial diagnosis was an ascending duodenal tumor with a possible gastrointestinal stromal tumor, upper gastrointestinal bleeding, and moderate anemia, we chose to perform tumor resection and digestive tract reconstruction in a fully robotic approach. The Xiangyang Central Hospital Ethics Committee gave its approval for this study.

Figure 1: Enhanced CT of the abdomen (section D 4 of the duodenum).

Fasting for 6 hours, no drinking for 2 hours, and prophylactic antibiotics for half an hour before surgery. The patient was placed in the supine position and separated legs. The surgical area was routinely disinfected and the 8 mm eyepiece Trocar (C) was placed about 3 cm above the pubic symphysis to establish the pneumoperitoneum, the other trocars were placed under the direct vision of the camera: 8 mm trocars were placed at the navel of the left axilla front line as the manipulator arm channel 1(R 1); 8 mm Trocar was placed at the medial 2 cm navel of the right axilla anterior line as the manipulator arm channel 2(R 2), 12 mm assistant Trocar 1(a 1) was placed at the anti-maxwell point, and 5 mm assistant Trocar 2(a 1) was placed at 2 cm below the right rib edge. A 4 cm transverse incision was made at the anterior superior iliac spine of the left lower abdomen for placement of a tubular stapler and specimen extraction (D) (Figure 2).

Figure 2: Total robotic resection of ascending gastrointestinal stromal tumors of the lower duodenum combined with Trocar placement using a common tubular stapler for duodeno-jejunostomy (Note: A1. Assisted Trocar 1; A2. Auxiliary Trocar 2; R1. Robotic Manipulator Arm Channel 1; R2. Robotic Manipulator Arm Channel 2; C. Robot Lens Hole; d. Tubular stapler placement and specimen extraction hole).

There was no evidence of abdominal or pelvic effusion or peritoneal metastasis and a 5 * 4 cm tumor was found on the mesentery side of the ascending duodenum near the flexor ligament (Figure 3), according to the scheme discussed before the operation, the side-to-side duodeno-jejunostomy was performed with linear cutting stapler under the whole robot.

Figure 3: Tumor detected by a probe.

The robot was docked on the right side of the patient's head and a robotic lens was inserted. The surgeon's robotic arms 1 and 2 were operated through robotic arm channels 1 and 2, respectively, and two assistants assisted on both sides of the patient. The jejunum was dissected and transected about 5 cm distal to the tumor using an Endo-GIA 60 mm white nail. The tumor was separated from the mesentery and Hemolok clamped the tumor vessels. When the level part of the duodenum was free, the level part of the duodenum was found to be deep and the operation was difficult, and the duodenal stump was short after resection of the tumor at the duodenal-jejunal junction [9], and the distance between the duodenal stump and the gut is insufficient for a side-to-side duodenal-jejunostomy, the end-to-side duodeno-jejunostomy was performed with a tubular stapler under the full robot instead. The mesentery of the ascending part of the duodenum was free and the duodenum was severed about 2 cm proximal to the tumor.

A 4 cm transverse incision was made at the anterior superior iliac spine of the left lower abdomen, and a 5 cm protective sleeve was inserted into the abdomen. The surgical specimen and bag were removed, and the gun body of the 23-gauge tube stapler and the nail base were prearranged, the aseptic gloves were fixed on the incision protective sleeve and gun body (Figure 4a), the pneumoperitoneum was re-established, the robot was re-connected, and the duodenal end was placed on the nail base, and the purse was sutured and fixed, the 23-gauge stapler was inserted into the distal jejunum and end-to-side duodenum-jejunum anastomosis was performed (Figure 4b), endo-gia 60 mm white nails were used to close the jejunal stump 2 cm from the anastomotic site, and 3-0 microarbor thread was used to sew the anastomotic site and the jejunal stump to the satisfaction (Figure 4).

Figure 4: The reconstruction of Digestive Tract: a) the gun body and the nail seat of the Stapler were preset, the 6.5-yard sterile gloves were fixed to the protective sleeve of the incision through the gun body, the distal part of the gun body was sealed with silk thread, and the pneumoperitoneum was re-established; b) end-to-side duodeno-jejunal anastomosis using a tubular stapler.

Complete hemostasis, anastomosis next to the indwelling of a drainage tube and body surface fixed. After examination of the operative field with no active bleeding, the pneumoperitoneum was gradually reduced, Trocar was pulled out, the incision was sutured, and the operation was ended.

The total operation time was 190 mins (30 mins for robot docking and 160 mins for robot manipulation), the blood loss was 10 ml, no conversion to laparotomy, and no severe complications, he got out of bed on the 1st day after the operation, passed gas on the 2nd day after operation, entered into the liquid diet on the 5th day after operation, and pulled out the drainage tube on the 8th day after operation. Upper gastrointestinal contrast examination was performed 1 week after surgery (Figure 5a): duodenal changes after surgery, no stenosis, and extravasation of contrast media. The postoperative hospital stay was 10 days and the patient recovered well.

The size of the tumor was 5.5 × 4.9 × 4.7 cm. Mitotic figures were less than 5/50 high power fields. No necrosis or rupture was found in the tumor, tumor tissue was not seen at bilateral margins, CD117(+), CD34(vascular +), Ki-67(+) risk: high risk (Figure 5b).

Figure 5: a) Upper gastrointestinal contrast examination was performed 1 week after surgery. b) Results of pathological sections of the patient.

Discussion

The anatomic location of gastrointestinal stromal tumors is rarely located in the ascending duodenum. Laparoscopic exploration can be used as one of the diagnostic methods, laparoscopy or robotic resection should be considered if the tumor is less than 5 cm in diameter, because of its special anatomic location, tumor resection with laparoscopy is relatively easy, whereas gastrointestinal reconstruction with total laparoscopy is relatively difficult [9]. It is difficult to perform proximal-distal end-to-side anastomosis with tubular stapler in obese patients. Robotic surgery has been gradually developed in the operation of gastrointestinal stromal tumors [10,11], with dynamic stability, ergonomic design, and operational accuracy, providing a three-dimensional view for clinical surgeons, the occurrence of tremors is minimized, thereby reducing unnecessary tissue trauma and tumor manipulation [5] and reducing the risk of recurrence of tumor rupture. For the reconstruction of the digestive tract after resection of stromal tumors at specific sites of the duodenum, a case of direct robotic distal suturing for intestinal anastomosis has been reported by a Korean scholar [12]. Orvil tubular stapler has also been used in robotic anastomosis [13]. It was found that there was no report of duodenal jejunum anastomosis with a common tubular stapler under the robot. This is the world's first robotic resection of an ascending gastrointestinal stromal tumor of the lower duodenum combined with a common tubular stapler duodeno-jejunostomy.

Although the incidence of duodenal GIST is low, its clinical symptoms and other parts of the Gist are basically the same, mainly manifested by upper gastrointestinal bleeding, abdominal pain, abdominal mass, etc. [4], gastrointestinal bleeding was the first symptom in this patient. Preoperative assessment of the tumor for endoscopic resection was not difficult, and the challenge was gastrointestinal reconstruction [9]. The way the digestive tract is reconstructed is flexible and most are end-to-end or end-to-side anastomoses of the duodenum and jejunum [6,14], which is often difficult because of the deep manual anastomosis at the anatomic site; An end-to-side anastomosis with a stapler may be considered [15-17]. The best choice is to free the level segment of the duodenum long enough and use a linear cutting stapler to perform side-to-side anastomosis of the duodenum and jejunum. During the operation, it was found that the horizontal segment of the duodenum was deep, the operation was difficult and the operative injury and time were increased, the successful completion of the operation, the significant reduction of the expected operation time, and the successful rehabilitation of the patients after the operation embody the advantages of minimally invasive robotic surgery and flexible suturing [5]. In view of this case, our team performed postoperative reoperation and reviewed and summarized the experience: (1) it is easier to suture the distal end of the lower duodenum with the purse string and insert the nail base with the robot; this may not be inferior to open surgery, especially in obese patients; (2) because it needs at least a 2-3 cm auxiliary incision to remove the specimen, the tubular stapler can be placed smoothly through this incision. The use of the tubular stapler to complete the anastomosis can obviously shorten the operation time and reduce the difficulty of anastomosis, therefore, it is recommended to choose a tubular stapler to replace manual anastomosis under certain conditions; (3) the use of a single body position during the whole operation reduced the time of changing body position and re-disinfecting cloth, and also reduced the risk of bleeding during the course of body position changing, so as to maximize the benefit of patients, due to the influence of re-establishing pneumoperitoneum, we performed a robotic secondary docking; (4) the position of the auxiliary incision was selected, which was located at the left lower abdomen and the transverse incision of the anterior superior iliac spine (Figure 2). The incision was protected by a small incision sleeve, and the stapler was inserted from the finger end of the glove, the incision effectively avoided the mechanical arm and the anastomosis was smooth; (5) to reflect on the need for optimization and improvement of the operation: it is difficult for the tubular stapler to be inserted into the distal small intestine in the abdominal cavity, and the serous membrane of the intestinal wall is broken, which increases the chance of contamination of the abdominal cavity, a self-assisted incision could be improved by introducing a distal small intestine to manually place the stapler into the small intestine and applying a rubber band to fix the small intestine onto the stapler to reduce abdominal contamination.

The successful implementation of this operation shows that it is safe and feasible to perform duodenal-jejunum anastomosis with a tubular stapler under the full robot, and provides some experience in the selection of surgical approaches for special site gastrointestinal stromal tumors.

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