Robotic Treatment for Large Duodenal Gastrointestinal Stromal Tumor

Duodenal gastrointestinal stromal tumors (D-GISTs) represent a rare entity.1 Surgery is the primary treatment choice for localized or potentially resectable D-GISTs. The main principle is the complete excision of the lesion with microscopically negative margins, without performing lymph node dissection.2 Nevertheless, the best surgical choice is still controversial since the strategy depends not only on the tumor size but also on its anatomic location.3^,4 As a result, surgical management ranges from a major resection such as pancreaticoduodenectomy to more conservative procedures.5-8 This video presents a duodenal sparing robotic resection of a large GIST of the second-third duodenal portion.

A 49-year-old healthy female complained episodes of melena. Endoscopy with endoscopic ultrasound identified a 6-cm lesion of the second-third portion of the duodenum with recent bleeding, arising from muscolaris propria. A computed tomography scan confirmed a large mass suspected to be a GIST without metastases or involvement of the ampulla of Vater. On the basis of these findings, after a multidisciplinary consultation, she was offered robotic surgery with a radical intent.

A duodenal-sparing da Vinci^®Si™ resection with robot-sewn primary duodenal closure was performed. After an uneventful postoperative course, the patient was discharged on post-operative day 7. Final pathology revealed a high-grade risk D-GIST with free margins: adjuvant Imatinib was recommended.9 At 4 years follow-up, no recurrence has been detected.

A robotic approach might be considered in cases of large D-GISTs amenable to a conservative R0 surgery. This system provides several technical advantages that facilitate otherwise complex resection and reconstruction.10.