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

Malignant duodenal obstruction is a common issue affecting up to 20% of patients with advanced gastrointestinal malignancies. Distal duodenal obstruction (DDO) poses unique surgical challenges, such as the need to drain the stomach and the proximal portions of the duodenum. The traditional approach, gastrojejunostomy, may not be as effective for relieving DDO, as gastrojejunostomy does not necessarily drain the duodenum. In this situation, a duodenojejunostomy could be more advantageous due to its ability to provide dual (stomach and duodenal) drainage. Here we present a case of a 75-year-old female with distal (D4) duodenal obstruction due to metastatic duodenal adenocarcinoma. Despite being previously treated with a gastrojejunostomy stent at an outside hospital, the patient presented with recurrent malignant DDO for which a robotic-assisted trans-mesocolic duodenojejunostomy was performed. This approach leverages the duodenal drainage ability of duodenojejunal bypass and the advantages of the minimally invasive robotic approach, resulting in effective and efficient relief of the obstruction. The patient's postoperative course was characterized by minimal postoperative pain, rapid resumption of solid intake, and early re-initiation of chemotherapy, underscoring the potential of this technique. This innovative surgical technique has notable clinical implications for patients in need of palliation from distal duodenal or proximal jejunal obstruction.