Open Duodenopancreatectomy and Robotic Pancreaticojejunal Anastomosis in High-Risk Fistula Score Pancreatic Cancer: Case Series and Literature Review

Background: Open Pancreaticoduodenectomy (OPD) in pancreatic carcinoma (PC) patients is a complex surgical procedure, with postoperative pancreatic fistula (POPF) being the main complication.Minimally invasive techniques, such as robotic PD (R-PD), offer the potential advantages of a more precise and less traumatic pancreaticojejunal anastomosis, however the demolitive time is longer, technically challenging and require a long learning curve.This study presents a case series and literature review on a combined approach, open PD (OPD) and robotic pancreaticojejunal terminolateral anastomosis (Ra-PJA), in high-risk fistula PC patients (HRFSC-PC).The acronymus of such original approach is OPD-Ra-PJA.Methods: A retrospective analysis of six high risk fistula score pancreatic cancer patients undergoing OPD-Ra-PJA.The open approach was performed using a conventional open technique, while the two-layer duct-to-mucosa pancreaticojejunal anastomosis was performed robotically, using a covered expandable coronary artery stent positioned intraoperatively in the pancreatic duct.The primary endpoints were the occurrence of clinically relevant POPF (grades B and C), while the secondary endpoints were postoperative mortality, hospital stay, and re-operation.A literature review on OPD-Ra-PJA was also performed.Results: All patients had soft pancreatic tissue and a pancreatic duct diameter of approximately 2 mm, with a mean fistula risk score (a-FRS) of 24.5 4.3.The mean operative time was 336.6 16.9 minutes.Two cases (33.3%) of biochemical leak were detected, which resolved spontaneously.No cases of clinically relevant POPF (grade B-C) were reported.The mean postoperative stay was 14.6 1.7 days.No re-operations or deaths occurred.We found no article describing such approach.The OPD-Ra-PJA approach combines the advantages of open surgery for resection with the precision of robotic surgery for pancreatic anastomosis in high-risk fistula score patients.Conclusion: The OPD-Ra-PJA technique represents a useful original variant in the initial approach to robotic pancreatic surgery, allowing for greater precision and less tissue trauma in pancreatic anastomosis in HRFSC-PC patients.