Is robotic resection feasible for the subcentimeter arterially enhancing focus in the distal pancreatic body, suspected to be a neuroendocrine tumor (NET)?

From the Guidelines

The tumor can likely be resected, but a robotic approach may not be the most suitable option due to the complexity of the case and the presence of liver metastases, splenomegaly, and chronic pancreatitis. Considering the patient's history of distal pancreatectomy and the presence of a subcentimeter arterially enhancing focus near the resection margin, a thorough evaluation of the tumor's resectability is necessary. The evidence from 1 suggests that open surgery remains the standard of care for pancreatic tumors, and minimally invasive techniques, such as robotic resection, may not be suitable for all cases. The patient's overall disease burden, including liver metastases and splenomegaly with gastric varices, increases the complexity of the surgical decision. As noted in 1, patients with limited hepatic disease may benefit from surgical excision of both the primary tumor and liver metastases, but the presence of metastatic disease in this case may affect the feasibility of complete resection. A multidisciplinary tumor board discussion is necessary to evaluate the appropriateness of resection, considering the patient's overall health status, vascular involvement, and prior surgical history. Additional imaging, such as the recommended MRI liver protocol with Eovist, would help better characterize the liver lesions and potentially influence the surgical approach. The decision to proceed with resection, and the choice of surgical approach, should be based on the surgeon's expertise, the patient's overall health status, and the potential benefits and risks of the procedure, as outlined in 1. Key factors to consider in the surgical decision include:

• The size and location of the tumor
• The presence of liver metastases and their potential impact on the surgical approach
• The patient's prior surgical history and the presence of chronic pancreatitis
• The potential benefits and risks of robotic resection versus open surgery
• The need for a multidisciplinary tumor board discussion to evaluate the appropriateness of resection.

From the Research

Tumor Resection

• The tumor in question is a subcentimeter arterially enhancing focus in the near resection margin in the distal pancreatic body, concerning for neuroendocrine tumor 2, 3, 4, 5, 6.
• Robotic pancreas surgery has become well accepted and is expanding to more centers annually, with the most studied robotic pancreas surgeries being pancreaticoduodenectomy and distal pancreatectomy 2.
• Robotic surgery for pancreatic lesions and malignancies offers several advantages over open and laparoscopic techniques, including stability of the operative field, 3D and magnified vision, and articulated robotic arms 3, 4, 6.
• The use of robotics in pancreatic surgery is safe and feasible, with at least equivalent if not better results than the open platform in terms of surgical and oncological outcomes 4, 5, 6.

Feasibility of Robotic Resection

• Robotic distal pancreatectomy is a possible minimally invasive technique for patients with solid pseudopapillary pancreatic tumors, presenting some advantages over the laparoscopic approach 3.
• The robotic platform is safe and feasible in the management of surgical sequelae of chronic pancreatitis, with a low rate of complications and no 30 or 90-day mortalities 5.
• Robotic pancreatic surgery is a safe and oncologically adequate technique to manage benign and malignant diseases arising from the head, body, and tail of the pancreas 6.

Considerations

• The decision to perform robotic resection should be based on the individual patient's characteristics, tumor location, and surgeon expertise 2, 3, 4, 5, 6.
• Further research is needed to establish the safety, cost-effectiveness, and efficacy of robotic pancreas surgery in providing the best outcomes 2, 6.