Conversion of Billroth II to Roux-en-Y Reconstruction for Refractory Marginal Ulcer After Pancreaticoduodenectomy: A Robotic-Assisted Case Report

Abstract

Background: Marginal ulcers following pancreaticoduodenectomy with Billroth II reconstruction are uncommon but may cause substantial morbidity when refractory to optimized medical therapy. Surgical revision is challenging because of altered anatomy, dense adhesions, and previous open surgery. Published evidence specifically addressing robotic revisional reconstruction for this late complication remains sparse. Case Presentation: A 43-year-old man presented with persistent epigastric pain that was refractory to prolonged high-dose proton pump inhibitor therapy four years after pancreaticoduodenectomy with Billroth II reconstruction for a pancreatic head cyst. Upper gastrointestinal endoscopy demonstrated a chronic marginal ulcer at the gastrojejunostomy. Cross-sectional imaging excluded recurrence, anastomotic stricture, and other intra-abdominal pathology. Following multidisciplinary evaluation and discussion of open, laparoscopic, and robotic options, robotic-assisted revision was selected. Results: The patient underwent robotic-assisted partial gastrectomy with conversion to Roux-en-Y reconstruction. Extensive adhesiolysis was required. Intraoperative indocyanine green (ICG) fluorescence angiography was used as an adjunct to confirm visually satisfactory perfusion of the reconstructed segments; it did not prompt a change in the planned reconstruction. Operative time was 120 minutes, with estimated blood loss <50 mL. Postoperatively, gastrojejunal anastomotic bleeding occurred and was successfully managed with endoscopic hemostasis (Clavien-Dindo grade IIIa). The patient was discharged on postoperative day 7, tolerating an oral diet. Conclusion: Robotic-assisted conversion from Billroth II to Roux-en-Y reconstruction may be a feasible option for carefully selected patients with refractory marginal ulcer after pancreaticoduodenectomy when performed by an experienced minimally invasive team. In this case, ICG fluorescence was used as an adjunctive perfusion assessment tool, although a single case cannot establish a clinical benefit. Larger series with longer follow-up and comparative cost-effectiveness data are required to validate these observations.