Simultaneous totally laparoscopic distal gastrectomy with distal splenorenal venous shunt in a patient with locally advanced gastric cancer and hepatitis C virus liver cirrhosis: a case report
Year: 2024
Type: article
Study design: Case Report
Abstract: Background: Laparoscopic distal gastrectomy has gradually become the “gold standard” surgical approach for gastric cancer worldwide. Liver cirrhosis can hamper surgical and interventional approaches to cancer treatment, influence pharmacokinetics of anticancer and antiviral drugs, increase the side effects of chemotherapy, and is associated with high mortality in patients with concomitant disease. Simultaneous minimally invasive surgical tumor removal and relief of portal hypertension may be beneficial in this group of patients. Our review of literature showed that most part of presented cases and cohorts included patients with Child-Pugh A. Rare reports of D2 radical surgery for gastric cancer in patients with class B liver cirrhosis and potential benefits of combined treatment of portal hypertension at once determines the relevance of our article. Case Description: A 68-year-old woman with hepatitis C-related liver cirrhosis complicated by repeated variceal bleedings and gastric cancer was referred to our clinic. Child-Pugh B liver cirrhosis, secondary to genotype 3a hepatitis C, with portal hypertension was diagnosed. Computed tomography (CT) imaging revealed dilated portal vein, moderate ascites, esophageal varices, and cT3N1M0 gastric adenocarcinoma. The endoscopic examination showed an ulcerous tumor 4 cm × 3 cm with infiltration of the lower part of stomach body on the greater curvature. No signs of active bleeding were identified, and esophageal varices were also found without bleeding at the moment of examination. The postoperative course was uneventful: no anastomotic leakage, pancreatitis, ascites, acute hepatic failure, wound infection, or delayed gastric emptying. She was discharged home on postoperative day 8. A month after surgery she received a 6-month course of antiviral treatment with complete response. Adjuvant systemic chemotherapy (XELOX) was also initiated, but the patient received only one course due to severe hematological toxicity. She experienced good quality of life until gastric cancer progression was noted 33 months after surgery, but without any signs of portal hypertension, ascites, or liver function degradation. After that control point, she was lost from follow-up. Conclusions: Totally laparoscopic surgical distal splenorenal venous shunt combined with laparoscopic distal gastrectomy with D2 lympadenectomy is feasible and this technically demanding procedure had important benefits for this patient with liver cirrhosis undergoing gastrectomy for cancer. The usage of minimally invasive techniques in this case may be preferable allowing to save collateral vessels of the abdominal wall, allowed faster postoperative recovery, and early start of antiviral therapy and systemic chemotherapy. The general indications for this kind of concomitant surgical procedures are limited at the moment, but further investigations may give us more reasons to use minimally invasive technologies for such associated comorbidities and may help to evaluate the efficacy and safety of this approach in general populations of patients with Child-Pugh A and B liver cirrhosis.
DOI: 10.21037/ales-24-5
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4404216808