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

Introduction

Laparoscopic distal gastrectomy has progressively become the standard of treatment for distal gastric cancer.

Liver cirrhosis is a limiting factor for treatment of gastric cancer and may complicate surgical and interventional approaches to gastric cancer treatment, negatively influence pharmacokinetics of anticancer drugs, increase the side effects of chemotherapy and hepatotoxicity, and ultimately result in an increased risk of morbidity and mortality (1). It was shown that liver cirrhosis Child-Pugh A and B leads to 71.9% morbidity and 25% mortality in patients who received gastrectomy with D2 lymphadenectomy for gastric cancer and the cases of successful treatment of patients with class B liver cirrhosis and gastric cancer are extremely rare in cause of high morbidity and mortality (2).

The management of patients with decompensated liver function and complications related to liver cirrhosis is challenging as life expectancy is mainly influenced by the liver disease and anti-tumor treatment itself can further worsen liver function, considering the variants of treatment strategy we need to choose between easier ways like transjugular intrahepatic portosystemic stents (TIPSs) with higher risk of occlusion and low efficiency without further liver transplantation and more difficult ways like surgical veno-venous shunt that have higher surgical risks and demands of surgical skills but provide higher efficiency and longer portal hypertension control even without liver transplantation (which is contraindicated in patients with active malignant tumor) (3). Little is known about anticancer treatment in patients with non-hepatic cancer and concomitant liver cirrhosis since clinical studies usually exclude patients with underlying liver cirrhosis. Most available data have been derived from trials with small patient numbers and retrospective studies (4). One recent study showed substantially higher postoperative morbidity and mortality after gastrectomy in patients with Child-Pugh B and severe portal hypertension (2).

Of note, patients with liver cirrhosis may be considered for liver transplantation only if no progression of cancer has occurred within 5 years after radical treatment of their malignancy. There is no description of concomitant minimally invasive surgical treatment of gastric cancer and portal hypertension, but the advantages of a minimally invasive approach should be highlighted in this setting. Moreover, the minimal access technique allows to preserve collateral vessels of the abdominal wall and accelerates postoperative recovery. We present this article in accordance with the CARE reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-5/rc).

Case presentation

A 68-year-old female was referred to our clinic in March 2017. Hepatitis C was diagnosed in 2004. Five years later, she experienced her first episode of esophageal variceal bleeding which was treated by endoscopic ligation. During further examination, Child-Pugh B liver cirrhosis [Model for End-Stage Liver Disease (MELD)] 9 points, with low prothrombin and albumin, moderate ascites, normal bilirubin, and no signs of encephalopathy, blood tests showed: creatinine 1.04 mg per deciliter, bilirubin 1.99 mg per deciliter, sodium 326.6 mg per deciliter, international normalized ratio (INR) 1.3, secondary to genotype 3a hepatitis C, complicated by portal hypertension (stage 2 oesophageal varices and ascites) was diagnosed (Figure 1). In January 2017, a new episode of esophageal variceal bleeding led to another endoscopic ligation during which a tumor of the distal stomach was found. Pathological examination showed poorly-differentiated gastric adenocarcinoma. Preoperative computed tomography (CT) imaging revealed a dilated portal vein, moderate ascites, esophageal varices and a cT3N1M0 gastric adenocarcinoma of the lower part of stomach body, two lymphatic nodes of the group 4d had signs of tumor growth (diameter 11 mm, active contrast accumulation). 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.

Figure 1 Portal hypertension (CT scan). CT, computed tomography.

The patient received a 5-day course of 20% albumin infusions (500 mL totally). She subsequently underwent a totally laparoscopic D2 distal gastrectomy with concomitant distal splenorenal venous shunt.

The patient’s Eastern Cooperative Oncology Group (ECOG) performance status was normal (ECOG 0) and she had no other severe comorbidities. Preoperative liver biopsy showed F4 fibrosis according to the Meta-Analysis of Histological Data in Viral Hepatitis (METAVIR) classification (5).

Surgical procedures are described below. The patient was placed in the supine position with both arms and legs extended. Initial abdominal access was obtained on the upper border of the umbilicus using Veress needle. A left subcostal 10-mm port was placed followed by a 12-mm port inserted to the left of the umbilicus (along the midclavicular line), a 5-mm port inserted in the right subcostal region, and another 12-mm port was inserted to the right of the umbilicus (along the midclavicular line). A 10 mm, 30-degree laparoscope was used for visualization.

We performed standard distal gastrectomy with D2 lymphadenectomy (according to Japanese gastric cancer treatment guidelines 2014, 4^th edition) followed by Roux-en-Y reconstruction (Figures 2-9). An ultrasound scalpel was used for mobilization and dissection. A drain was placed at the level of the anastomosis.

Figure 2 Bound splenic vein.

Figure 3 Splenic vein stump preparation.

Figure 4 Renal vein with vessel clips.

Figure 5 Splenorenal venous shunt. Posterior suture line.

Figure 6 Splenorenal venous shunt. Anterior suture line.

Figure 7 Splenorenal venous shunt final view.

Figure 8 Liver view. View after lymphadenectomy.

Figure 9 Final view of gastrojejunal anastomosis.

Next the inferior border of pancreas was mobilized to approach and visualize the splenic vein under the pancreas. The splenic vein was skeletonized with harmonic scalpel dissection from left to right up to the portal vein. A vessel clamps were placed distally to the confluence and the vein was divided by scissors. The left renal vein was then skeletonized and opened with scissors after a vessel clamp was placed on both sides. The distal segment of the splenic vein was anastomosed end-to-side to the renal vein with continuous hand sewn non-absorbable monofilament suture 5/0. The vessel clamps were removed and hemostasis was completed. Adequate blood flow was assessed by ultrasound. The total intraoperative blood loss was 100 mL.

The postoperative course was uneventful: no anastomotic leakage, pancreatitis, ascites, acute hepatic failure, wound infection, or delayed gastric emptying. The patient left the intensive care unit on postoperative day 1. The drain was removed on postoperative day 4 (when the daily drainage volume had dropped below 300 mL). The patient started liquid food intake on postoperative day 5 and was successfully discharged on postoperative day 8. Postoperative ultrasound was negative for ascites. CT scan on postoperative day 3 confirmed normal blood flow through the splenorenal venous shunt and no signs of pancreatitis or bleeding were seen (Figure 10). Laboratory tests showed normal bilirubin and no cytolysis. During the postoperative hospital stay, there were no clinical signs of hepatic encephalopathy.

Figure 10 Splenorenal venous shunt. Postoperative day 3 CT scan. The arrows show venous anastomosis between splenic and renal veins with no signs of thrombosis nor extravasation. CT, computed tomography.

Pathological examination classed the tumor pT3N2 with four of 23 positive lymph nodes.

Non-interferon antiviral treatment was started 1 month later, resulting in remission of hepatitis C virus (HCV) infection 6 months after [no RNA on the control polymerase chain reaction (PCR) test]. Adjuvant XELOX chemotherapy was started but had to be interrupted after the first course because of severe hemotologic toxicity (anemia and leucopenia). In March 2018 a neoplasm in the region of left Fallopian tube was suspected suggestive of metastatic disease. Diagnostic laparoscopy with biopsy identified a Sertoli-Leydig cell tumor (Figure 11), confirmed by immunohistochemical markers (Figure 12). Laparoscopic total hysterectomy was performed.

Figure 11 Microscopic scan of ovarian tumor (hematoxylin and eosin staining).

Figure 12 Immunohistochemical staining with CK20. CK20, cytokeratin 20.

During further follow-up until 33 months after initial surgery there were no signs of portal hypertension progression, she had ECOG 1 status, but anemia and thrombocytopenia persisted. Bone marrow biopsy did not find any signs of immune thrombocytopenia nor bone marrow metastases. During all the period after surgery the patient had normal somatic status, normal nutrition status, no pain, no dyspepsia, no edema on legs, normal blood total protein, albumin, prothrombin, alanine transaminase (ALT), aspartate aminotransferase (AST), urea, creatinine.

CT-scan 33 months after surgery identified two hyper-vascular images in the soft tissues of abdominal and thoracic wall: biopsy was positive for metastatic disease (adenocarcinoma cells similar to the original gastric cancer). After that control point, the patient was lost from follow-up.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Minimally invasive distal gastrectomy combined with distal splenorenal venous shunt was feasible and deemed preferable for this patient with gastric cancer and liver cirrhosis due to faster postoperative recovery and abdominal wall collateral vessels preservation. Concomitant gastrectomy and splenorenal shunt were well tolerated and potentially reduced the morbidity and mortality associated with two major operations.

The standard of treatment of patients with locally advanced gastric cancer is radical gastrectomy with D2 lymphadenectomy followed by adjuvant or perioperative chemotherapy. Cancer associated with HCV infection (with or without cirrhosis) is a unique situation rarely seen in the general population: HCV infection is associated with potential interactions between antineoplastic agents and HCV therapeutics (including side effects of both), reason why no standard of treatment exists for patients with cancer and HCV infection (6).

Median survival in patients with compensated cirrhosis exceeds 12 years, whereas it is only 1.8 years in patients with decompensated disease (3). Prognosis for patients with portal hypertension and gastric or esophageal varices is poor: 5-year mortality is greater than 80% when patients have variceal bleeding in association with other complications. Patients who recover from their first variceal bleeding episode have a high risk of rebleeding (60% in the first year), with a mortality of up to 33%. In general, the severity of liver dysfunction is a main prognostic factor in patients with liver cirrhosis undergoing surgery. The mortality rates increase with more advanced liver cirrhosis and were 10%, 30–31%, and 76–82% for Child-Pugh stages A, B, and C after major abdominal surgery (2). In gastric cancer, liver cirrhosis was an independent risk factor for post-discharge morbidity after radical gastrectomy and patients with more advanced (Child-Pugh B-C) cirrhosis had a significantly higher postoperative complication rate (72.7% vs. 30.4%) and mortality rate (27.2% vs. 4.3%) as well as a shorter long-term survival (5-year survival rate, 11% vs. 66%) after curative surgery than patients at Child-Pugh stage A. It’s important to mention that all participants with preoperative portal hypertension experienced postoperative complications. But as a general consensus, elective surgery is well tolerated in patients with Child-Pugh A cirrhosis. Especially if portal hypertension can be managed (2). While the prognosis of patients with cancer and very advanced (decompensated, Child-Pugh C) liver cirrhosis is mostly determined by the liver disease patients with compensated disease (median survival based on liver function impairment: >12 years) rather die from tumor-related complications and therefore might derive a clinically relevant benefit from anticancer treatment (3).

It is also important to mention that liver transplantation candidates with a prior extrahepatic malignancy should have received definitive treatment with adequate tumor-free survival (more than 5 years) prior to listing for liver transplantation (1-B) (7). That is why all possible ways of portal hypertension control without liver transplantation are especially important for long-term outcomes of cancer patients.

Endoscopic variceal ligation is a local therapy that consists of placing rubber bands around esophageal varices in repeated sessions until they become obliterated. Considering the fact that this method has no effect on portal hypertension, the recurrence of varices is the rule, and patients require indefinite endoscopic monitoring.

A recent randomized clinical trial compared different treatment methods of variceal bleeding prevention such as endoscopic ligation, transjugular intrahepatic portosystemic shunt, and portacaval shunt in more than 500 patients. The results showed that permanent control of variceal bleeding was achieved in 97–100% of patients treated by portocaval shunt, compared with 27–29% by endoscopic ligation. TIPS was even less effective, achieving long-term control of variceal bleeding in only 6%. Survival rates after portocaval shunt were greater at all time intervals and in all child classes (P=0.0012). Repeated episodes of encephalopathy occurred in 50% of TIPS patients, 16–17% treated by endoscopic procedures, and 8–11% treated by portocaval shunt. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0–2% of portocaval shunt patients (8). Understanding that the patient would not receive liver transplantation and previous ineffective attempts of endoscopic ligation, we preferred surgical splenorenal shunt for portal hypertension reduction.

Laparoscopic approach has several benefits for this category of patients such as: reduced blood loss, faster activization after surgery, preservation of venous collaterals of the abdominal wall, in comparison with approach through conventional laparotomy (9).

Thereby the choice of surgical procedure and approach for this case was not absolutely evident. Liver cirrhosis significantly limited chemotherapeutic options (high risk of acute liver failure) that is why adequate gastric resection with appropriate D2 lymphadenectomy as the main anti-tumor option was needed, cause the management of portal hypertension alone could lead to uncontrolled cancer progression. Portal hypertension without management could lead to repeated variceal bleedings and other complications in the early postoperative period and further cirrhosis progression in the future. For those reasons and without evident perspective of liver transplantation we decided to perform a totally laparoscopic distal gastrectomy with simultaneous distal splenorenal venous shunt for tumor elimination and to reduce portal hypertension.

Conclusions

Totally laparoscopic surgical distal splenorenal venous shunt 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 during the surgical procedure, 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.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-5/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-5/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-5/coif). A.F. serves as the co-Editor-in-Chief of Annals of Laparoscopic and Endoscopic Surgery from April 2016 to April 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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