As an advanced-stage type of gastric cancer，GCLM is usually translobal, multifocal or even diffusely spread, and complicated by peritoneal, extensive lymph node and organ metastasis due to its highly malignant and rapidly invasive oncologic nature. Poor prognosis and deadly surgical complications make the resection rate so low that there is no multicenter clinical trial with large samples on the significance of liver resection for GCLM. No well-established criteria exist except for a few retrospective studies with a limited number of cases(4). However, it is worth noting that the results of these limited studies almost indicate that patients with GCLM can benefit from radical resection (6-9). According to follow-up results, the patient we reported also obtained a good prognosis and lived with a good quality of life.
According to the C-GCLM, the definitions of both type I and II include the same criterion:“technological resectability of liver metastases judged by a hepatobiliary surgeon”. It emphasizes the principle that surgery should be performed only when R0 resection is anticipated(4). The aforementioned question arises: what if the size and scope of liver metastases comply with this standard, but the anatomical complexity puts the hepatobiliary surgeon into a dilemma? The most common situation is that the tumor is located deeply within the liver and has extensive involvement with the main hepatic veins or retrohepatic vena cava. Conventional radical resection is extremely hazardous due to the potential risk of uncontrollable hemorrhage and long ischemia time(10). These types of tumors are usually deemed unresectable because they can not be completely removed with conventional surgery(11) .
We can infer that ELRA may overcome this issue from our case report. It effectively alleviated the technical bottleneck caused by the special location of the tumor in traditional hepatectomy and allowed the hepatobiliary surgeons to perform precise liver tumor resection and effective vascular/repair by enabling them to operate with bloodless vision and access to critical structures easily since the first report of ex vivo hepatectomy by Pichlmayr et al in 1988(4, 12, 13).
The theoretical basis and detailed surgical procedures that have been reported systematically in many studies will not be repeated here(14). What we want to discuss is the subtle principle of contradiction：with greater benefit comes higher risk. From the surgical records described above, we can see that ELRA is a challenging and time-consuming surgery with cumbersome procedures and complex operations. As a satisfactory prognosis is determined by multiple factors in addition to surgery，the most valuable experience our team has summarized from this case is that accurate preoperative evaluation for specific patients based on detailed medical examination is of great importance. Strict patient selection and precise assessment of the size and quality of the remnant liver are pivotal to the decision-making process(14). Although experiences gained from previous studies have indicated that after extended hepatectomy involving 70 to 75% of the liver, the remnant liver can still function well in non-cirrhosis patients(15, 16), the strategy may need to be adjusted in the application of ERLA according to the specific situation. A major feature of ERAT is the longer CIT compared with ordinary LT(17). In addition, ERAT procedures are more complex than LT and hepatectomy so a longer operative time and more intraoperative blood loss seem inevitable(10).These are two poor prognostic indicators for LT recipients and hepatectomy patients because they may lead to graft loss due to the high incidence of postoperative biliary and arterial complications or severe hepatic dysfunction(18). Based on the above theory, the liver function, quality and estimated RLV of ELRA patients need to meet higher requirements. Livers with poor quality are less tolerant to cold ischemia-reperfusion injury. In addition, sufficient preoperative preparations, such as biliary drainage in patients with obstructive jaundice and nutritional support in malnourished patients, are indispensable once the doctor and patient reach a consensus to perform the surgery. Without exaggeration, it can be considered that half the success will be achieved if suitable GCLM patients are screened out, but inaccurate preoperative assessments will force surgeons to discontinue the operation or will even cause fatal postoperative complications such as SFSS or ALF(19). Aji T and Dong JH et al described the largest case series of 69 patients with end-stage hepatic AE who underwent ELRA .The detailed methods and procedures applied to select patients preoperatively are explicitly described in the literature. We also adopted the same issues to evaluate the patient in this case report(14).
With greater benefit comes higher risk. Hepatobiliary surgeons must pursue more accurate and rapid surgical techniques to shorten the CIT and anhepatic phase. Under the condition of the liver in vitro, full exposure of the surgical area can help reduce the risk due to vascular or bile duct variation, which may not be detected before the operation. A longer anhepatic period can lead to circulatory and metabolic disorders. This is also a major test for the monitoring and intraoperative management of the anesthesiology department. Launching this type of major surgery can help improve the overall medical level of institutions and optimize the multidisciplinary diagnosis and treatment model. The lack of consensus and guidance on the application of ELRA drives us to accumulate more successful cases and precious experiences. For instance, Yiwen Qiu et al proposed their vascular infiltration-based classification as a tool to improve anatomic comprehension and facilitate surgical planning for ELRA(20). With the continuous accumulation of experience and the gradual improvement of technology, many so-called surgical penalty areas will also be broken through. The favorable implementation of this surgery can also enable surgeons to build confidence in dealing with more complex situations. Once successful, it will bring great significance in two aspects. For patients and their families, the painful clinical symptoms caused by the tumor will be controlled, and the quality of life will be dramatically improved. They will see improvements in mood and will achieve a better physical state that remains for the rest of their lives. From a medical point of view, an increased survival rate may provide a longer time for more postoperative treatment options and promote the progress of clinical research.
We must admit the limitation that many diseases, such as advanced cancer, still cannot be completely cured, although medical science has made rapid progress in recent years. However, it is a responsibility and obligation to create an opportunity for patients who never give up on themselves to extend their lives to fulfill their unfinished wishes. To a certain extent, this is also the meaning and motivation to encourage us to explore and push the surgical boundary. During the disease-free survival period, the female patient in our case spent irreplaceable days with her three cute children who filled her life with happiness and hope. She was deeply grateful for her brave choice and expressed her endless gratitude to our team.
In conclusion, the application of ELRA in radical resection of GCLM, as our case shows, could provide an alternative for selected patients. Surgeons’technical expertise combined with careful patient selection and perioperative management guaranteed by an experienced MDT could contribute to favorable clinical outcomes.