2.1 Preoperative assessment
The patient was a 29-year-old female had a chief complaint of chronic abdominal pain for one year and she experienced continuous weight loss of 5kg over 2 months prior to her admission. She underwent ovarian cystectomy, appendectomy and subtotal hysterectomy for uncontrollable hemorrhage according to her past medical history. No special family history was provided except that her mother was diagnosed with squamous cell carcinoma of the vulvar epithelium and the disease was cured according to her description. Other detailed basic information is displayed in Table 1. Upon physical examination, a round mass approximately 7 cm in diameter could be palpated in the right upper abdomen and the mass was smooth, pushable, hard and indistinguishable from adjacent tissue. Abdominal CT and MRI examination suggested a mass of unknown pathological nature located in segment(VIII) and it was between the first and second hila and the margin of the lower segment of the right liver lobe(Figure 2). The anterior wall of the gastric antrum was unevenly thickened. PET/CT (whole body) examination showed two main points: 1. the anterior wall of the gastric antrum was unevenly thickened , and FDG uptake was increased, which was consistent with the manifestations of gastric cancer; and 2. a mass shadow was located at the first and second hepatic hila and the lower right lobe of the liver. As increased FDG uptake is a sign of malignancy, whether the mass was liver metastasis or primary liver cancer remained to be identified. The results of puncture biopsy with gastroscopy guidance supported the pathological diagnosis of gastric antrum intramucosal well-differentiated adenocarcinoma. ECG, chest DR and CT of the lower abdomen and pelvis showed no obvious abnormalities. Laboratory data demonstrated normal liver function and routine blood test results(Table2). The tumor marker results showed that AFP was 9850 ng/ml and CEA was 55 ng/ml. Preoperative volumetric calculation was achieved by using 3D visualization imaging. The remnant liver-to-standard liver volume ratio was 56%. ICGR15 was 2.1%. The preoperative Child-Pugh score was 3. Due to the unknown nature and special location of the mass in the liver, it was considered to be a liver metastatic focus of gastric cancer after consultation by general and hepatobiliary surgeons. After fully understanding the risk and difficulty of the operation and after careful consideration, the patient decided to accept ELRA combined with simultaneous radical resection for gastric cancer.
2.2 Surgical procedure
A tumor protruding through the liver capsule with unclear borders and an uneven surface was found in the right liver during abdominal exploration. It was hard and pale and was tightly adhered to the surrounding omentum. Consistent with the preoperative imaging findings, the tumor extended to the junction of the left and right liver lobes and was adjacent to the vena cava. Intraoperative frozen biopsy of the liver mass was performed and the results supported a poorly differentiated malignant tumor. The presence of intrahepatic microlesions was ruled out by intraoperative ultrasound. The results of intraoperative exploration led us to perform ELRA combined with radical resection for gastric cancer as the original plan.
Hepatectomy was accomplished by using standard technique (5) with extensive lymph node dissection around the SMA and celiac trunk. The common bile duct was completely removed up to the head of the pancreas. Preservation and perfusion of the removed isolated liver was performed with ice-cold solution at 4 ℃ and UW solution via the intact portal vein. At the same time, temporary channel was established between the SHIVC and IHIVC with an internal diameter of 2 cm and Geo-Tex artificial vessel. The PV was also anastomosed to the vessel to construct portacaval shunt. After the intrahepatic tumor and target liver segment (VIII)were completely resected and the repairment of the middle and right hepatic vein was done, the aforementioned temporary venous channel was removed. The remnant of the liver was implanted similar to OLT which was followed by anastomosis of the SHIVC, IHIVC, PV, HA, and bile duct. The total anhepatic period was 245 minutes: including 180 minutes of CIT for extracorporeal tumor resection and vein repair, 40 minutes of vena cava anastomosis and 25 minutes of portal vein anastomosis. Observation of the normal liver surface color after reperfusion was commonly performed, and the surgeons usually confirmed bile outflow before bile duct anastomosis. Some of intraoperative photos are presented in Figure 1. As we performed ex vivo liver resection on the back table, radical surgery for gastric cancer was accomplished simultaneously by general surgeons on the operating table. The stomach and duodenum were respectively transected at 15 cm from the distal end of the cardia and 2 cm from the distal end of the pylorus with a disposable linear cutting closure.After they cleaned the lymph nodes around the portal vein, they rebuilt the digestive tract with gastrojejunal anastomosis and insert the gastric tube into the jejunum for input Loop.
2.3 Postoperative management and follow-up
Our medical team provided her with symptomatic treatment after surgery such as gastrointestinal decompression, abdominal drainage, anti-infection medication and nutritional support. She underwent bile leakage drainage on the fifth day after the operation. Fluid accumulated in the liver section and caused symptoms of gastric compression. The effusion was completely drained out after CT-guided puncture and catheter drainage. No other postoperative complications such as SFSS, ALF, vascular embolism, intra-abdominal infection, or hemorrhage occurred. She was successfully discharged on the 20th day after the operation. Postoperative pathological examination of the excised specimen indicated that gastrectomy with D2 lymph node dissection for primary gastric tumors and R0 resection for liver metastases were achieved. The resected mass was confirmed to be poorly differentiated gastric carcinoma (hepatoid adenocarcinoma with neuroendocrine differentiation) with liver metastases in segments of 6 and 8. The patient began her first follow-up one month after the operation, and received 6 courses of XELOX chemotherapy every 21 days, during which no serious adverse reactions or treatment discontinuation occurred. The patient also insisted on oral Tegafur Gimeracil and Oteracil Potassium Capsul for one month after intravenous chemotherapy. She went back to the hospital on time for follow-up every 3 months after the end of chemotherapy. Routine blood, liver and kidney function, tumor markers test and abdominal CT are routine examination items. No obvious signs of tumor recurrence or metastasis within the abdomen or liver were recorded during a 7.5-year follow-up. The patient had a good overall condition and did not undergo a second operation. Selected pre and post operative abdominal CT images of the patient were displayed in Figure 2. Postoperative laboratory data of the patient were displayed in Table 3.