The treatment of end-stage liver disease is liver transplantation. The studies have shown patients transplanted for NET liver metastasis had comparable outcome to the patients with HCC within Milan criteria . The patients are required to have at least 2 years following primary surgery for NET and the disease should be confined to liver at the time of liver transplantation .
Majority of the rectal NET are small and localized to the mucosa and submucosa. Majority of the cases are dormant and symptomatic. However, as the tumor size and invasion depth increases, the risk of metastasis and aggressive biologic behavior increases. This has an effect on the postoperative outcome of these tumors and therefore. Early diagnosis has paramount importance for a favorable postoperative prognosis . The definitive treatment of rectal NET’s are resection. European Society of Medical Oncology guidelines state that surgery is the primary treatment of gastrointestinal NETs . The 5-years survival rates of patients with rectal NET is 80–100% [9, 10]. Smaller tumors can be treated with endoscopic mucosal resection, transanal minimally invasive surgery. However larger tumors (> 2 cm) or tumors that penetrate and extend through muscularispropria require low anterior resection and abdominoperineal resection .
In the present study we performed concomitant LDLT and low anterior to patients with HBV related end stage liver disease and rectal NET. The majority of early postoperative infective complications (30–40%) observed following liver transplantation is intraabdominal sepsis. This is due to the fact that biliary and gastrointestinal surgeries are contaminated surgeries [12. We took every necessary precaution to prevent abdominal sepsis in a dismal surgical environment. The patient is now in postoperative second year with and uneventful postoperative follow-up. Our literature search has shown that there is only one reported case with concomitant liver transplantation and resection . This was the case for our patient and only rectal resection may lead to decompensation of the patient due to surgical trauma. On the other hand, performing LDLT would be contraindicated due to high risk of tumor progression due to immunosuppressive therapy. For this reason, we performed both LDLT and LAR in the same session.Portal clamping during liver transplantation causes edema in the colon. Since this edema will affect the anastomosis safety, we first performed LDLT and then LAR.
In conclusion, the present study shows that concomitant liver transplantation and resection for gastrointestinal NET can be performed under strict selection. The characteristics of the patient in the present study showed that if the tumor has favorable biological characteristics, localized to primary site and the liver failure is unrelated to the NET; than synchronous operations can be performed to the patients because staged procedure has definitive risks that would preclude definitive treatment and survival.
Tuncer A, Ogut Z and Usta S conceived and designed research. Akbulut S, Sahin TT and Yilmaz S conducted the research. Tuncer A, Usta S, Ogut Z, and Akbulut S contributed to data extraction. All authors wrote the manuscript. All authors read and approved the manuscript.