Live surgeryJuly 14, 20221:34:328 speakersAvailable in: EN / IT
Clinical Round: Gastric Surgery — Real-Life Case of Double Malignancy (Cholangiocarcinoma and Gastric Adenocarcinoma)
ICG Permanent School clinical round: a patient with a liver nodule (T4N0 cholangiocarcinoma) and an incidental diagnosis of T1a gastric adenocarcinoma, managed with minimally invasive liver resection and near-total gastrectomy.
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Clinical case
Doppia neoplasia sincrona: colangiocarcinoma intraepatico S4 con infiltrazione della colecisti (T4N0) e adenocarcinoma gastrico scarsamente differenziato con cellule ad anello con castone, intramucoso (T1a N0)
DiagnosisDoppia neoplasia sincrona: colangiocarcinoma intraepatico S4 con infiltrazione della colecisti (T4N0) e adenocarcinoma gastrico scarsamente differenziato con cellule ad anello con castone, intramucoso (T1a N0)
Prior treatmentResezione epatica laparoscopica S4 con linfadenectomia del peduncolo; successiva chemioterapia neoadiuvante FOLFOX
Clinical historyDiabetico, iperteso, forte fumatore e bevitore, dislipidemia con trigliceridi ~500, BMI 28. Nodulo epatico S4 inizialmente etichettato come angioma, cresciuto di 1 cm in un anno.
NotesCaso real life che evidenzia il rischio di operare prima del risultato delle biopsie endoscopiche random (Sydney score) eseguite contestualmente
Overview
Episode of the Permanent School on ICG Surgery (2022 edition) dedicated to gastric surgery, moderated by Gian Luca Baiocchi, with Felice Borghi (IRCCS Candiolo) and Luigi Boccia (ASST Mantova) as senior discussants, together with residents from San Raffaele (Valentina Andreasi and Davide Socci) and Brescia (Federica Gabella and Paolo Belotti), coordinated by Luca Quarti. After an introduction on the five possible applications of indocyanine green (angiography, biliary tree, lymph node navigation, peritoneal carcinomatosis, liver lesions), the panel discusses the educational value of fluorescence along the learning curve and the prospects of signal quantification.
The clinical case involves a 67-year-old man with a liver nodule in segment 4 in contact with the gallbladder, which had grown by 1 cm in one year and was biopsied as adenocarcinoma without an evident primary. After macroscopically negative gastroscopy and colonoscopy, the patient underwent laparoscopic liver resection with pedicle lymphadenectomy, using intravenous ICG the previous afternoon to visualize the biliary tree and the peritumoral rim. Histology confirmed T4N0 cholangiocarcinoma (gallbladder infiltration, 12 negative lymph nodes). However, the gastric biopsies performed according to the Sydney protocol turned out to be positive for poorly differentiated adenocarcinoma with signet-ring cells.
A detailed discussion follows on strategy: repeat gastroscopy with tattooing, choice between neoadjuvant chemotherapy (FOLFOX) and immediate surgery, and the dilemma between principle total gastrectomy versus near-total/subtotal resection. The decision is for neoadjuvant FOLFOX followed by laparoscopic near-total gastrectomy with omentectomy and lymphadenectomy, with a high gastro-jejunal anastomosis. Final histology is T1a N0 (intramucosal early gastric cancer). Significant attention is given to the technical comparison between energy devices (ultrasonic, bipolar, monopolar/hook) in perivascular lymphadenectomy, the role of the robot, esophago-jejunal anastomotic techniques (hand-sewn vs OrVil vs Hiringer), and the management of hepatic clamping (Pringle, preconditioning).
