Situs inversus totalis patients with gastric cancer: Robotic surgery the standard of treatment?-A case report

Laparoscopic retroperitoneal lymphadenectomy for ovarian mixed germ cell tumor in a patient with situs inversus totalis; reporting the first case worldwide with literature review and in silico analysis

BACKGROUND

Situs inversus totalis (SIT) is a rare autosomal recessive inheritance at which the abdomino-thoracic organs are mirror-image transposed. Germ cell tumors originate from the primitive germ cell of the ovary and testis.

CASE REPORT PRESENTATION

A rare association between malignant ovarian mixed germ cell tumor and SIT was presented in a 32-years-old Egyptian female, successfully treated with laparoscopic total abdominal hysterectomy, right salpingo-oophorectomy, and retroperitoneal lymphadenectomy (laparoscopic retroperitoneal lymphadenectomy) of both sides. This case is considered the first of its kind worldwide.

CONCLUSION

SIT may be associated with malignant ovarian germ cell tumors. Surgical intervention could be done laparoscopically.

Association between types of abdominopelvic cancer in patients with situs inversus total: Systematic review

BACKGROUND

Situs inversus is a rare congenital anatomical variant that involves a group of anomalies regarding the arrangement of intrathoracic and intraabdominal organs. Being able to find in the abdominal region the liver, gallbladder, inferior vena cava, and head of the pancreas and ascending colon on the left side of the abdomen, while on the right side there is the spleen, the stomach, the body of the pancreas, the ligament of Treitz, descending colon among others. In this same way, the thoracic organs, lungs and heart, are changed in their position in a mirror translocation.

METHODS

We systematically searched MEDLINE, Web of Science, Google Scholar, CINAHL, Scopus, and LILACS; the search strategy included a combination of the following terms: "Situs inversus," "Situs inversus totalis," "Cancer," "Neoplasm," "Abdominopelvic regions," and "clinical anatomy."

RESULTS

Within the 41 included studies, 46 patients with situs inversus who had cancer, in addition to being found in this organ and in these regions, we also found as a result that the majority of the studies in the research were in stage II; finally, no one study could assert the direct relationship between the situs inversus totalis and the cancer.

CONCLUSION

If our hallmarks could make us think that more exhaustive follow-up of the stomach and other organs should be carried out in these patients, there could also be other predisposing factors for cancer, which is why more studies are suggested to give future diagnostic and treatment guidelines treatment.

Laparoscopy-assisted gastrectomy for advanced gastric cancer patients with situs inversus totalis: Two case reports and review of literature

BACKGROUND

Situs inversus totalis (SIT) is a rare condition in which the positions of abdominal and thoracic organs present a "mirror image" of the normal ones in the median sagittal plane. Although minimally invasive surgery has evolved to achieve laparoscopic gastrectomy for gastric cancer (GC) patients with SIT, it is difficult to perform lymphadenectomy (LND) in such a transposed anatomical condition. Herein, we report the cases of two patients with SIT who successfully underwent laparoscopy-assisted gastrectomy (LAG) with D2 LND.

CASE SUMMARY

Case 1: A 65-year-old man was admitted for intermittent abdominal pain and distension, occasional belching, and acid reflux for 4 mo. He was diagnosed with GC (cT3N1-2M0) with SIT. Before surgery, he had undergone four cycles of neoadjuvant chemotherapy and immunotherapy. Then, the patient was evaluated as having a partial response, and laparoscopy-assisted distal gastrectomy with D2 LND and Billroth II reconstruction were performed. The operation was performed successfully within 240 min with an estimated blood loss of 50 mL and no severe complications. The patient was discharged on postoperative day (POD) 9. Case 2: A 55-year-old man was admitted for upper abdominal distension with pain and discomfort after eating for 3 mo. He was diagnosed with GC (cT3N1M0) with SIT. He had a history of hypertension for more than 10 years; however, his blood pressure was well-controlled via regular medication. We performed laparoscopy-assisted total gastrectomy with D2 LND and Roux-en-Y reconstruction. The operation was performed successfully within 168 min with an estimated blood loss of 50 mL and no severe complications. The patient was discharged on POD 10.

CONCLUSION

LAG with D2 LND could be considered an accessible, safe, and curative procedure for advanced GC patients with SIT.

Laparoscopic common bile duct exploration to treat choledocholithiasis in situs inversus patients: A technical review

Situs inversus (SI) is a rare congenital condition characterized by a mirror-image transposition of the major visceral organs. Since the 1990s, more than one hundred SI patients have been reported to have successfully undergone laparoscopic cholecystectomy. In these cases, the major problem is to overcome is the left-right condition for right-handed surgeons. Laparoscopic common bile duct exploration (LCBDE), an alternative to treat patients with bile duct stones, has shown equivalent efficacy and is less likely to cause pancreatitis than endoscopic retrograde cholangiopancreatography. Recent updated meta-analyses revealed that a shorter postoperative hospital stay, fewer procedural interventions, cost-effectiveness, a higher stone clearance rate, and fewer perioperative complications are additional advantages of LCBDE. However, the technique is technically demanding, even for skilled laparoscopic surgeons. Conducting LCBDE in patients with difficult situations, such as SI, is more complex than usual. We herein review published SI patients with choledocholithiasis treated by LCBDE, including our own experience, and this paper focuses on the technical aspects.

Indocyanine green fluorescence imaging-guided laparoscopy-assisted distal gastrectomy for early gastric cancer in a patient with situs inversus totalis: A case report with video

Situs inversus totalis is a rare congenital anomaly. Most surgeons have seldom performed laparoscopy-assisted distal gastrectomy for situs inversus totalis. Inadequate knowledge regarding the anatomy of situs inversus totalis can result in increased intraoperative bleeding and prolonged operative time. A 74-year-old man was diagnosed with early gastric cancer with situs inversus totalis. We performed laparoscopy-assisted distal gastrectomy with D1+ lymphadenectomy and Billroth-I reconstruction by reversing the standard laparoscopy-assisted distal gastrectomy setup. Mirror images of the operative video of the standardized laparoscopy-assisted distal gastrectomy were created using video editing software. Lymphadenectomy was performed by indocyanine green fluorescence imaging of the lymphatic flow with operative time of 220 minutes and 100 mL intraoperative bleeding. The patient was discharged on postoperative day 10, without postoperative complications. Laparoscopy-assisted distal gastrectomy with indocyanine green navigation is safe and effective in patients with situs inversus totalis and is comparable with standard laparoscopy-assisted distal gastrectomy.

Case report: Robot-assisted laparoscopic partial nephrectomy for renal cell carcinoma in a patient with situs inversus totalis and abdominal cocoon

Background

Situs inversus totalis (SIT) is a congenital condition wherein organs in abdominal or thoracic cavity are mirrored from their normal positions. Abdominal cocoon, is a rare disease of unknown aetiology that is characterised by total or partial small intestine encapsulation by a compact fibrocollagenous membrane. Aside from having two extremely rare conditions (SIT and Abdominal cocoon), our patient developed renal cell carcinoma (RCC), which makes this case even more uncommon.

Case Presentation

We report the case of a 64-year-old man who was admitted to our hospital with an extremely rare case of localized RCC in the left kidney complicated with SIT and abdominal cocoon. Computer tomography urography (CTU) and angiography (CTA) showed that the patient was confirmed as having SIT, for the space-occupying lesion in the left kidney, clear cell RCC (ccRCC) was considered, the lesion in the right kidney was probably cystic. We diagnosed our patient as having a cT1aN0M0 left RCC, and the RENAL score was 7x. With partial nephrectomy (PN) being the preferred treatment approach, robot-assisted laparoscopic partial nephrectomy (RALPN) was performed after obtaining informed consent. After insertion of the laparoscope, adhesions were observed between the entire colon and the anterior abdominal wall. Then, abdominal cocoon was diagnosed. The surgery was uneventful, and the tumour was resected successfully while preserving the tumour capsule. No intestinal injury or any other complication occurred in the intraoperative or postoperative, and the patient recovered well after the operation.

Conclusion

PN is an extremely challenging procedure in patients with SIT and abdominal cocoon. The da Vinci Xi surgical system and thorough preoperative assessment allowed the surgeon to overcome stereotyping, visual inversion, and successfully perform PN in a patient with SIT and abdominal cocoon without increasing the risk of complications and preserving as much renal function as possible. Considering the satisfactory outcomes, this report may hopefully provide a practical reference for the treatment of RCC in patients with other special conditions.

Laparoscopic vs. Robotic Gastrectomy in Patients with Situs Inversus Totalis: A Systematic Review

Background

Situs inversus totalis (SIT) is a rare genetic anomaly involving the mirror-image transposition of organs. This transposition can potentially make surgical treatments difficult because of the reversed anatomy and intraoperative confusion. The aim of this systematic review is to compare the perioperative outcomes and safety of robotic and laparoscopic gastrectomy in patients with SIT.

Methods

We included full-text case reports with brief reviews and standalone case studies on SIT patients age ≥21, undergoing laparoscopic or robotic gastrectomy. We excluded case studies focusing on procedures other than laparoscopic and robotic gastrectomy, namely, open gastrectomy, gastric banding, and gastric bypass. English was selected as the language and articles published in the last 10 years were selected with a date range from Jan, 2011, to Aug, 2021. We focused on intraoperative and postoperative outcomes including blood loss, vascular aberrancy, operation duration, mortality, operative complications, duration of hospitalization, and follow-up interval. Online databases included Clinical Key, Embase, ScienceDirect, Ovid, and Google Scholar. The last search was conducted on Aug 15, 2021. For all eligible articles, risk of bias assessment was carried out using JBI critical appraisal checklist (Table 1). Continuous data were analyzed using t-test with p value of 0.05.

Results

From our search, we retained 29 case reports which reported information from 30 cases. The results reported in each study were summarized (Table 2). The laparoscopic procedure was used in 21 cases and robot-assisted surgery was used in 9 cases. Operative time was mentioned in 24 out of the 30 cases and the average operative time was 205.67 min. Blood loss was reported in 16 out of the 30 cases, with an average blood loss of 51.9 mL. Hospital stay information was provided in 26 out of the 30 cases, with an average length of stay of 8.5 days. A statistically significant difference was not found for the operative time, length of hospitalization, or age of the patient. However, intraoperative blood loss in robot-assisted gastrectomy was lower compared to laparoscopic gastrectomy, with a p value of 0.0293. Perioperative death was not reported in any of the cases. Only three cases of postoperative complications were reported in laparoscopic surgery. Only one of the three cases suggested that the complication was due to an anomaly, whereas the other two of them reported complications due to procedural errors.

Conclusion

Laparoscopic and robotic gastrectomy can be safely used for SIT patients if performed cautiously. Some precautions include thoroughly assessing anatomical aberrations using preoperative imaging, adjusting the operative set up, and having experienced surgeons. The robotic approach may have a few advantages over laparoscopic procedures that may enhance the surgical safety for SIT patients and need to be further explored in future research. Advantages of the robotic approach may include improved surgical safety with better visualization of the surgical field, promoting the stability of surgical instruments and perhaps allowing ease of surgical orientation and positioning when operating on patients with SIT. Further research in this field is merited.

Advances in the application of robotic surgical systems in gastric cancer: A narrative review

Gastric cancer is one of the common malignant tumors in the gastrointestinal tract, and surgery is currently an important treatment for progressive gastric cancer. With the development of technology, the simultaneous maturation of artificial intelligence (AI), fifth-generation (5G) telecommunication networks and the internet of things (IOT) has brought significant efficacy and new opportunities for the surgical treatment of gastric malignancies. The combination of 5G network and remote surgical robotic system is the future trend of radical gastric cancer surgery, and the "unmanned" treatment mode of fully automated robotic gastric cancer radical surgery will be realized soon.

Laparoscopic distal gastrectomy for gastric cancer in a patient with situs inversus: a case report

Background

Situs inversus (SI) is a rare congenital condition characterized by organ transposition from their normal positions. Careful preoperative planning is important for the safe operation of patients with SI because only a few surgeons have operated on such patients. Here, we report the case of a patient with SI who underwent laparoscopic distal gastrectomy (LDG) with D2 lymph node dissection (LND) for advanced gastric cancer (GC).

Case presentation

The patient was a 72-year-old man diagnosed with GC. Upper endoscopy revealed a type 3 tumor in the anterior wall of the stomach body. Multidetector computed tomography showed no obvious GC metastasis or inverted organs. The preoperative diagnosis was cStage IIB (i.e., cT3, cN0, and cM0) GC with SI. Although liver retracting and intracorporeal suturing required special attention, LDG with D2 LND and Billroth-I reconstruction were safely performed by reversing the usual procedure. The patient was discharged 10 days after the surgery.

Conclusions

To safely perform laparoscopic surgery for GC in patients with SI, sufficient preoperative preparation is necessary. In particular, a reversible method of liver retraction should be prepared.

Robotic-assisted pulmonary lobectomy with lung cancer in a patient with situs inversus totalis

Background

Situs inversus totalis (SIT) is a relatively rare congenital abnormality in which the major thoracic and abdominal visceral organs are reversed from their usual positions. In patients with SIT and bronchial carcinoma, surgical difficulty increases sharply. It has been reported that the video-assisted thoracic surgery (VATS) still poses the operator to a challenge situation. The similarity of surgical positions and the flexibility of the mechanical arm in robotic surgery, may be beneficial to SIT patients due to reducing technical difficulties. Here, we present a first case of SIT patient with lung cancer, in which Da Vinci robot-assisted thoracic surgery (RATS) was performed successfully.

Case presentation

A 66-year old patient, previously diagnosed with SIT since childhood, came to our hospital with two pulmonary nodules in his left lung field. The bigger one had increased somewhat for the last 2 years of follow-up. Software Mimics was preoperatively carried out to analyze anatomical variations. RATS was conducted to complete left upper lobectomy and left middle wedge resection. The patient had no intraoperative complications and was discharged day 5 after the operation.

Conclusions

This is the first report of a successful robot-assisted lung cancer resection in a patient with SIT. In such challenging cases as lung cancer and rare anomaly as SIT, RATS is more advantageous and suitable than VATS with the help of software Mimics utilized for 3D reconstruction, which can identify the anatomical abnormalities and facilitate the surgical procedures.

Icariin Regulates the hsa_circ_0003159/eIF4A3/bcl-2 Axis to Promote Gastric Cancer Cell Apoptosis

Objective

To clarify the mechanism of icariin (ICA) promoting gastric cancer (GC) cell apoptosis by regulating circ_0003159/eIF4A3/bcl-2 axis.

Methods

The mRNA or protein levels were detected by qRT-PCR or the western blot. The interaction between eIF4A3 protein and circ_0003159 or eIF4A3 protein and bcl-2 mRNA were validated by RNA pull down assays and the RNA immunoprecipitation (RIP) assay. The cell viability was measured by the cell counting kit (CCK)-8 kit. The cell apoptosis was measured by flow cytometry.

Results

Compared with the group Vector, the ratio of cytoplasmic eIF4A3/nuclear eIF4A3 in the cell with circ_0003159 overexpression was significantly higher. RIP and RNA pull down results proved the interaction between eIF4A3 and circ_0003159. The RIP assay further validated the interaction between eIF4A3 and bcl-2. By gain or loss of the functional experiment, hsa_circ_0003159 was proved to recruit eIF4A3 to inhibit bcl-2 expression. Hsa_circ_0003159 regulates eIF4A3/bcl-2 to reduce GC cell viability and increase apoptosis Furthermore, ICA regulates hsa_circ_0003159/eIF4A3/bcl-2 axis to inhibit GC cell activity and induce GC cell apoptosis in vitro.

Conclusion

These data showed that ICA could effectively reduce the GC cell activity and induce GC cell apoptosis via hsa_circ_0003159/eIF4A3/bcl-2 axis, which provides new theoretical evidence for the treatment of GC by ICA.

Robot-assisted transhiatal lower esophagectomy and proximal gastrectomy for Siewert type II advanced esophagogastric junction cancer with situs inversus totalis: a case report

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital abnormality in which the thoracic and abdominal organs are reversed or mirrored from their usual positions. We herein report the first case of robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with esophagogastrostomy for treatment of Siewert type II advanced esophagogastric junction (EGJ) cancer with SIT.

CASE PRESENTATION

A 62-year-old man with SIT and intestinal malrotation was diagnosed with T3N0M0 Stage IIA EGJ cancer. Three-dimensional reconstruction of a computed tomography angiogram showed that the common hepatic artery was absent, the proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery, and an accessary left hepatic artery arose from the left gastric artery. The patient underwent robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with D2 lymph node dissection, including lower mediastinal lymphadenectomy. Intraoperative examination revealed minor vascular abnormalities, including three branches of the left gastric artery and two left gastric veins, that had not been recognized preoperatively. The surgery was performed safely, and the patient had an uneventful postoperative course.

CONCLUSIONS

Robotic-assisted surgery is efficient even for complex conditions, such as Siewert type II advanced EGJ cancer with SIT.

Icariin inhibits gastric cancer cell growth by regulating the hsa_circ_0003159/miR-223-3p/NLRP3 signaling axis

This study aimed to clarify the expression and role of hsa_circ_0003159 in gastric carcinogenesis, and validate the protective effects of Icariin (ICA) against gastric cancer (GC) cell growth through the in vitro and in vivo experiments. The levels of hsa_circ_0003159, microRNA (miR)-223-3p and NLRP3 were measured by Quantitative real time Polymerase Chain Reaction or western blot. The cell counting kit (CCK)-8 was used to determine cell proliferation. The target relationship of miR-223-3p/hsa_circ_0003159 and miR-223-3p/NLRP3 was predicted by bioinformatics and validated by the dual-luciferase reporter and pull-down assays. Xenograft model was constructed to assess the roles of hsa_circ_0003159 and protective effects of ICA in GC in vivo. Results showed that hsa_circ_0003159 was downregulated in GC cell lines and its overexpression promoted GC cell viability. MiR-223-3p was identified as a target of hsa_circ_0003159. By competitively sponging miR-223-3p, hsa_circ_0003159 positively regulated NLRP3 expression. MiR-223-3p mimics reversed the suppressive effect of hsa_circ_0003159 on GC cell viability and cell pyroptosis. Importantly, ICA inhibited GC cell viability and triggered GC cell pyroptosis by regulating the hsa_circ_0003159/miR-223-3p/NLRP3 axis in vitro and in vivo. In conclusion, this study indicated ICA inhibits GC cell growth by regulating the hsa_circ_0003159/miR-223-3p/NLRP3 signaling axis. This study not only reveals the mechanism of gastric carcinogenesis but also provides potential molecular targets and therapeutic tools for its treatment.

Robotic-assisted proximal gastrectomy using the double-flap technique for early gastric cancer with situs inversus totalis: a case report

Background

The robotic system has been applied in the treatment of gastric cancer (GC), and the procedure has been found to be safe and feasible. Situs inversus totalis (SIT) is a relatively rare autosomal recessive congenital anomaly. We successfully performed robot-assisted proximal gastrectomy (RAPG) and handsewn double-flap esophagogastrostomy for GC in a patient with SIT.

Case presentation

A 71-year-old woman was referred to us with an asymptomatic ulcerative lesion in the upper body of the stomach. Computed tomography revealed that she had SIT. She was diagnosed with cT1bN0M0, cStageIA gastric cancer. RAPG with lymph node dissection and handsewn double-flap esophagogastrostomy was performed. Robotic surgery enabled the surgeon to perform the surgery without changing his position and experiencing any confusion resulting from the patient’s reversed anatomy. It took 448 min, and no intraoperative complications occurred. Her postoperative course was uneventful; she was discharged on postoperative day 10. The final pathologic report showed pT1b1N0M0, pStage IA.

Conclusions

This is the first case describing RAPG with handsewn double-flap esophagogastrostomy for a SIT patient with early GC.