Laparoscopy-assisted distal gastrectomy for advanced gastric cancer with situs inversus totalis: A case report

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.

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.

Three-dimensional laparoscopic treatment of situs inversus totalis combined with gastric cancer: Case report with review of literature

Situs inversus totalis (SIT) is a rare congenital disease. Due to the abnormal distribution of blood vessels in the organs of SIT patients, the anatomical structure is different from that of normal people, which increases the difficulty of surgery, especially laparoscopic surgery. However, there are few reports on the treatment of SIT combined with gastric cancer surgery by three-dimensional (3D) laparoscopy. Here, we describe a case of SIT combined with gastric cancer who underwent 3D laparoscopy-assisted distal radical gastrectomy in March 2021 and with a brief review of the literature.

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.

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.

Laparoscopic distal gastrectomy for advanced gastric cancer with situs inversus totalis: a case report

Background

Situs inversus totalis (SIT) is a relatively rare condition, in which the thoracic and abdominal organs are reversed or mirrored from their normal positions. Here, we reported a case of a patient with SIT and advanced gastric cancer with lymph node metastasis who underwent laparoscopic distal gastrectomy (LDG).

Case presentation

A 67-year-old man with SIT was clinically diagnosed with T3N2M0 advanced gastric cancer located in the middle gastric body. Three-dimensional reconstruction of computed tomography angiogram revealed that the common hepatic artery originated from the superior mesenteric artery. The patient underwent LDG with D2 lymph node dissection and Roux-en-Y reconstruction. The postoperative course was uneventful.

Conclusion

This case report showed that LDG could be safely performed on a patient even under complex conditions, such as advanced gastric cancer with lymph node metastasis with SIT and vascular anomalies.

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.

Laparoscopic Distal Gastrectomy for Synchronous Gastric Cancer and Gastrointestinal Stromal Tumor With Situs Inversus Totalis

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital condition in which the thoracic and abdominal organs are inverted like a mirror image.

CASE REPORT

We present a case of synchronous gastric cancer and gastrointestinal stromal tumor (GIST) associated with SIT in a 74-year-old man who was admitted to our department to treat gastric cancer. Esophagogastroduodenoscopy revealed a depressed lesion and a submucosal tumor (SMT) in the middle-third of the stomach. Abdominal contrast-enhanced computed tomography revealed complete inversion of the internal organs, and the common hepatic artery branched from the superior mesenteric artery. The patient underwent laparoscopic distal gastrectomy with regional lymph node dissection and Billroth I reconstruction. The macroscopic observation of the resected specimen revealed a depressed lesion measuring 2.0×1.5 cm in diameter and an SMT measuring 2.2×1.8 cm.

CONCLUSION

Careful preoperative anatomic evaluation is important in SIT because the situs anomalies may be accompanied by major vascular anomalies.

Superficial Spreading-type Gastric Cancer with Situs Inversus Totalis

Situs inversus totalis (SIT) is a congenital anomaly characterized by a complete mirror-image transposition of the thoracic and abdominal viscera. We report on a rare case of superficial spreading gastric cancer associated with SIT in a 66-year-old woman referred to our hospital for examination of gastric cancer initially diagnosed by medical check-up. Esophagogastroduodenoscopy showed a slightly depressed lesion in the lesser curvature side of the stomach. Abdominal contrast-enhanced computed tomography showed complete transposition of the abdominal viscera, confirming SIT. The patient underwent total gastrectomy with regional lymph node dissection and Roux-en-Y reconstruction. Gross examination of the surgically resected specimen showed a slightly depressed lesion measuring 12×8 cm in diameter, and histopathology confirmed the diagnosis of signet-ring cell carcinoma, confined to the gastric mucosal layer without lymph node metastasis. The postoperative course was favorable, and the patient has been well without evidence of recurrence for 11 years following the operation. To the best of our knowledge, this is only the second case of a superficial spreading-type gastric cancer in a patient with SIT reported in the English literature.

Gastric cancer with situs inversus totalis: does it really create difficulties for surgeons?

Introduction

Situs inversus totalis (SIT) is a very rare condition that is seen at a rate of one in about 6000–8000 births.

Aim

To offer a general view on the coexistence of SIT and gastric cancer, accompanied by a literature review.

Material and methods

Within the scope of this study, the case of a patient with gastric adenocarcinoma and SIT has been presented. Previous research on gastric cancer cases with SIT was reviewed through a comprehensive search of the PubMed, Medline, and Google Scholar databases. The keywords used to conduct this research were “situs inversus totalis and gastric cancer,” “situs inversus totalis and gastric malignant,” and “situs inversus totalis and gastric resection.” The database search covered English studies published between 2000 and 2016.

Results

The results of our literature review revealed 20 studies of patients with gastric cancer and SIT, and 21 related cases. Overall, 12 of the patients were male, 9 were female, and their mean age was 61.8 ±10.97 years. The vascular assessment data showed that three out of the 13 mentioned cases had vascular anomalies. Eleven of the patients had laparoscopic resections, and one of the patients that had a surgical procedure exhibiting a postoperative mechanical obstruction.

Conclusions

The coexistence of SIT and gastric cancer is a very rare condition, and a careful preoperative radiological assessment should be conducted because there can be accompanying vascular anomalies. Laparoscopies and robotic surgeries can be performed for suitable patients at experienced centres, consistent with oncological principles.

Robot-assisted distal gastrectomy with lymph node dissection for gastric cancer in a patient with situs inversus partialis: a case report with video file

BACKGROUND

Situs inversus is a rare congenital condition that is currently classified into two types: complete situs inversus (situs inversus totalis, SIT) and partial situs inversus (situs inversus partialis, SIP). In SIP patients, some organs are inverted and others are in their expected position, and individual patient variation in organ position increases surgical difficulty. Several surgeons have performed laparoscopic or robotic surgeries in situs inversus patients, but almost all were SIT patients. We report the first case, to our knowledge, of an SIP patient with gastric cancer who was successfully treated by robot-assisted distal gastrectomy (RADG) with lymph node dissection.

CASE PRESENTATION

A 64-year-old woman diagnosed with early gastric cancer on the posterior midbody of the stomach was referred to our hospital for treatment. Computed tomography showed levocardia and inverted abdominal organs without enlarged lymph nodes or distant metastases. Polysplenia syndrome, intestinal malrotation, and left-sided gallbladder were also detected. RADG with D1+ lymph node dissection and Billroth I reconstruction (delta-shaped anastomosis) were performed using robotics. Hepatopathy caused by a liver retractor and pancreatic fistula were identified during the postoperative course, and the latter was classified as grade II based on Clavien-Dindo classification. The patient was discharged 18 days after the operation.

CONCLUSIONS

Preoperative three-dimensional imaging is beneficial, and anatomical organ identification should be routinely performed, especially in SIP patients. We consider RADG a therapeutic option in SIP patients.

Laparoscopic total gastrectomy for advanced gastric cancer in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly. Generally, laparoscopic surgery is difficult to perform in patients with SIT because of both the potential challenges associated with unexpected vascular anomalies and the lack of standardized strategy for handling such cases. This is the first report of laparoscopic total gastrectomy with lymph node dissection for advanced gastric cancer in a patient with SIT. A 79-year-old man with SIT was diagnosed with advanced gastric cancer. We performed laparoscopic total gastrectomy with modified D2 lymph node dissection (D2 without splenectomy) and esophagojejunal anastomosis using an overlap method involving retrocolic Roux-en-Y reconstruction. The total operating time was 232 min, and blood loss was 110 mL. There were no postoperative complications. In summary, laparoscopic total gastrectomy for gastric cancer can be performed safely, even in a patient with SIT.

Gastric cancer in a situs inversus totalis patient with multiple intestinal and vessel variations related to gastrectomy surgery: A case report and literature review

RATIONALE

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete inversion of the abdominal and thoracic organs, and often involves multiple genetic mutations. The most suitable surgical technique for patients with multiple vessel and organ variations as well as SIT remains unclear. Furthermore, there has been insufficient clinical evidence that demonstrates which surgical techniques achieve the best outcomes. Finally, the standard of care has not yet been determined. We present the case of a 60-year-old man with SIT, who was diagnosed with moderately and poorly differentiated adenocarcinoma at the gastroesophageal junction. We further describe the advantage of using robotic-assisted laparoscopic surgery in patients with this anomaly.

PATIENT CONCERNS

A 60-year-old man complained of pain in his upper abdomen for 3 months. Physical examination revealed an apex beat in the right fifth intercostal space, and vascular anomalies were noted on abdominal angiographic computed tomography.

DIAGNOSES

Moderately and poorly differentiated adenocarcinoma at the gastroesophageal junction with SIT.

INTERVENTIONS

Robot-assisted total gastrectomy with D2 lymph node dissection and hand-sewn Roux-en-Y anastomosis was performed.

OUTCOMES

The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day.

LESSONS

Robotic surgery for gastric cancer is a safe and feasible alternative to laparoscopic surgery and it can be successfully used to treat gastric cancer in patients with SIT with multiple anatomic variations. As exemplified by our case, SIT might be accompanied by multiple anatomic variations. Detailed preoperative detailed imaging of the blood vessels and gastrointestinal tract is useful in these patients.

Transumbilical Surgery for Duodenal Stenosis in a Child with Situs Inversus: The First Report

Background. Situs inversus is a rare congenital anomaly with a reported incidence of only 1 in 5,000 to 10,000 live births. Congenital duodenal stenosis complicated with situs inversus is an even rarer entity. Case Presentation. A 1-year-old girl with situs inversus who had undergone a hemi-Fontan procedure against a single ventricle in our hospital was referred to our department for vomiting and failure to thrive. An upper gastrointestinal contrast study and endoscopy revealed duodenal stenosis. A transumbilical radical operation as a minimally invasive surgery was successfully performed. After the surgery, she stopped vomiting, and the postoperative course was uneventful with good cosmetic results. Conclusions. To our knowledge, this is the first report of transumbilical surgery for congenital duodenal stenosis with situs inversus as minimally invasive surgery. Transumbilical surgery to situs inversus patient can be performed safely and lead to good cosmetic outcome.

Gastrectomy for gastric carcinoma with situs inversus totalis: case report and literature review

BACKGROUND

Situs inversus totalis (SIT), a rare congenital anomaly, is characterized by a complete mirror image transposition of the thoracic and abdominal viscera. We report the case of a 66-year-old woman with SIT who was diagnosed with gastric antral carcinoma. Curative distal gastrectomy with Billroth-I anastomosis was performed. Description of the case: A 66-year-old woman visited our outpatient department complaining of abdominal pain in the left upper quadrant for about one year. Physical examination revealed that the apex beat was in the right fifth intercostal space, just at the midclavicular line while a soft systolic murmur was audible at the upper right sternal border. The abdominal examination was unremarkable. The preoperative diagnosis was confirmed by gastroscopy and biopsy. Preoperative echocardiogram revealed the presence of dextrocardia and atrial septal defect. Preoperative contrasted computed tomography showed a complete right-left reversal of the thoracic and abdominal organs and thickened wall of gastric antrum without distant metastasis. Laparotomy through a midline incision confirmed the complete mirror-image transposition of the abdominal visceral organs and a 4-cm tumor with serosal involvement at the gastric antrum. Curative distal gastrectomy with D2 lymphadenectomy and Billroth-I anastomosis was performed. The patient had a rapid recovery and was discharged without any complications. The final staging of this case was pT4aN1M0, stage IIIa and she received chemotherapy with the SOX regimen for three cycles. Fifteen months after the operation, the patient is alive without any signs of recurrence.

CONCLUSIONS

The incidence of gastric cancer with SIT is very rare. Appropriate diagnostic modalities are very helpful for the diagnosis and preoperative planning. Gastrectomy with D2 lymphadenectomy in patients with SIT can be performed successfully with sufficient preoperative evaluation, comprehensive knowledge of anatomy, and meticulous surgical manipulation. Caution should be given to the possibility of coexisting cardiopulmonary malformations and synchronous cancers. Hippokratia 2015; 19 (4): 360-362.