Approximately 4% of patients with esophageal cancer develop a second primary malignancy in the upper gastrointestinal trunk. However, hepatectomy following esophagectomy for esophageal cancer has rarely been reported. We report the case of a 70-year-old man who underwent an esophagectomy for esophageal cancer with retrosternal gastric tube reconstruction. Nine years later, he developed hepatocellular carcinoma with tumor thrombus involving the left portal vein, and was successfully treated with left hemihepatectomy. Special attention should be paid to avoiding incidental injury of the gastric tube as well as the right gastroepiploic artery during the hepatectomy

Fujiwara, Toshiyoshi

Kuise, Takashi

Maeda, Naoaki

Nagai, Yasuo

Noma, Kazuhiro

Takagi, Kosei

Tanabe, Shunsuke

Umeda, Yuzo

Yagi, Takahito

Yoshida, Kazuhiro

Yoshida, Ryuichi

English

Okayama University Scientific Achievement Repository

A lthough the prognosis following esophagectomy for esophageal cancer has improved due to recent advances in multidisciplinary treatment and periopera-tive care [1],  it has been reported that approximately 4% of patients with esophageal cancer develop a second primary malignancy in the upper gastrointestinal trunk [2 , 3].  Surgical interventions including gastrectomy and pancreatoduodenectomy for second primary malignan-cies in the upper gastrointestinal trunk have been reported in patients following esophagectomy [3 , 4].  However,  to date few studies have reported on cases of esophageal cancer in which hepatectomy was per-formed following esophagectomy.  A gastric tube has often been used as an esophageal substitute in alimen-tary tract reconstruction in patients undergoing esophagectomy for esophageal cancer [4 , 5].  Therefore special attention to the gastric tube is necessary when abdominal surgery is performed following esophagec-tomy.  Herein,  we present the case of a patient who underwent left hemihepatectomy for hepatocellular carcinoma (HCC) nine years after esophagectomy with retrosternal gastric tube reconstruction for esophageal cancer.Case ReportA 70-year-old man underwent neoadjuvant chemo-radiotherapy and esophagectomy for esophageal cancer with retrosternal gastric tube reconstruction at our institute.  The details of the surgical procedure were described previously [6].  Nine years later,  at his annual follow-up,  positron emission tomography/computed tomography (PET/CT) revealed a large liver tumor with Acta Med.  Okayama,  2021Vol.  75,  No.  6,  pp.  755-758CopyrightⒸ 2021 by Okayama University Medical School.http ://escholarship.lib.okayama-u.ac.jp/amo/Case ReportLeft Hemihepatectomy for Hepatocellular Carcinoma Following Esophagectomy with Retrosternal Gastric Tube Reconstruction  for Esophageal CancerKosei Takagi＊,  Takashi Kuise,  Yuzo Umeda,  Ryuichi Yoshida,   Kazuhiro Yoshida,  Yasuo Nagai,  Kazuhiro Noma,  Shunsuke Tanabe,   Naoaki Maeda,  Takahito Yagi,  and Toshiyoshi FujiwaraDepartment of Gastroenterological Surgery,  Okayama University Graduate School of Medicine,   Dentistry and Pharmaceutical Sciences,  Okayama 700-8558,  JapanApproximately 4% of patients with esophageal cancer develop a second primary malignancy in the upper gas-trointestinal trunk.  However,  hepatectomy following esophagectomy for esophageal cancer has rarely been reported.  We report the case of a 70-year-old man who underwent an esophagectomy for esophageal cancer with retrosternal gastric tube reconstruction.  Nine years later,  he developed hepatocellular carcinoma with tumor thrombus involving the left portal vein,  and was successfully treated with left hemihepatectomy.  Special attention should be paid to avoiding incidental injury of the gastric tube as well as the right gastroepiploic artery during the hepatectomy.Key words:  liver resection,  esophagectomy,  retrosternal gastric tube reconstructionReceived March 7, 2021 ; accepted June 30, 2021.＊Corresponding author. Phone : +81-86-223-7151; Fax : +81-86-221-8775E-mail : kotakagi15@gmail.com (K. Takagi)Conflict of Interest Disclosures: No potential conflict of interest relevant to this article was reported.no symptoms.  Abdominal CT images revealed a 9 cm tumor at the left lateral segment.  The tumor com-pressed the umbilical portion,  as the tumor thrombus protruded into the left portal vein,  and also com-pressed the middle hepatic vein.  The enhancement pattern on the CT image showed early arterial enhance-ment with rapid washout,  suggesting the presence of HCC rather than liver cancer that had metastasized from esophageal cancer.  Therefore,  we diagnosed the tumor as HCC accompanied by a portal vein tumor thrombus,  and not as an extrahepatic metastasis.  The CT also confirmed the gastric tube running through the retrosternal pathway as well as the right gastroepiploic artery.  The CT images are shown in Fig. 1.The laboratory values were as follows: total bilirubin,  0.99 mg/dL; alanine transaminase,  20 IU/L; albumin,  4.2 g/dL; and prothrombin time,  104%.  The tumor markers were elevated: alpha-fetoprotein,  27,462 ng/mL;  prothrombin induced by vitamin K absence or antago-nist-II,  4,699 mAU/mL.  The serological markers for hepatitis B virus (HBV) showed a hepatitis B virus sur-face antigen (HBsAg) seroconversion pattern: HBsAg negative,  hepatitis B e antigen negative,  antihepatitis B e antibody positive (77%),  antibodies to hepatitis B core antigen positive (17.6 s/co),  antihepatitis B surface antigen antibody positive (344 mIU/mL),  and unde-tectable HBV-DNA.  Hepatitis C virus antibody was negative.  The patient had undergone no treatment for HBV infection,  and his family history of HBV infection was unknown.  In addition,  the patient had a history of alcohol abuse prior to undergoing esophagectomy for esophageal cancer.  With respect to the liver functional reserve,  the indocyanine green retention rate at 15 min was 15.8%,  and the Child-Pugh classification was grade A (score 5).  The technetium-99 m-galactosyl human serum albumin showed the following results: the clearance index (HH15) was 0.518,  and the receptor index (LHL5) was 0.867.  Accordingly,  a left hemihepatectomy was scheduled.  Following the dissection of the adhesions around the liver,  the gastric tube was encircled (Fig. 2A).  The left lobe of the liver was stuck under the gastric tube,  and thus we were unable to mobilize the left lobe and per-form the extrahepatic Glissonean approach.  Therefore,  the liver parenchyma was initially dissected along Rex-Cantlie’s line using a Cavitron Ultrasonic Surgical Aspirator and vessel sealing system (LigaSure).  Subsequently,  the left hepatic artery and the left portal vein were identified and transected,  and the left hepatic duct was then divided.  Finally,  the middle hepatic vein and left hepatic vein were transected to achieve com-plete dissection of the liver parenchyma.  During sur-gery,  it was necessary to pay additional attention to the gastric tube as well as the right gastroepiploic artery in order to prevent incidental injury (Fig. 2B).  The total operative time was 239 minutes,  and the estimated blood loss was 350 mL.The patient was discharged on postoperative day eight with an uneventful course.  The pathological find-ings confirmed moderately differentiated HCC with microvascular invasions into the secondary branch of the portal vein (vp2) and peripheral hepatic vein (vv1).DiscussionTo the best of our knowledge,  this report is the first to highlight the technical aspects of hepatectomy fol-lowing esophagectomy with retrosternal gastric tube reconstruction.  We found that hepatectomy following esophagectomy was feasible.  Furthermore,  special attention should be paid to avoid incidental injury of the gastric tube as well as the right gastroepiploic artery during hepatectomy following esophagectomy with gas-tric tube reconstruction.  The treatment strategy for complicated cases with HCC should be determined depending on availability and experience of facilities.  According to the clinical practice guidelines,  hepatectomy,  embolization,  hepatic arterial infusion chemotherapy,  and molecu-lar-targeted therapy are recommended for patients with HCC accompanied by vascular invasion without extra-hepatic metastasis [7].  However,  hepatectomy has been shown to have a survival benefit for patients with HCC with portal vein invasion [8].  Therefore,  surgical inter-vention was performed in this patient.  Although hepa-to-biliary-pancreatic surgery following prior abdominal surgery has been shown to be feasible,  several concerns regarding this course of treatment should be noted,  including the higher risks of intraoperative organ injury and postoperative complications,  as well as the pro-longed operative time and greater blood loss [9].In esophagectomy followed by alimentary tract reconstruction using a gastric tube,  reconstruction can be achieved by either the retrosternal route or the pre-vertebral route through the mediastinum [5].  Although there is an ongoing discussion as to which approach has 756 Takagi et al. Acta Med.  Okayama　Vol.  75,  No.  6December 2021 Hepatectomy after Esophagectomy 757A BC DFig. 1　 Contrast-enhanced computed tomography images.  (A),  The well-enhanced tumor in the arterial phase.  The gastric tube running through the retrosternal pathway and the right gastroepiploic artery (RGEA) are confirmed; (B),  The enhancement pattern of the portal phase revealing the tumor thrombus protruding into the left portal vein; (C),  The enhancement pattern of the venous phase showing rapid washout.  The middle hepatic vein is compressed by the tumor; (D),  The relationship between the tumor and the RGEA based on three-dimensional imaging.BAGastric tube Gastric tubeHepatoduodenalligamentTumorRGEAFig. 2　 Intraoperative findings.  (A),  The gastric tube and the right gastroepiploic artery (RGEA) were carefully dissected and encircled after the dissection of adhesions around the liver; (B),  Following left hemihepatectomy,  the gastric tube and the RGEA were preserved without incidental injury.more advantages,  the prevertebral route might add less technical difficulty when performing hepatectomy fol-lowing esophagectomy.  In our case,  the retrosternal route using the gastric tube interfered with the surgical field due to adhesion between the liver and the gastric tube.  Furthermore,  the right gastroepiploic artery,  which runs along the gastric tube,  should be carefully dissected.  With respect to the etiology of the HCC in this case,  it is speculated that it developed due to previous alcohol abuse and/or HBV infection.  Chronic liver disease due to HBV and alcoholic liver disease are well known as major risk factors for HCC [10].  Although the patient consumed less alcohol after undergoing the esophagec-tomy,  his previous alcohol abuse might have been related to the development of HCC.  In contrast,  nine years ago the serological markers for HBV demon-strated an HBsAg seroconversion pattern,  which meant that this case developed HCC more than nine years after HBsAg seroclearance.  A recent study has reported that patients with HBsAg seroclearance had a signifi-cantly lower incidence of HCC than those who were HBsAg positive; however,  the pooled incidence of HCC after HBsAg seroclearance was 1. 88% [11].  Therefore,  a surveillance program for HCC should also be applied in patients who have shown HBsAg sero-clearance.  In conclusion,  we report the case of patient who underwent left hemihepatectomy for HCC following esophagectomy with retrosternal gastric tube recon-struction for esophageal cancer.  Special attention should be paid to avoid incidental injuries during the hepatectomy,  such as injuries to the gastric tube and the right gastroepiploic artery.  References 1. Moaven O and Wang TN: Combined Modality Therapy for Management of Esophageal Cancer: Current Approach Based on Experiences from East and West.  Surg Clin North Am (2019) 99: 479-499. 2. Zhu G,  Chen Y,  Zhu Z,  Lu L,  Bi X,  Deng Q,  Chen X,  Su H,  Liu Y,  Guo H,  Zheng T,  Yu H and Zhang Y: Risk of second primary can-cer after treatment for esophageal cancer: a pooled analysis of nine cancer registries.  Dis Esophagus (2012) 25: 505-511. 3. Honig SE,  Lundgren MP,  Kowalski TE,  Lavu H and Yeo CJ:  Advanced Endoscopic Rescue of a Complication (Duodenojejunostomy Leak) After a Pylorus-Preserving Pancreaticoduodenectomy in a Post-Esophagectomy Patient with Pancreatic Adenocarcinoma: A Case Report and Review of the Literature.  J Pancreat Cancer (2020) 6: 5-11. 4. 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Hepatol Res (2019) 49: 1109-1113. 8. Kokudo T,  Hasegawa K,  Matsuyama Y,  Takayama T,  Izumi N,  Kadoya M,  Kudo M,  Ku Y,  Sakamoto M,  Nakashima O,  Kaneko S and Kokudo N; Liver Cancer Study Group of Japan: Survival ben-efit of liver resection for hepatocellular carcinoma associated with portal vein invasion.  J Hepatol (2016) 65: 938-943. 9. Nanashima A,  Hiyoshi M,  Imamura N,  Yano K,  Hamada T,  Wada T,  Nishida T,  Tsuchiya K,  Kawano F,  Ikeda T and Takeno S: A cohort study on the risk of hepatectomy and pancreatectomy after history of abdominal surgery on other organs.  Ann Hepatobiliary Pancreat Surg (2018) 22: 344-349.10. Melnik BC: Dairy consumption and hepatocellular carcinoma risk.  Ann Transl Med (2021) 9: 736.11. Song A,  Wang X,  Lu J,  Jin Y,  Ma L,  Hu Z,  Zheng Y,  Shen C and Chen X: Durability of hepatitis B surface antigen seroclear-ance and subsequent risk for hepatocellular carcinoma: A meta-analysis.  J Viral Hepat (2021) 28: 601-612.758 Takagi et al. Acta Med.  Okayama　Vol.  75,  No.  6

Left Hemihepatectomy for Hepatocellular Carcinoma Following Esophagectomy with Retrosternal Gastric Tube Reconstruction for Esophageal Cancer

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Left Hemihepatectomy for Hepatocellular Carcinoma Following Esophagectomy with Retrosternal Gastric Tube Reconstruction for Esophageal Cancer

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