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SUBTOTAL GASTRECTOMY FOR GASTRIC ADENOCARCINOMA IN A PATIENT WITH POLYSPLENIA
Jacob R. Stover
*, Paige Deville, Omeed Moaven, Kevin Sullivan
Surgery, LSU Health New Orleans, New Orleans, LA
NTRODUCTION
Heterotaxies such as a polysplenia are extraordinarily rare conditions with significant impacts on patient anatomy that can affect surgical approaches for treatment malignancy. We present only the second documented patient with polysplenia to undergo a subtotal gastrectomy for gastric adenocarcinoma. The patient’s case of polysplenia was notable for multiple splenules, azygous continuation of the IVC, midline liver, and abnormal vascular supply to the stomach.
CASE REPORT
The patient is an 81 year old male with a history of hypertension, hyperlipidemia, atrial fibrillation, diabetes mellitus, open cholecystectomy, and polysplenia syndrome who was referred after a 20mm gastric ulcer in the gastric body was biopsied as part of a work-up for anemia and found to be a moderately to poorly differentiated adenocarcinoma. Staging was performed including cross sectional imaging, endoscopic ultrasound, and diagnostic laparoscopy with a final clinical stage of cT2N0M0. His imaging was notable for location of the stomach and multiple splenules in the right hemiabdomen. He had previously undergone cardiac echocardiogram without valvular defects. He completed neoadjuvant therapy consisting of 4 cycles of FOLFOX. Follow-up imaging demonstrated no evidence of progressive or distant disease, and we proceeded with open operation due to allow for maximum visualization and assessment of the patient’s aberrant anatomy.
After laparotomy and lysis of adhesions from the prior cholecystectomy, the antrum, pylorus, and duodenum were identified. The duodenum was found to be midline and intraperitoneal, and the stomach was divided just distal to the pylorus. Medially and to the left of the pylorus was the porta hepatis which was cleared of all fibrofatty and nodal tissue. The dissection of the lesser and greater curves was performed proximally until grossly normal proximal stomach was identified and it was divided 5 cm distal to the GEJ. The left gastric artery was identified and ligated, and the specimen passed off the field. Intra-operative EGD confirmed no concerning lesions within the remnant stomach. Roux-en-Y reconstruction was performed. His postoperative course was uncomplicated, and diet was advanced until he was tolerating a regular diet by day 6 and was discharged home. Final pathology showed pT1b pN0 (0/32 positive lymph nodes) gastric adenocarcinoma with negative margins. At 2 weeks post-op the patient was ambulatory, tolerating regular diet, and was cleared to resume chemotherapy at 4 weeks post-operatively.
CONCLUSION
Our patient’s case demonstrated many of the anatomical abnormalities that can be encountered when treating a patient with polysplenia and proves the feasibility of still safely performing curative resection including lymphadenectomy.
Representative cross-sectional imaging demonstrating patient's polysplenia and abnormal anatomy.
Intra-operative pictures demonstrating surgical specimen in situ and after resection. Patient's midline liver and several splenules are visible.
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