Laparoscopic right colectomy for colon cancer after liver transplantation.

The incidence of colorectal cancer (CRC) after liver transplantation is 0.5%-4%. Laparoscopic surgery is the standard-of-care treatment, however it is rarely performed in patients who had previously undergone liver transplantation. Few reports exist regarding minimally invasive surgery in such context and none about laparoscopic right colectomy. We present the case of a 64-year-old female with a history of liver transplantation in 2001 and who developed a right-sided CRC. A laparoscopic right colectomy was successfully performed, and the post-operative course was uneventful. Given the known benefits, we believe that laparoscopic approach should be considered in such patients.

INTRODUCTION

Solid organ transplant patients tend to be considered at high risk due to their immunosuppressive state, coexisting comorbidities and previous surgery. Laparoscopic approach in such patients is therefore debated, but for this very reason, they will most likely benefit from minimally invasive surgery. There are very few reports about laparoscopic colectomy on patients who had previously undergone liver transplantation (LT).[1234] We report the first case of a laparoscopic right colectomy for colorectal cancer (CRC) in a LT recipient.

CASE REPORT

A 64-year-old female underwent LT in 2001 for alcoholic and hepatitis C virus-induced cirrhosis through a Kocher incision with upper midline extension. The patient had a history of open appendectomy, thyroidectomy for toxic multinodular goitre, endoscopic excision of urothelial bladder carcinoma, moderate aortic and severe mitral valve insufficiency and chronic renal insufficiency. Because of the incidental finding of anaemia (19 years after the LT) treated with red blood cell transfusion, the patient underwent colonoscopy, revealing an ulcerative-vegetative, 4.5-cm diameter lesion of the ascending colon; the biopsy reported the diagnosis of well-differentiated adenocarcinoma. In consideration of the renal insufficiency, it was decided not to perform a contrast-enhanced computed tomography. A whole abdominal ultrasound and a high-resolution chest tomography excluded nodal involvement and metastases. Pre-operative blood tests showed normal liver function and haemoglobin level, while serum creatinine and glomerular filtration rate were, respectively, 3.17 mg/dl and 15 ml/min/1.73 m2. Surgery was scheduled. The patient was positioned supine with mild right up and anti-Trendelenburg tilt, when needed. Pneumoperitoneum was established at 12 mmHg through an open coelioscopy access in left-lower periumbilical position. The inspection of the abdominal cavity with a 30° laparoscope revealed the presence of diffuse post-operative adhesions within the right and upper quadrants. Trocar positioning as well as operators' position and management of trocars is reported in Figure 1; we found this arrangement very convenient to tackle the vascular pedicles. Adhesiolysis was performed using a laparoscopic bipolar dissector (Caiman® 5 mm by Aesculap AG, 78532 Tuttlingen, Germany); the toughest adhesions were at the hepatic flexure [Figure 2]. The tumour was previously endoscopically ink marked and well visible. The ileo-colic vessels were ligated with vascular clips and taken. Dissection proceeded with the mobilisation of the right mesocolon with a mediolateral approach till complete mobilisation of the terminal ileum, right colon including the hepatic flexure and the proximal transverse colon. A small right colic artery as well as the right branch of the middle colic artery was tackled with vascular clips and taken. The terminal ileum was divided with an endoscopic linear cutting stapler and so the proximal transverse colon. There was no need to change the camera position. The specimen was delivered through a 6-cm supra-umbilical median laparotomy, including the epigastric incision, after positioning of a wound protector device. The intestinal continuity was restored with a handsewn anastomosis. A closed-suction, flat (4 mm × 10 mm) silicone drain (Jackson–Pratt® Type) was placed in the pelvis through the hypogastric access. Blood loss was 100 ml, and no transfusions were required. The overall operative time was 260 min. No anaesthetic complications were reported during surgery and, after the procedure, the patient was transferred to the intensive care unit for 1 day. During the perioperative period, immunosuppressive and antiplatelet therapies were continued as well as accurate glycaemic control and hydroelectrolytic balance were kept in order to preserve renal, cardiac and liver functions. The drain was removed on the 2nd post-operative day. Bowel movements started on the 3rd post-operative day, and a full diet was given. She was discharged on the 6th post-operative day. No major deterioration of the renal function was observed. Histologic examination of the specimen revealed a Stage II disease with 19 negative lymph nodes: PTNM: PT3, N0, M0 (TNM VIII ed., 2017). The patient did not experience complications and is free of disease 4 months after surgery.

Figure 1

Scheme of operators, trocar positioning and mini-laparotomy (dashed tract: previous scars). The assistant managed camera (left hand) and epigastric trocar, the latter for retraction. The operator managed hypogastric trocar (left hand) for retraction and left flank trocar for dissection

Figure 2

Intraoperative picture. Tackling tight adhesions near the colonic hepatic flexure; rear on the right liver graft

DISCUSSION

Solid organ transplant recipients are at an increased risk of developing a broad spectrum of cancer, including gastrointestinal, compared to the general population.[56] CRC in patients who had previously undergone LT is not a rare event, with an incidence of 0.5%–4.1%.[56] Transplanted patients for primary sclerosing cholangitis with underlying ulcerative colitis have an increased risk for CRC.[57] Laparoscopic surgery in the management of CRC is widely accepted as the standard of care although previous abdominal surgery is considered a relative contraindication. Although several studies suggest that immunosuppressive treatment and post-operative paraphysiological ascites could reduce peritoneal adherence formation after LT,[18] we found diffused and tight perihepatic adhesions. To date, only four cases of laparoscopic colectomies in LT recipients have been reported: three total colectomies for chronic ulcerative colitis, one of which 'hand assisted',[123] and a left colectomy for CRC,[4] while there are no reports on right laparoscopic colectomy. No post-operative major complications were observed. Knowledge of patient's previous surgery is crucial, together with adequate laparoscopic skills, to carry out a successful surgical procedure and reach a good outcome. Despite the limited experience, laparoscopic colectomies after LT seem to be feasible, safe and of great potential benefit compared to the 'open' ones, thus, in appropriate setting, could be considered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.