Transjugular intrahepatic portosystemic shunt and endoscopic submucosal dissection for treatment of early gastric cancer in a cirrhotic patient.

morbidity and mortality in cirrhotic pa− tients undergoing gastric surgery. There− fore, these patients are often rejected for gastric surgery, and portal decompres− sion is essential prior to further invasive treatment [1 ± 2]. A 63−year−old patient was admitted to our institution with acute variceal bleed− ing due to Child−B cirrhosis. Variceal bleeding was controlled by endoscopic band ligation. During endoscopy an intes− tinal adenocarcinoma (cT1N0M0) was in− cidentally detected. The patient was re− jected for gastrectomy due to severe por− tal hypertension and subsequent high peri−operative risk. Because of its mini− mal invasiveness, transjugular intra− hepatic portosystemic shunt (TIPS) com− bined with endoscopic submucosal dis− section (ESD) seemed an appropriate treatment option (l" Fig. 1a ± e, l" Video 1). Histologically, R0 resection was achieved but submucosal infiltration was visible (l" Fig. 1 f). Biopsies 6 months after ESD showed no residual cancer. At follow−up 1 year later, the gastric cancer had reoccurred and was already meta− static. No hydropic decompensation, vari− ceal bleeding, or episode of hepatic ence− phalopathy had occurred in the mean− time. TIPS combined with ESD seemed safe and effective in this patient not eligible for gastric surgery [1 ± 5]. The treatment de− cision was based on the favorable results of ESD in early gastric cancer [3 ± 5]. TIPS implantation was performed to minimize the bleeding risk at ESD. Despite R0 resec− tion the gastric cancer reoccurred 1 year later. Thus, gastrectomy and radical lymph node dissection might have brought additional benefit [2]. For cura− tive endoscopic therapy, a maximum sub− mucosal infiltration of 500 m is recom− mended. Infiltration depth evaluated by endoscopic ultrasound (EUS) has unfor− tunately not shown a consistent high lev− el of accuracy [5]. Application of 30−MHz EUS probes, optical coherence tomog− raphy or confocal laser microscopy might be able to overcome these limitations [5]. Because of the rare coincidence of gastric cancer and Child−B cirrhosis, no estab− lished treatment guidelines exist, and specific treatment has to consider the perioperative risk on an individual pa− tient basis.