Is preservation of the remnant stomach safe during distal pancreatectomy in patients who have undergone distal gastrectomy? World J Surg. 2013;37:430-436. [PMID: 23188537 DOI: 10.1007/s00268-012-1860-1]

Fluorescence-guided pancreatic surgery: A scoping review

BACKGROUND

Although fluorescence guidance during various surgical procedures has been shown to be safe and have possible better clinical outcomes than without the guidance, the use of fluorophores in pancreatic surgery is novel and not yet well described. This scoping review involved a systematic methodology of the currently available literature and aimed to illuminate the use of fluorophores in pancreatic surgery from a clinical view.

METHODS

The PRISMA and the PRISMA-ScR guidelines were used when appropriate and the following databases were searched: PubMed, Embase, Scopus, The Cochrane Collection, and Web of Science. Human original articles and case reports were included. Bias was assessed with the Newcastle-Ottawa Scale and the IDEAL framework was used for evaluation of surgical innovation.

RESULTS

A total of 5,565 search hits were screened, and 23 original articles and 24 case reports consisting of 754 patients met the inclusion criteria. The use of indocyanine green was both the most prominent and the most promising method for securing sufficient perfusion of neighboring organs, enhancing the detection and distinguishing of neuroendocrine tumors, and assisting in the identification of hepatic micrometastases.

CONCLUSION

The included studies were generally heterogenic, exploratory, and small. Indocyanine green was used in several ways, and it may add clinical value in different settings during pancreatic surgery. Tumor-targeted probes are a rapidly developing and promising field of research.

Pylorus-preserving pancreatoduodenectomy preserving blood supply for pancreatic cancer with a history of proximal gastrectomy and sigmoidectomy: a case report

BACKGROUND

Blood supply to the remnant stomach should be preserved during pancreatectomy in patients with a history of gastrectomy. Moreover, ischemic complications should be considered when performing pancreatoduodenectomy in patients with celiac axis and superior mesenteric artery (SMA) stenosis. However, whether these surgical procedures can be safely performed remains unclear.

CASE PRESENTATION

A 75-year-old man had a history of laparoscopic proximal gastrectomy (PG) with double-flap technique for gastric cancer and laparoscopic sigmoidectomy for sigmoid cancer treated 4 years ago. Follow-up computed tomography (CT) revealed an irregular nodular tumor measuring 13 mm in the pancreatic head. The patient was diagnosed with resectable pancreatic head cancer without lymph node metastasis (cT1cN0M0, cStageIA) according to the Union for International Cancer Control, 8th edition. As a standard pancreatic cancer treatment, two courses of preoperative chemotherapy with gemcitabine plus S-1 were administered. CT after preoperative chemotherapy identified no significant changes in tumor size but revealed SMA stenosis due to atherosclerosis. Blood flow to the left-sided colon was supplied from the middle colic artery via the SMA because of the past sigmoidectomy with inferior mesenteric artery detachment. Therefore, SMA stent placement was performed 1 day preoperatively. Subsequently, pylorus-preserving pancreatoduodenectomy (PPPD) was performed, preserving the remnant stomach with the right gastroepiploic (RGE) artery and vein. After resection, indocyanine green fluorescence imaging confirmed a good blood supply to the remnant stomach. The operation time was 467 min, and the blood lost was 442 mL. Histopathologically, the tumor was diagnosed as moderate adenocarcinoma and pT1cN0M0, Stage IA. The postoperative course was uneventful. The patient was discharged on postoperative day 23. S-1 as adjuvant chemotherapy was administered on postoperative day 63. The patient has been alive without recurrence for 7 months.

CONCLUSIONS

We performed PPPD preserving blood supply for pancreatic head cancer in a patient with benign SMA stenosis and a history of PG and sigmoidectomy. Blood supply was preserved through preoperative SMA stent placement and a surgical procedure preserving the RGE vessels. Furthermore, S-1 adjuvant chemotherapy was successfully initiated. These multimodal therapies contributed to a favorable clinical outcome.

Intraoperative severe gastric venous congestion during total pancreatectomy with replaced common hepatic artery: a case report

BACKGROUND

Gastric venous congestion (GVC) is one of the complications of total pancreatectomy (TP). Here, we report a case of intraoperative severe GVC during TP with a replaced common hepatic artery (RCHA).

CASE PRESENTATION

A 65-year-old female patient was diagnosed with intraductal papillary mucinous carcinoma. Her CHA branched from the superior mesenteric artery as RCHA. She underwent subtotal stomach preserving TP. The tumor was resected with splenic artery (SpA) and total gastric vein transections. Severe GVC and bleeding from the stomach tube occurred intraoperatively. A strong pulsation was observed in the left gastric artery (LGA), and we suspected an increased blood flow from the celiac artery (CeA) to the LGA after SpA resection. Total gastrectomy (TG) was then performed to control the severe GVC-related bleeding. The patient was discharged without complications 19 days postoperatively.

CONCLUSION

TP with RCHA may increase the risk of severe GVC due to increased blood flow from CeA to LGA.

Laparoscopic partial splenectomy in a patient with splenic hemangioma after distal gastrectomy for a neuroendocrine tumor

Herein, we report the case of a patient with splenic hemangioma after distal gastrectomy who was treated with laparoscopic partial splenectomy. A 64-year-old woman previously underwent laparoscopic distal gastrectomy with regional lymph-node dissection for a gastric neuroendocrine tumor (G3) with venous infiltration and no lymph-node metastases. Periodic follow-up abdominal computed tomography revealed a well-defined, heterogeneous mass in the lower pole of the spleen 5 years after the operation, which grew from 12 to 19 mm 1 year later. A laparoscopic partial splenectomy was planned. During surgery, a smooth-surfaced mass with a lighter color than that of the surrounding area was observed at the lower pole of the spleen. The inferior polar branch of the splenic artery was transected, and the ischemic area of the lower pole of the spleen, where the tumor was present, was confirmed. First, the line used to perform splenic transection was determined using soft coagulation. The splenic parenchyma was then gradually transected using a vessel-sealing device system, and partial splenectomy was possible with almost no bleeding. The patient was discharged on postoperative day 8 without any complications. Pathological examination revealed a hemangioma without any malignant findings. Laparoscopic partial splenectomy is a safe and useful procedure that can be performed, considering the tumor size and location.

Robotic Splenic Vessels Preserving Distal Pancreatectomy in a Post-Distal Gastrectomy Patient

BACKGROUND

The optimal procedure during distal pancreatectomy (DP) for patients who have undergone distal gastrectomy (DG) remains unclear. Several papers on remnant gastric ischemia have reported that the preserved splenic vessels are essential for the proximal remnant stomach.1-4 We evaluated the outcomes of DP for post-DG patients in our hospital and introduced robotic splenic vessels preserving DP (R-SPDP).

METHODS

Postoperative short-term outcomes of DP for post-DG patients during 2014 and 2021 were evaluated. Next, R-SPDP was performed for a post-DG patient with the intention of preserving the remnant stomach safely. The double bipolar method was used to dissect the adhesions around the splenic vessels.5,6 The splenic artery was clamped at the root side to prevent bleeding.7 All short gastric arteries and veins, which were the main feeders of the remnant stomach, were preserved and resection was completed. After resection, the indocyanine green (ICG) fluorescence angiography confirmed blood flow in the short gastric arteries and veins and good return blood flow to the splenic vein.8 RESULTS: Of four patients (50.0%, of 8 DP patients) in whom the remnant stomach was preserved, one conventional DP case had poor ICG perfusion and presented with remnant stomach ischemia postoperatively. The R-SPDP case with good ICG perfusion had a total operation time of 371 minutes and intraoperative blood loss of 10 mL. The oral diet was started on postoperative Day 3, and the postoperative course was uneventful.

CONCLUSIONS

R-SPDP can be a good option for post-DG patients to preserve the remnant stomach safely.

Simultaneous robotic distal gastrectomy and distal pancreatectomy: Avoiding total gastrectomy using indocyanine green fluorescence imaging

Remnant gastric ischemia is the most significant complication in distal pancreatectomy (DP) after distal gastrectomy (DG). Some studies have reported the safety of asynchronous DP in patients who underwent DG. We report a case of simultaneous robotic DG and DP. A 78-year-old man was diagnosed with gastric and pancreatic cancer. We preoperatively confirmed the absence of anomalies in the left inferior phrenic artery. Robotic simultaneous DG and DP was performed; subtotal resection of the stomach was carried out, enabling the left inferior phrenic artery to maintain perfusion of the remnant stomach, even after ligation of the splenic artery. The remnant stomach was preserved as scheduled, and indocyanine green fluorescence imaging confirmed sufficient remnant stomach tissue perfusion. Robotic surgery using the da Vinci surgical system (with a fluorescence imaging system and technology enabling surgical precision) is suitable for this surgical procedure because it considers tumor radicality and allows for function preservation.

Total pancreatectomy with remnant stomach preservation in a patient with a history of proximal gastrectomy and interposed jejunal reconstruction with right gastroepiploic conduit preservation: a case report

BACKGROUND

Pancreatic head resection following proximal gastrectomy jeopardizes the blood flow of the remnant stomach owing to right gastroepiploic conduit sacrifice, thereby necessitating total gastrectomy. However, owing to its high invasiveness, concomitant remnant total gastrectomy with pancreatectomy should be avoided as much as possible. Herein, we describe our experience of total pancreatectomy with right gastroepiploic conduit preservation in a patient with a history of proximal gastrectomy and reconstruction by jejunum interposition.

CASE PRESENTATION

A 78-year-old woman with a history of gastric cancer was followed up at our institute for multiple intraductal papillary mucinous neoplasm, and main pancreatic duct stricture in the pancreatic head was newly detected. The cystic lesion was extended to the pancreatic body. Proximal gastrectomy and reconstruction by jejunal interposition were previously performed, and the mesenteric stalk of the interposed jejunum was approached through the retrocolic route. We planned total pancreatectomy with right gastroepiploic conduit preservation. Following adhesiolysis, the interposed jejunum and its mesentery lying in front of the pancreas were isolated. The arterial arcade from the common hepatic artery to the right gastroepiploic artery was detached from the pancreas. Furthermore, the right gastroepiploic vein was isolated from the pancreas. The pancreatic body and tail were pulled up in front of the remnant stomach, and the splenic artery and vein were resected. The pancreatic body and tail were pulled out to the right side, and the pancreatic head was divided from the pancreatic nerve plexus to the portal vein. The jejunal limb for entero-biliary anastomosis was passed through the hole behind the superior mesenteric artery and vein, and gastrointestinal anastomosis using the antecolic route and Braun anastomosis were performed.

CONCLUSIONS

To avoid remnant total gastrectomy, right gastroepiploic conduit preservation is an optional procedure for pancreatic head resection in patients who have undergone proximal gastrectomy with reconstruction by jejunal interposition.

Safety of performing distal pancreatosplenectomy in patients who underwent distal gastrectomy previously: a multicenter cohort analysis with systematic literature review

Purpose

In patients who have previously undergone subtotal gastrectomy (STG), the remnant stomach is supplied with arterial blood through the splenic artery. It is currently unclear whether the remnant stomach can be safely preserved when performing distal pancreatosplenectomy (DPS) in these patients. Thus, this study aimed to evaluate the safety and feasibility of performing DPS in patients who had undergone a previous STG.

Methods

A multicenter cohort study was performed to identify patients who underwent DPS. Electronic medical data of Clinical Data Warehouse from 7 representative high-volume centers in 5 cities were retrospectively reviewed. A propensity score-matched analysis was performed to match patients who had no history of upper abdominal surgery with patients who had undergone a previous STG.

Results

Fourteen DPS patients who had a history of STG (STG group) were studied and matched to 70 patients who underwent DPS without any history of upper abdominal surgery (non-STG group). All patients in the STG group had the remnant stomach preserved. In most patients, the blood vessel supplying blood to the remnant stomach was the left inferior phrenic artery. There was no significant difference in the incidence of stomach-related complications or length of hospital stay between the 2 groups.

Conclusion

Our study results suggest that the remnant stomach could be safely preserved when performing DPS in patients with a prior STG. However, it is necessary to carefully evaluate the vascular structure of the remnant stomach through preoperative imaging study and closely observe changes to the blue stomach during the operation.

Pancreatoduodenectomy in a patient with celiac axis stenosis and a replaced common hepatic artery: A case report

INTRODUCTION

Evaluation of anatomical variations is important in pancreatoduodenectomy (PD) because an arterial anomaly is a risk factor for morbidity. Herein, we report a rare case of PD for lower bile duct cancer in which celiac axis stenosis and a replaced common hepatic artery (rCHA) coexisted.

PRESENTATION OF CASE

An 84-year-old woman presented with epigastric pain. She was diagnosed with a lower bile duct cancer and underwent PD. Preoperative computed tomography showed celiac axis stenosis, and the deformed celiac artery had a "hooked appearance," suggesting compression by the median arcuate ligament (MAL). The rCHA branched from the superior mesenteric artery. The gastroduodenal artery (GDA) diverged from the rCHA, forming a developed arterial arcade of the pancreatic head. There was an oncological safety margin between the rCHA and common bile duct; however, a part of the collateral artery was close to the common bile duct. Therefore, we planned to preserve the rCHA and resect the GDA to form collateral circulation. The MAL was divided and we evaluated the blood flow of the left upper abdominal organs using indocyanine green fluorescence imaging with a near-infrared camera system. We considered that perfusion of organs was preserved, and PD was performed without vessel reconstruction. No ischemic complication occurred in the postoperative course.

DISCUSSION

The coexistence of these arterial anomalies made the procedure of PD more complicated.

CONCLUSION

Precise preoperative diagnosis of arterial anomalies is necessary to avoid postoperative complications that may be induced by intraoperative arterial injury and organ ischemia.

Evaluating gastric remnant ischemia by indocyanine green fluorescence-guided surgery after distal gastrectomy in a patient with prior Nissen fundoplication: A case report

Introduction

Recent studies showed that intraoperative indocyanine green (ICG) fluorescence imaging-guided surgery helped evaluate organ perfusion. Whereas whether the gastric remnant can be preserved after distal gastrectomy for the cases of post-Nissen fundoplication remains unclarified. This case report demonstrated the applicability of intraoperative ICG fluorescence-guided surgery to assess the gastric remnant's blood supply after distal gastrectomy.

Case presentation

A 68-year-old man who previously underwent Nissen fundoplication for esophageal hiatal hernia was diagnosed with early gastric cancer in the lower body of the stomach. We performed laparoscopic distal gastrectomy to preserve the left gastroepiploic vessels considering the dissection of a part of the short gastric vessel from the previous Nissen fundoplication. After completing Billroth I reconstruction, the color of the serosal surface did not show any signs of ischemia. However, intraoperative esophagogastroduodenoscopy showed an ischemic change of the remnant stomach. In addition, ICG fluorography revealed insufficient blood supply to the gastric remnant compared with that to the pancreas and liver. Consequently, we converted to total gastrectomy to avoid necrosis in the gastric remnant.

Conclusion

We performed intraoperative ICG fluorescence-guided surgery in patients with early gastric cancer after Nissen fundoplication. ICG fluorescence may be useful in preventing postoperative gastric remnant ischemia, especially in high-risk patients.

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Intraoperative indocyanine green (ICG) fluorescence-guided surgery provides appreciable visualization of organ perfusion.

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The usefulness of ICG fluorescence-guided surgery in gastric cancer remains less explored.

•

This case report demonstrated the applicability of intraoperative ICG fluorescence-guided surgery to assess the gastric remnant’s blood supply after distal gastrectomy after Nissen fundoplication.

Indocyanine green (ICG) fluorography and digital subtraction angiography (DSA) of vessels supplying the remnant stomach that were performed during distal pancreatectomy in a patient with a history of distal gastrectomy: a case report

A 68-year-old man who had undergone distal gastrectomy for gastric cancer 3 years previously, presented to our hospital for examination of dilatation of the main pancreatic duct on follow-up computed tomography and magnetic resonance cholangiopancreatography. After examination, he was diagnosed with early-stage pancreatic cancer and distal pancreatectomy (DP) was planned. With informed consent, we performed indocyanine green (ICG) fluorography during DP and digital subtraction angiography (DSA) of vessels supplying the remnant stomach immediately before and after DP. On ICG fluorography, the remnant stomach gradually became fluoresced starting at the area of the lesser curvature, and the fluorescence eventually intensified over the entire area of the remnant stomach to the same brightness as that of the liver and duodenum. On DSA following DP, the terminal branches of the left inferior phrenic artery (LIPA) were distributed to more than half of the area of the remnant stomach, centering around the proximal area. It is useful to confirm blood flows to the remnant stomach by ICG fluorography using a near-infrared imaging camera during DP. We found that the LIPA played an important role in maintaining the blood supply to the remnant stomach in the absence of the left gastric artery and splenic artery.

Indocyanine green fluorescence imaging ensures perfusion of the remnant stomach during laparoscopic splenectomy in a patient after distal gastrectomy: A case report

Background

After distal gastrectomy, ischemic necrosis of the remnant stomach is a rare but serious complication. For distal pancreatectomy or splenectomy, ensuring adequate blood supply to the remnant stomach is important for patients with a history of distal gastrectomy. We report a case of successful splenectomy with indocyanine green (ICG) used to evaluate the blood supply to the remnant stomach in a patient after distal gastrectomy.

Case presentation

A 65-year-old woman who underwent distal gastrectomy for gastric cancer a year earlier had a splenic tumor that was increasing in size. We planned laparoscopic splenectomy because there was a possibility of a malignant splenic tumor. Intraoperative ICG fluorescence imaging confirmed perfusion of the remnant stomach. The patient was discharged on postoperative day 8 after an uncomplicated postoperative course.

Conclusion

ICG fluorescence imaging is useful for evaluating blood flow to the remnant stomach during laparoscopic splenectomy in patients after distal gastrectomy.

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Ischemic necrosis of the remnant stomach is a serious complication for patients with a history of distal gastrectomy.

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During laparoscopic surgery, the method for evaluating the blood supply to remnant stomach has not been established.

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ICG fluorescence imaging is only way to visually evaluate the blood supply to organs during surgery.

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Using ICG fluorescence imaging during laparoscopic splenectomy, ischemic necrosis of the remnant stomach can be prevented.

The efficacy of intraoperative indocyanine green fluorescence angiography in gastric cancer operation after living donor liver transplantation: A case report

INTRODUCTION

The incidence of de novo malignancies after organ transplantation is increasing. We herein report a patient who developed gastric cancer after living donor liver transplantation (LDLT) and splenectomy. Intraoperative indocyanine green (ICG) fluorescence angiography immediately after gastrectomy was useful for evaluating the blood supply into the remnant stomach in this patient.

PRESENTATION OF CASE

A 69-year-old woman underwent LDLT and splenectomy for end-stage liver disease. Gastric cancer was found by an endoscopic examination eight years after LDLT. Although total gastrectomy was considered due to previous splenectomy, we decided to intraoperatively evaluate the flow of the remnant stomach using ICG fluorescence. After ligation of the left gastric artery and transection of the stomach with a sufficient proximal margin from the tumor, intraoperative ICG fluorescence angiography showed abundant intramural blood flow of the remnant stomach. We were able to preserve the proximal stomach with confidence and she recovered smoothly after the operation without any signs of acute rejection.

CONCLUSION

Intraoperative ICG fluorescence angiography may be helpful for evaluating the blood flow in the remnant stomach during surgery for de novo gastric cancer after LDLT.

Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report

Background

The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube.

Case presentation

A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient’s candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88.

Conclusions

Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.

Splenic sarcoid reaction mimicking metachronous metastasis in patients after distal gastrectomy for gastric cancer: a case report and literature review

Background

The occurrence of sarcoid reactions has been recognized in various cancers. The common location for observing these granulomas is mainly the lymph nodes, but a rare occurrence in the spleen has been reported.

Almost all splenic sarcoid reactions associated with gastric cancer have been resected synchronously and diagnosed accidentally, and a rare metachronous occurrence of a sarcoid reaction in the spleen after distal gastrectomy can mimic cancer metastasis. We describe a rare case of a splenic sarcoid reaction recognized in a patient with gastric cancer 6 months after distal gastrectomy.

Case presentation

An 82-year-old man underwent laparoscopic distal gastrectomy for gastric cancer (T3N0M0, stage IIA). Six months after gastrectomy, CT and 18F-fluorodeoxyglucose (FDG)-PET/CT showed the appearance of a splenic mass. We diagnosed solitary splenic metastasis from gastric cancer and performed laparoscopic-assisted splenectomy. His splenic tumor was diagnosed as a sarcoid reaction by histopathological examination.

Conclusion

To our knowledge, this is the first report of a splenic sarcoid reaction recognized 6 months after distal gastrectomy for gastric cancer without any chemotherapy. The splenic sarcoid reaction and cancer metastasis to the spleen were undistinguishable from the CT and FDG-PET/CT findings. The present case and literature review showed that cases of splenic sarcoid reactions associated with gastric cancer can also be accompanied by the occurrence of these granulomas in lymph nodes. When the appearance of a solitary mass is observed in the spleen after resection of primary cancer, it is necessary to consider not only cancer metastasis but also sarcoid reactions. Retrospective histopathological confirmation of the existence of sarcoid reactions in lymph nodes from resected specimens might possibly avoid incorrect diagnosis and intervention.

Feasibility of preserving the remnant stomach during distal pancreatectomy after distal gastrectomy

PURPOSE

The safety and feasibility of preserving the remnant stomach during distal pancreatectomy (DP) in patients who have undergone distal gastrectomy (DG) remains unclear.

METHODS

A retrospective review of a prospectively maintained database was performed to identify patients who underwent DP. A propensity score-matched analysis was performed to match post-DG patients with control patients.

RESULTS

Among the 226 patients included in this study, 9 DP patients who had a history of DG were studied (4.0%). These nine patients in the DG group were matched to 45 patients in the control group. There were no significant differences in the incidence of postoperative morbidities, including postoperative pancreatic fistula rate or stomach-related complications. The hemoglobin A1C (HbA1c) levels in the DG group after surgery decreased to the normal range.

CONCLUSION

Our study suggested that the remnant stomach may be safely preserved when performing DP in patients with a history of DG with respect to short-term morbidities. However, there are some concerns about the long-term nutritional status in patients with a history of DG.

Pylorus-preserving pancreatoduodenectomy preserving the right gastroepiploic vessels following proximal gastrectomy: report of two cases

BACKGROUND

Blood flow of the remnant stomach is supplied via the right gastric and right gastroepiploic vessels after proximal gastrectomy (PG). Whether the remnant stomach can be safely preserved in patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) after PG remains unclear. We herein report two cases in which the remnant stomach was safely preserved by performing PPPD.

CASE PRESENTATION

The first patient, a 76-year-old man, was diagnosed with cancer of the common bile duct and underwent PPPD 2 years after PG for gastric cancer. The remnant stomach and right gastroepiploic vessels were safely preserved. The second patient, a 56-year-old man with a history of PG for gastric cancer 20 years previously, was diagnosed with cancer of the common bile duct and underwent PPPD. We could safely preserve the remnant stomach and right gastroepiploic vessels.

CONCLUSION

The remnant stomach could be preserved in performing PPPD following PG by preserving the right gastroepiploic vessels.

Less Invasive Surgery for Remnant Stomach Cancer After Esophago-proximal Gastrectomy with ICG-guided Blood Flow Evaluation: A Case Report

The standard procedure for remnant gastric cancer after esophago-proximal gastrectomy is total resection of the remnant stomach considering blood supply. However, sometimes surgery may be too invasive due to severe adhesion in the thoracic and mediastinal cavity. The blood supply to the remnant stomach depends on the right gastroepiploic artery and the right gastric artery. Therefore, preservation of the proximal region of the remnant stomach is thought to be anatomically impossible. We report a case of remnant gastric cancer that developed more than 12 years after lower thoracic esophagectomy plus proximal gastrectomy for Siewert Type I squamous cell carcinoma. We used intra-operative indocyanine green (ICG) venous-injection to evaluate blood flow and distal gastrectomy of the remnant stomach was performed by preserving the proximal stomach in the thoracic cavity through an abdominal approach. There were no complications of the remnant stomach or the anastomosis to the jejunum after surgery. In this case, we focused on the blood supply by collateral circulation through the anastomotic line from the remnant esophagus. After confirming blood supply with intra-operative evaluation using ICG fluorescence, less-invasive distal gastrectomy was successfully performed. As the intra-operative ICG-based evaluation for blood supply is a simple and safe method, it might be useful for determining the resection margin of various organs and be effective for the introduction of less invasive surgery. Here, we report a case and a review of the literature.

Usefulness of indocyanine green fluorescence imaging: A case of laparoscopic distal gastrectomy after distal pancreatectomy with splenectomy

Safe preservation of the remnant stomach during distal gastrectomy in patients who have undergone distal pancreatectomy is important. During distal pancreatectomy, the splenic artery that supplies arterial blood to the cardiac part of stomach is resected. Previous reports suggested that blood flow to the remnant stomach may be insufficient when supplied by only the left inferior phrenic artery. In the present case, a 79-year-old woman who underwent distal pancreatectomy with splenectomy 20 years before she was diagnosed with gastric cancer and referred to our hospital. We performed laparoscopic distal gastrectomy and Roux-en-Y reconstruction because preoperative CT scan indicated a developed left inferior phrenic artery. To evaluate the blood supply, we employed indocyanine green fluorescence and were able to safely preserve the remnant stomach. Our experience suggests that indocyanine green fluorescence is potentially useful for evaluating blood flow to the remnant stomach.

Intraoperative assessment of tissue oxygen saturation of the remnant stomach by near-infrared spectroscopy in two cases of pancreatectomy following gastrectomy

INTRODUCTION

Objective and quantitative intraoperative methods of bowel viability assessment could decrease the risk of postoperative ischemic complications in gastrointestinal surgery. Because the remnant stomach and the pancreas share an arterial blood supply, it is often unclear whether the remnant stomach can be safely preserved when performing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) post gastrectomy. We herein report two cases in which the remnant stomach was safely preserved using near-infrared spectroscopy to assess the regional saturation of oxygen (rSO2) in the remnant stomach during operation.

PRESENTATION OF CASE

The first patient, a 68-year-old man, was diagnosed with cancer of the pancreatic head and underwent PD a year after proximal gastrectomy for gastric cancer. The remnant stomach was safely preserved by evaluation of the rSO2 before and after reconstruction of the arteries. The second patient, an 82-year-old woman with a history of distal gastrectomy for gastric cancer 40 years previously, was diagnosed with a main duct intraductal papillary mucinous neoplasm of the pancreatic body, requiring DP. As in the previous case, we could safely preserve the remnant stomach through assessing the intraoperative rSO2 of the remnant stomach.

DISCUSSION

Through comparing changes in the rSO2 during surgery, near-infrared spectroscopy provides objective and quantitative assessments of intestinal viability to predict ischemic complications.

CONCLUSION

This method may be a viable option to evaluate the blood supply to the alimentary tract.

Risk factors for radical reoperation in patients with remnant gastric cancer

AIM: To identify the risk factors for radical reoperation in patients with remnant gastric cancer.

METHODS: A retrospective analysis was performed of clinical data for 60 patients with recurrent gastric stump cancer who underwent a second surgery from January 2009 to January 2015 at Ningxia Guyuan Hospital. Risk factors for radical reoperation were identified.

RESULTS: Of 60 patients, 26 (43.33%) were treated by radical surgery, 16 (26.67%) were treated by palliative surgery, 15 (25.00%) by gastric bypass surgery and jejunostomy, and 3 (5.00%) did not underwent surgery. Univariate analysis showed that age, gastrointestinal reconstruction, TNM stage at initial surgery, N stage at initial surgery, lymph node dissection, symptomatic recurrence, interval between recurrence and the second surgery, time to recurrence, adjuvant chemotherapy, Helicobacter pylori (H. pylori) infection, low stomach acid, and histology were significantly associated with a second radical surgery (P < 0.05). Multivariate Logistic regression analysis showed that age > 60 years, N stage at initial surgery, TNM stage at initial surgery, symptomatic relapse, H. pylori infection, histological type and low stomach acid were independent risk factors for a second radical surgery (P < 0.05).

CONCLUSION: Age > 60 years, TMN stage III at initial surgery, N0 stage at initial surgery, symptomatic relapse, H. pylori infection, low acid and histological type are independent risk factors for a second radical surgery in patients with remnant gastric cancer.

Preservation of the left gastric artery on the basis of anatomical features in patients undergoing distal pancreatectomy with celiac axis en-bloc resection (DP-CAR)

BACKGROUND

The incidence of delayed gastric emptying (DGE) is high in patients undergoing distal pancreatectomy with celiac axis en-bloc resection (DP-CAR).

METHODS

The medical records of 37 consecutive patients who underwent DP-CAR were evaluated for the incidence of DGE in 23 patients (62 %) with left gastric artery (LGA)-resecting DP-CAR (conventional DP-CAR) compared with 14 patients (38 %) who underwent distal pancreatectomy with resection of the common hepatic artery and splenic artery, with preservation of the LGA (modified DP-CAR) for pancreatic carcinoma. The patients with tumors situated more than 10 mm away from the antecedent branching LGA underwent modified DP-CAR.

RESULTS

Antecedent branching of the LGA was found in 19 patients (51 %) in this series. In the conventional DP-CAR group, the LGA was involved in 20 patients (87.0 %). The International Study Group of Pancreatic Surgery (ISGPS) grades for the conventional DP-CAR group were as follows: no DGE = 43 %, grade A = 26 %, B = 13 %, and C = 17 %. In the modified DP-CAR group, they were as follows: no DGE = 93 %, grade A = 7 %, and grade B/C = 0 %. The R0 rate was higher in the modified DP-CAR group (79 %) than in the conventional DP-CAR group (43 %) (p = 0.048). Univariate analyses revealed resection of LGA, residual tumor status (R1), and clinically relevant (Grade B, C) pancreatic fistula increased the risk of DGE. On multivariate analysis, resection of the LGA was an independent risk factor for increased incidence of DGE.

CONCLUSION

Modified DP-CAR, when it is feasible, significantly reduces the incidence of DGE in comparison with conventional DP-CAR.

Visualization of Lymph/Blood Flow in Laparoscopic Colorectal Cancer Surgery by ICG Fluorescence Imaging (Lap-IGFI)

PURPOSE

In laparoscopic colorectal cancer (Lap-CRC) surgery, determination of a suitable mesentery division line and the appropriate degree of lymphadenectomy by tracing the blood supply is critical. We performed visualization of the lymph and blood flow by laparoscopic indocyanine green (ICG) fluorescence imaging (Lap-IGFI).

METHODS

ICG is injected into the submucosa near the tumor via colonoscopy, and the lymph flow is observed. Intestinal blood flow is evaluated by administering ICG intravenously.

RESULTS

For lymph flow, visualization of the main lymph node basin helped to determine the surgical division line for cases in which the blood flow was not completely visualized. Lap-IGFI changed the surgical plan of the lymphadenectomy in 23.5 %. In our experience, the metastatic rate of ICG-positive nodes was 10.0 %, and the metastatic rate of ICG-negative nodes was 5.3 %. Furthermore, there were no metastatic nodes that were ICG negative more than 5 cm from the tumor. For blood flow, the blood flow distribution of the intestinal wall from the last branch of the vasa recta of the anastomotic site was clearly visualized and proved useful in choosing the extent of intestinal resection. Lap-IGFI changed the surgical plan of the extensive intestinal resection in 16.7 %.

CONCLUSIONS

Lap-IGFI can noninvasively provide detailed lymph and blood flow information and is a useful device to aid in the accurate identification of individual patients' lymph drainage. This helps dictate adequate lymphadenectomy and the extent of intestinal resection in Lap-CRC surgery.