Distal partial gastrectomy for gastric tube cancer with intraoperative blood flow evaluation using indocyanine green fluorescence
An 80-year-old man developed gastric tube adenocarcinoma after radical esophagectomy for squamous cell carcinoma. He underwent video-assisted subtotal esophagectomy followed by reconstruction of the gastric tube through the retrosternal route and cervical anastomosis 7 years ago. Based on his age and co-morbidities, such as interstitial pneumonia, paroxysmal atrial fibrillation, aortic regurgitation and hypertension, he has been followed up by regular check-ups without adjuvant therapy.\nUpper gastrointestinal endoscopy at the seventh year of follow-up revealed a polypoid tumor of 3 cm in diameter at the pyloric region of the gastric tube with pyloric obstruction (). Endoscopic biopsy from the tumor revealed papillary adenocarcinoma (pap > tub1). Contrast-enhanced computed tomography (CT) demonstrated a solid mass with slight enhancement at the abdominal part of the gastric tube located below the lower border of the sternum (). Neither lymph node metastasis nor distant metastasis was detected, leading to a diagnosis of clinical stage IB (cT2N0M0) gastric cancer according to the seventh edition of the Union for International Cancer Control system.\nTGTR with sternotomy was considered a radical surgery; however, in consideration of surgical invasion and the patient’s physical condition, gastric vessel-preserving partial distal gastrectomy was conducted.\nUnder upper midline laparotomy, the abdominal part of the gastric tube was mobilized along with the RGEA and RGA after careful dissection. The first and second branches of the RGEA and RGA were divided along the gastric wall, carefully preserving the main vessels. Supra-duodenal arteries were also divided. Then, the anal side margin was set at 1 cm from the distal side of the pylorus, and the duodenum was divided using a linear stapler (). Before setting the proximal surgical margin, blood supply in the gastric tube was assessed by ICG fluorescence []. The visualized ICG fluorescence demonstrated an irregular demarcation line at the distal side of the preserved gastric tube, indicating insufficient blood supply at the greater and lesser curvature compared with the center of the gastric wall (). The gastric tube was thus divided at 2 cm on the oral side from the proximal margin of the tumor, confirming complete removal of the ischemic area. Then gastro-jejunostomy was performed for Roux-en-Y reconstruction ().\nThe surgery was uneventful. The operation time was 3 h 49 min, and the amount of blood loss was 60 g. The patient fully recovered and was discharged 16 days after surgery.\nThe resected specimens are shown in . Pathological examination of the surgical specimen demonstrated moderately differentiated adenocarcinoma (pT2), indicating R0 resection. The patient is healthy at 26 months after surgery without recurrence.