Intraoperative Indocyanine Green Imaging for Blood Flow Assessment in Very Small Remnant Stomach: A Case Report.

[BACKGROUND/AIM] In recent years, blood flow assessment using indocyanine green (ICG) fluorescence imaging has been widely used in gastrointestinal surgeries. Several studies have reported the superiority of distal gastrectomy with preservation of a very small remnant stomach (subtotal gastrectomy; STG) over total gastrectomy (TG), which has become an increasingly interesting topic. However, in such cases, inadequate blood supply to the remnant stomach can become a critical issue. Herein, we report a case of laparoscopic STG for gastric cancer in which intraoperative evaluation of blood flow using ICG led to conversion to TG to avoid the risk of postoperative complications and present a review of the literature.

[CASE REPORT] A 73-year-old man was diagnosed with early gastric cancer in the lower gastric body and underwent endoscopic submucosal dissection (ESD). Histopathological examination revealed submucosal invasion with lymphatic and venous involvement, which required additional resection. During ESD, two more early gastric cancers were identified in the upper and middle gastric body. Although preoperative computed tomography yielded poor visualization of the left inferior phrenic artery, raising concerns regarding insufficient perfusion, laparoscopic STG with Roux-en-Y reconstruction, rather than TG, was planned with priority given to functional preservation. Intraoperatively, the short gastric and posterior gastric arteries were ligated because of the tumor location. While the remnant stomach appeared viable after STG, blood flow was assessed using ICG fluorescence imaging, and blood flow insufficiency was diagnosed. The preservation of a small remnant stomach was abandoned, and TG was performed. The patient was discharged without any postoperative complications.

[CONCLUSION] In distal gastrectomy, particularly in cases of STG or when compromised perfusion is anticipated, intraoperative blood flow assessment using ICG can be effective in preventing complications.