Dr. Alba Torroella

Vascular assessment of the gastrojejunal anastomosis with indocyanine green may reduce the leak rate

Case A 75 year-old man with a medical history of atrial fibrillation and laparoscopic radical prostatectomy for prostate adenocarcinoma. He came to the Emergency Department due to melena and hemodynamic instability with a blood test which found a Hemoglobin level of 7.9 g/dL. And emergent upper endoscopy showed early gastric neoplasia (type IIa + IIc) with a biopsy compatible with gastric adenocarcinoma. A CT scan showed a tumor in the right kidney with no signs of locally advanced gastric cancer. Thus a minimally invasive subtotal gastrectomy with D2 lymphadenectomy was scheduled. Treatment Surgery started with a lymphadenectomy of the greater curvature, with dissection of the gastroepiploic artery and vein. (Later, dissection of the pylorus and postpyloric section with an EndoGIA was performed. Lymphadenectomy of the left gastric artery, celiac trunk, hepatic artery and splenic artery followed. D2 lymphadenectomy with preservation of the ganglionar stations 1 and 2 was performed. Once this was done, the vascularization of the gastric stump was assessed with 5mg of ICG inserted through a central catheter,  and the decision to section the stomach in a well-perfused portion of the gastric stump was made, as this would be the site of the gastrojejunal anastomosis. A end-to-side anastomosis was created using an Orvil®. The mesenteric defect was then closed. Outcome The patient had an uneventful postoperative evolution and started oral intake on the first day after surgery. He was discharged on the 4th postoperative day. Pathology reported a T2N0 (0/18) gastric adenocarcinoma. Conclusions Even though leakage after a subtotal gastrectomy with gastrojejunal anastomosis is uncommon, when a leak occurs the consequences are devastating, both in the oncologic long-term as well as in terms of function, morbidity and mortality. The use of tools such as ICG, which provide a guide for safer anastomosis, are useful and may help to further reduce this dreadful complication.