Indocyanine Green Fluorescence-Guided Laparoscopic Subtotal Gastrectomy for Remnant Gastric Cancer after Pancreaticoduodenectomy: A Case Report
TL;DR
Laroscopic subtotal gastrectomy with ICG fluorescence guidance can be considered a technically useful surgical option for RGC, even 24 years after PD, and provides precise tumor localization and real-time perfusion assessment, assisting surgical resection in high-risk patients with multiple comorbidities and complex reoperative anatomy.
Abstract
ABSTRACT INTRODUCTION Remnant gastric cancer (RGC) is rare after pancreaticoduodenectomy (PD). Surgical management of such cases is technically challenging because of postoperative adhesions and altered anatomy due to reconstruction. Although a completion total gastrectomy is the standard treatment for RGC, it can be highly invasive, particularly in elderly patients with significant comorbidities. While function-preserving subtotal gastrectomy or minimally invasive approaches have been considered, they remain technically demanding. Recent advances in indocyanine green (ICG) fluorescence imaging have facilitated precise tumor localization and real-time tissue perfusion assessment in complex surgical settings. CASE PRESENTATION A 75-year-old man with a 24-year survival history after PD for pancreatic cancer presented with early-stage RGC (0–IIa, size 35 mm, invading the submucosa). The patient was at high risk, with a history of cerebral infarction requiring dual antiplatelet therapy and long-term corticosteroid therapy for pemphigus vulgaris. A laparoscopic subtotal gastrectomy was performed. Preoperative endoscopic ICG fluorescent clipping guided the determination of an adequate surgical margin under near-infrared visualization, despite dense adhesions. ICG fluorescence enabled precise tumor localization and confirmation of adequate perfusion, thereby facilitating stomach-preserving resection. Although the postoperative course was complicated by a Grade B pancreatic fistula that was managed conservatively, the patient was discharged. CONCLUSIONS Laparoscopic subtotal gastrectomy with ICG fluorescence guidance can be considered a technically useful surgical option for RGC, even 24 years after PD. This technique provides precise tumor localization and real-time perfusion assessment, assisting surgical resection in high-risk patients with multiple comorbidities and complex reoperative anatomy.