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.