Laparoscopic management of gastric remnant ischemia after laparoscopic distal gastrectomy with Billroth-I anastomosis—A case report

Highlights • Gastric remnant ischemia after laparoscopic distal gastrectomy (LDG) is very rare.• Laparoscopic subtotal gastrectomy for gastric remnant ischemia is effective.• Routine esophagogastroduodenoscopy and laparoscopic can help avoid fatal outcomes.


Introduction
Good gastric cancer screening programs in South Korea are attributable for the high rate of early gastric cancer detection in this region, which has in turn led to the increasing use of laparoscopic gastrectomy and lymph node dissection including that of D1, D1+, and D2 lymph nodes with a variety of reconstruction techniques in this field with an excellent reported survival rate [1]. Gastric remnant ischemia is one of the very rare complications of this procedure and can occur in certain complicated cases especially those compli-cated intra-operatively by splenic infarction or iatrogenic vascular injury mandating splenectomy [2,3].
Here, we present a case wherein postoperative ischemia was detected in a patient after laparoscopic distal gastrectomy (LDG) during which splenectomy was performed owing to splenic artery injury. Close follow-up with esophagogastroduodenoscopy (EGD) and laparoscopic exploration helped us avoid fatal consequences.
This work has been reported in line with the SCARE criteria [4].

Presentation of case
A 72-year-old male with no comorbid diseases was admitted after routine gastric screening with an endoscopic diagnoses of type IIc lower stomach cancer. Endoscopic ultrasound showed a lesion extending to the submucosal layer (T1, Nx, Mx). Histopathological examination showed early well-differentiated gastric adenocarcinoma (type IIc). All blood parameters and tumour markers were within normal limits.   Abdominal computed tomography (CT) with contrast showed no demonstratable primary gastric lesion or metastatic lesions; however, an enlarged lymph node (LN) in the lesser curvature side was noted. LDG with D2 LN dissection was performed. However, an iatrogenic splenic artery injury occurred intraoperatively during LN dissection mandating splenectomy. Billroth-I reconstruction was performed after confirming the clinical viability of the gastric remnant and a drain (J-Vac) was inserted (Fig. 1). The histological examination of the final specimen revealed T1b, N1, M0.
Day 2 postoperatively, upper abdominal pain was noticed by the patient; however, all other clinical signs were normal with a slight increase in laboratory parameters, including complete blood count and C-reactive protein (CRP) levels, within the normal range. Over the next two days, the abdominal pain persisted, and the patient developed fever (38.3 • ). Heart rate was 84/min with significant elevation of inflammatory markers (white blood cell [WBC], 21.9 × 10 3 /L; CRP, 26.88 mg/dl; Table 1). Esophagogastroduodenoscopy (EGD) revealed distal remnant stomach necrotic and oedematous changes but the anastomosis site and duodenal mucosa were normal (Fig. 2).
Conservative treatment involved nil per os and administration of total parenteral nutrition was initiated with close observation. Subsequently, the patient's clinical condition improved with no fever and very mild intermittent upper abdominal pain. Moreover, his laboratory findings improved (WBC 11.1 × 10 3 /L; CRP 5.22 mg/dl).
On postoperative day 10, follow-up EGD (Fig. 3) showed that the mucosal necrosis had improved slightly along with other clinical parameters; thus, ingestion of oral fluid was allowed and tolerated well by the patient. No fever was noted. On postoperative day 15, the patient again developed upper abdominal pain with high fever. His laboratory parameters were also elevated (WBC 19.4 × 10 3 /L; CRP 6.55 mg/dl; Table 1).
EGD showed that the necrosis had worsened, and progressive ischemia was suspected. Abdominal CT with contrast also suggested a high possibility of gastric ischemia (Fig. 4). Subsequently, laparoscopic exploration was performed and necrosis of the distal part of the remnant stomach was noted with severe adhesion over it (Figs. 5 and 6).
Subtotal gastrectomy leaving approximately 10 % of the proximal viable stomach was performed with Roux-en-Y gastrojejunostomy reconstruction. Two large J-vac drains were inserted, one under the gastrojejunostomy site and one near the resected duodenal stump. Postoperatively, the patient was stable and had an uneventful hospital course. He was started on oral fluids on the second day post-operatively with no complications. On postoperative day 5, all clinical and laboratory markers had dramatically improved (WBC 10.1 × 10 3 /L; CRP 6.1 mg/dl; Table 1).
The patient was discharged to home in good condition on postoperative day 7 after the second surgery, with hospital discharge instructions and an outpatient department appointment. Six months later, clinical follow-up with EGD showed no sign of recurrence (Fig. 7).

Discussion
The anatomical distribution of vascular supply and collateral vessels around the stomach make it an organ with exceptionally rich blood supply [2,3]; thus, necrosis in any part of the stomach is a rare complication post-gastrectomy. However, postoperative gastric remnant ischemia is a life-threatening condition in gastrectomy cases especially when accompanied by other comorbid diseases like atherosclerosis or venous thrombosis [5] or intra-operative complications such as bleeding or conditions requiring splenectomy [6].
In our case, wherein splenectomy was performed, although a subsequent Billroth-I reconstruction was executed based on approximately 50 % viable well-perfused gastric remnant, we still speculate that the long remnant part of the stomach after splenectomy and ligation of the short gastric vessels may have led to a significantly reduced perfusion to the distal part of the stomach.
Moreover, a major concern in these cases is that gastric anastomosis disruption and perforation due to ischemia may lead to a high risk of morbidity and mortality in up to 70 % of cases [7,8]; however, our patient did not show any clinical signs of peritonitis. Further, timely CT examination with contrast may help in the detection of ischemia, leakage, or perforation, although, CT sometimes cannot rule out the early signs of ischemia in the early postoperative period [9]. We consider EGD to be the most effective diagnostic modality used in this case that revealed necrotic patches covering the mucosal surface of distal remnant stomach albeit with intact anastomosis and duodenal mucosa, thus facilitating early diagnosis. Although some similar cases have been reported previously, our      case was managed completely on the basis on the clinical findings of the patient [10]. Moreover, we selected a completely laparoscopic approach in contrast to the other reported cases wherein laparotomy was employed.
Close follow-up of the patient's condition, including that for clinical, laboratory, and radiological findings, can facilitate the evaluation of the recovery and detection of worsening and progression of the necrosis. It can also help determine the appropriate time for a repeat EGD, which may be more informative in addition to the clinical parameters as in our case to determine the appropriate time for surgical intervention either in stable condition as a semielective procedure, as in our case, or in emergency situations if the condition deteriorates. Laparoscopic exploration and management in such cases may carry some risk of bleeding, leakage, and perforation of other intact parts due to adhesions, active inflammatory processes, and tissue friability, but is still a feasible and good option, as seen in our case, when performed by an expert surgeon.

Conclusion
Careful dissection of the lymph nodes over the major vessels is essential to avoid complications in gastric cancer patients requiring laparoscopic surgeries. Moreover, major complications occurring intra-operatively may necessitate changes in the surgical plan, including re-excision of the remnant stomach or conversion to Roux-en-Y reconstruction. Further, laparoscopic subtotal gastrectomy for remnant gastric ischemia after LDG is a feasible management approach and can help to minimize the short and long term post-operative complications and enhance the quality of life of patients. EGD is considered the cornerstone diagnostic tool for the detection of early signs of gastric remnant ischemia especially in the early postoperative period.

Funding
This study did not receive any financial support.

Ethical approval
This study is exempt from ethical approval at Asan Medical Center Cancer Institute. Patient approval and written consent was taken.

Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.