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

INTRODUCTION: Gastric remnant ischemia after laparoscopic distal gastrectomy (LDG) in gastric cancer patients is a very rare but life-threatening condition, especially when accompanied by a splenic infarction or unplanned splenectomy.

PRESENTATION OF CASE: A 72-year-old male with no comorbid diseases was diagnosed with a well-differentiated adenocarcinoma of the lower stomach and underwent LDG with D2 lymph node dissection. However, a splenic artery injury necessitated a splenectomy intra-operatively, and delta anastomosis was performed based on a clinically viable remnant stomach. During the late post-operative period, the patient developed abdominal pain and showed increased levels of inflammatory biomarkers with hemodynamic stability. Esophagogastroduodenoscopy (EGD) showed necrotic patches over the distal part of the remnant stomach with normal anastomosis and duodenal mucosa. Progression of the necrosis was noted on follow up EGD performed 15 days post-surgery. Total laparoscopic subtotal gastrectomy with Roux-en-Y reconstruction was performed and the patient recovered uneventfully.

DISCUSSION: Careful dissection of the lymph nodes over the major vessels is essential to avoid complications in gastric cancer patients requiring LDG. 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.

CONCLUSION: Careful evaluation of the clinical findings and close observation with EGD can help detect mucosal demarcation lines and ascertain the perfect timing for intervention in cases with suspected ischemia. Although gastric remnant ischemia requires emergency treatment, laparoscopic management is a feasible option when performed by an expert surgeon.