Minimally invasive surgery for cancer arising in a reconstructed gastric tube after esophagectomy based on evaluation of blood and lymphatic flow by indocyanine green fluorescence imaging

A 69-year-old man was admitted to our hospital for treatment of gastric tube cancer detected by screening upper gastrointestinal endoscopy. Seven years previously, he had undergone subtotal esophagectomy for esophageal cancer with gastric pull-up via the retrosternal route. Contrast study revealed a filling defect in the distal part of the reconstructed gastric tube. Nasopharyngeal cancer was detected at the same time. After chemoradiotherapy for nasopharyngeal cancer, surgery was performed for gastric tube cancer. Because the radiation field included the anastomotic site of the pervious surgery, resection of the distal part of the gastric tube was considered. For this purpose, we intraoperatively evaluated blood and lymphatic flow along the gastric tube by using indocyanine green (ICG) fluorescence imaging. Submucosal ICG injection around the tumor revealed lymphatic flow localized around the right gastroepiploic artery. In addition, intravenous ICG injection revealed blood flow from the oral side of the gastric tube into the distal part. Based on this finding, we performed distal gastrectomy (resection of the distal part of the gastric tube) with Roux-en-Y reconstruction (gastro-jejunal anastomosis). The postoperative course was uneventful. On histological examination, the tumor was diagnosed as pT1b (SM) N0M0, pStage IA. Intraoperative evaluation of blood and lymphatic flow using ICG fluorescence imaging is useful during minimally invasive surgery for cancer in a reconstructed gastric tube.