Usefulness of indocyanine green angiography for evaluation of blood supply in a reconstructed gastric tube during esophagectomy

Abstract

We report a case of necrosis of a reconstructed gastric tube in a 77-year-old male patient who had undergone esophagectomy. At the time of admission, the patient had active gastric ulcers, but these were resolved by treatment with a proton pump inhibitor. Subtotal esophagectomy with gastric tube reconstruction was performed. Visually, the reconstructed gastric tube appeared to be well perfused with blood. Using indocyanine green (ICG) fluorescence imaging the gastroepiploic vessels were well enhanced and no enhancement was visable 3 to 4 cm from the tip of the gastric tube. Four days after esophagectomy, gastric tube necrosis was confirmed, necessitating a second operation. The necrosis of the gastric tube matched the area that had been shown to lack blood perfusion by ICG angiography imaging. It seems that ICG angiography is useful for the evaluation of perfusion in a reconstructed gastric tube.

Fig. 1

(A) Endoscopic observation of the upper digestive tract at the time of admission to our hospital. Active gastric ulcers at the anterior and posterior wall of the gastric body were detected. (B) Two weeks after proton pump inhibitor medication, the ulcers were healed and scars remained.

Fig. 2

(A) Macroscopic appearance of the gastric tube before anastomosis (white right mode: Photodynamic Eye; Hamamatsu Photonics K.K, Hamamatsu, Japan). The gastric tube was pinkish in color, and therefore considered to be well perfused with blood. (B) ICG angiography image of the gastric tube. A portion of the gastric tube 3 to 4 cm from the tip was not enhanced with ICG, and an apparent demarcation line was visualized. (C) The gastric tube during the second operation. A portion of the gastric tube 5 cm from the tip revealed total layer necrosis. The necrotic area appeared to match the poorly perfused area that had been suggested by ICG fluorescence during the initial operation.