Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report

Abstract

Background: Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization.

Case presentation: A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired.

Conclusions: Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.

Keywords: Blue toe syndrome; Case report; Cholesterol crystal embolization; Distal gastrectomy; Gastric remnant necrosis.

Fig. 1

Endoscopic examination of the stomach. Endoscopy revealing a type 4 tumor circumferentially obstructing the pyloric ring

Fig. 2

Computed tomography of the abdomen before surgery. Computed tomography of the abdomen revealing focal wall thickening of the prepyloric antrum with several enlarged perigastric lymph nodes

Fig. 3

Pathological finding of the resected stomach. Multiple cholesterol emboli are found within the gastric arterial walls (arrow)

Fig. 4

Gross findings of the gastric remnant. Most parts of the stomach, except for the greater curvature around the spleen, are completely necrosed

Fig. 5

Pathological findings of the gastric remnant. The histopathological findings of the gastric remnant revealing total mucosal necrosis with cholesterol crystal emboli filling the arterioles (arrow)