Live surgeryMay 25, 20221:30:075 speakersAvailable in: EN / IT
Clinical Round – Gastric cancer: antral T1b case, ICG-guided D2 lymphadenectomy and management of complications
Permanent School ICG Clinical Round: discussion of an antral gastric adenocarcinoma case treated with ICG-guided laparoscopic D2 subtotal gastrectomy and management of postoperative hemorrhage with duodenal leak.
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Clinical case
Adenocarcinoma gastrico antrale, istotipo tubulare intestinale (OMS 2018); ulcera 30 mm piccola curva/parete anteriore
Clinical historyAnemia da circa un anno (inizialmente attribuita a emorroidi), calo ponderale, iperteso, forte fumatore, depresso, leggermente sovrappeso, mai operato
NotesDecorso post-operatorio complicato in 6ª giornata da shock emorragico per spandimento dell'arteria epatica sinistra, trattato con embolizzazione (Glubran), successiva laparoscopia di lavaggio, leak del moncone duodenale gestito con reintervento open e tubo di Care; dimissione in 43ª giornata
Overview
Third 2022 session of the Permanent School on ICG Surgery and second clinical round of the year, dedicated to gastric cancer. Gian Luca Baiocchi introduces the rationale for indocyanine green in gastric oncologic surgery, emphasizing that the only currently solid application is lymphatic navigation: ICG as a "satellite navigator" that democratizes D2 lymphadenectomy, highlights non-standard drainage pathways (e.g., the pre-pancreatic lymphatic channel toward 14V, station 8p nodes), and protects the patient during the learning curve. International experiences (Stryker Lymphatic Mapping 2019/2021) and future perspectives on quantification and personalization are recalled.
A real-life clinical case follows: 64-year-old man with anemia, weight loss, antral ulcer with tubular intestinal-type adenocarcinoma. Discussion covers biopsy adequacy (MSI, HER2, PD-L1), CT and endoscopic ultrasound staging (cT2N0), the role of PET and staging laparoscopy, upfront vs neoadjuvant choice, and technical details of laparoscopic subtotal gastrectomy (trocar and scope positioning, liver retraction, colo-epiploic detachment vs section, Wangensteen's area, station 6, 8a/8p, 12 lymphadenectomy, role of vessel-loops, uncut Roux-en-Y anastomosis).
The procedure shows endoscopic ICG marking performed the day before, with lymph nodes and lymphatic channels clearly visible. The course is complicated on postoperative day 6 by hemorrhagic shock from left hepatic artery bleeding, treated by embolization (complete closure of the hepatic and gastroduodenal arteries), followed by laparoscopic washout, then onset of a duodenal stump leak, open reoperation with creation of a Care tube and jejunostomy. Final histology: pT1bN0 G1 on 40 lymph nodes. Edoardo Rosso and Stefano Berti comment on technical choices, complication management, the role of percutaneous biliary drainage, and the importance of clipping the pyloric artery.
Topics
Rationale for ICG in oncologic gastric surgery
Lymphatic navigation and ICG-guided D2 lymphadenectomy
Preoperative endoscopic ICG marking
Gastric cancer staging (CT, endoscopic ultrasound, PET, laparoscopy)
Molecular work-up (MSI, HER2, PD-L1) and neoadjuvant therapy (FLOT)
Laparoscopic subtotal gastrectomy technique
Colo-epiploic detachment vs section of the gastrocolic ligament
Lymphadenectomy of stations 6, 8a/8p, 12, 14V
Reconstruction: Roux-en-Y vs uncut Roux
Management of complications: postoperative bleeding and embolization
Duodenal stump leak and Care tube
Importance of MDT and molecular staging
Tools used
Verde di indocianina (ICG)Piattaforma di fluorescenza Stryker (Novadaq)Termofusione (energy device)Suturatrici meccaniche lineari e circolariVessel-loopRetrattore epatico (Nathanson)ClipVisiport / ago di VeressTubo di CareEmbolizzazione con Glubran
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