Remnant Gastric Necrosis after Laparoscopic Distal Gastrectomy Managed with Double-Elemental Diet Tube and Laparoscopic Gastrojejunostomy: A Case Report

Abstract

INTRODUCTION: Although the stomach has a robust intramural microvascular network and is generally considered resistant to ischemia, remnant gastric necrosis after gastrectomy is very rare and potentially fatal. However, diagnosis can be challenging, and optimal management strategies are still not well established.

CASE PRESENTATION: A 78-year-old man with hypertension, arteriosclerosis, chronic renal dysfunction, chronic obstructive pulmonary disease, internal carotid artery stenosis on antiplatelet therapy, long-term heavy smoking, and daily alcohol intake presented with anemia. Esophagogastroduodenoscopy (EGD) revealed a type 3 tumor in the lower stomach. Histopathological examination of biopsied specimens revealed moderately differentiated adenocarcinoma with poorly differentiated components. Preoperative imaging revealed severe vascular calcification of the abdominal aorta and splenic artery. The patient underwent laparoscopic distal gastrectomy with D1+ lymphadenectomy and Billroth I reconstruction (delta-shaped anastomosis). Postoperatively, he developed fever and elevated C-reactive protein levels without clinical or radiological evidence of peritonitis or shock. Contrast-enhanced CT and EGD revealed circumferential mucosal necrosis in the distal remnant stomach. A double-elemental diet (W-ED) tube was placed for intragastric decompression and enteral feeding. A minor anastomotic leak resolved with conservative management. However, a severe anastomotic stricture required an elective laparoscopic gastrojejunostomy (Billroth II with Braun anastomosis). The patient recovered and remained disease-free with stable oral intake for 4 years.

CONCLUSIONS: Conservative management using a W-ED tube, followed by elective gastrojejunostomy for stricture, may be a viable treatment option for remnant gastric necrosis after distal gastrectomy in patients with high surgical risk when peritonitis is absent and systemic status is stable.