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Laparoscopic Distal Gastrectomy for Gastric Cancer Patient With Intestinal Malrotation: Report of a Case

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Laparoscopic Distal Gastrectomy for Gastric Cancer Patient With Intestinal Malrotation: Report of a Case

Susumu Inamoto et al. Surg Case Rep.

Abstract

Background: Intestinal malrotation, which arises from incomplete rotation of the embryonic midgut, is one of the congenital anomalies usually diagnosed in infancy. On the other hand, intestinal malrotation detected in asymptomatic adults is very rare. It is frequently diagnosed incidentally during abdominal surgery. We report a case of asymptomatic intestinal malrotation diagnosed during laparoscopic distal gastrectomy for gastric cancer.

Case presentation: A 59-year-old female was diagnosed with early-stage gastric cancer during health screening and admitted to our hospital for radical surgical treatment. Physical examinations and blood tests revealed nothing of note. The type 0-IIc gastric cancer was located in the posterior wall of the mid-body of the stomach. The histological type was poorly differentiated adenocarcinoma. Esophagogastroduodenoscopy and computed tomography (CT) suggested that the depth of tumor invasion was the submucosal layer without regional lymph node swelling. The clinical stage according to the TNM 7th edition was cT1b N0 M0, cStage I. Laparoscopic distal gastrectomy with D1+ lymph node dissection and Billroth-I method reconstruction was planned. During the infrapyloric lymph node dissection, a part of the pancreatic head showed unusual adherence to the first part of the duodenal wall. For safe and accurate lymphadenectomy while avoiding pancreatic injury, we deliberately focused on tracing the dissectible layer between the pancreatic parenchyma and fatty tissues including lymph nodes. Also, we changed the reconstruction procedure from Billroth-I to Roux-en-Y. After distal gastrostomy, we could not find the ligament of Treitz or jejunum on the left side below the transverse colon. Based on a review of the CT image, this patient was diagnosed with intestinal malrotation. Although the detection of malrotation during the operation was incidental, we could complete radical surgery and Roux-en-Y reconstruction safely. The type of malrotation was non-rotation (90°). She was discharged from our hospital without any complications.

Conclusion: We encountered a case of adult asymptomatic intestinal malrotation with gastric cancer. Even when encountering such a case during laparoscopic gastrectomy, reviewing CT images carefully to reconsider the anatomical anomalies, and tracing the dissectible layer accurately with adequate countertraction can facilitate safe and successful surgery.

Keywords: Congenital anomalies; Gastric cancer; Intestinal malrotation; Laparoscopic distal gastrectomy; Roux-en-Y reconstruction.

Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for the publication of this report.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Gastric endoscopy and CT. a Gastric endoscopy revealed a type 0-IIc tumor, which was located in the posterior wall of the mid-body. Histological findings indicated a poorly differentiated adenocarcinoma. Tumor recession without ulceration indicated tumor invasion deeper into the submucosal layer. b There was no lymph node swelling based on CT. The preoperative clinical stage was cT1b, cN0, cM0, cStage I
Fig. 2
Fig. 2
Operative views during infrapyloric lymph node dissection. a View of the infrapyloric area. Right gastroepiploic vessels were dissected and cut during the infrapyloric lymph node dissection in close proximity to the pancreas. b, c A part of the pancreatic head could not be separated from the first part of the duodenal wall during the infrapyloric lymph node dissection. Irregular adhesion of the pancreatic head to the pylorus made it difficult to dissect the infrapyloric lymph node. d We performed meticulous lymph node dissection by accurately tracing the dissectable layer, created by adequate countertraction. Subsequently, the right gastroepiploic vessels were cut and infrapyloric lymph node dissection was performed
Fig. 3
Fig. 3
Operative views before reconstruction and CT findings, indicating asymptomatic intestinal malrotation. a,b There was no right-side colon at the hepatic flexure, and the duodenum did not rotate to the left side of the body. The small intestine was located on the right side of the abdomen, with a completely mobilized duodenum. c A right-sided small bowel and left-sided colon sign were confirmed on reviewing the CT image. d SMV rotation sign: SMV existed abnormally on the left side of the superior mesenteric artery (SMA)
Fig. 4
Fig. 4
Schema of the infrapyloric lymph node area. The left-side schema represents normal anatomy, while the right-side schema represents intestinal malrotation

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