Indocyanine green (ICG) fluorography and digital subtraction angiography (DSA) of vessels supplying the remnant stomach that were performed during distal pancreatectomy in a patient with a history of distal gastrectomy: a case report

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Figure legends

Figure 1, Follow-up computed tomography (CT) and magnetic resonance cholangiopancreatography

(MRCP) three years after DG for gastric cancer revealed dilatation of the main pancreatic duct.

a) Contrast-enhanced CT image revealed dilatation of the distal main pancreatic duct (arrow) without a tumor in

the pancreas. b) MRCP image also depicted dilatation of the distal end of the main pancreatic duct (arrow).

Figure 2

Digital subtraction angiography (DSA) performed before distal pancreatectomy (DP). DSA was performed to

confirm the arterial flows to the remnant stomach. a) Angiogram of the celiac artery: The left inferior phrenic

artery (LIPA), splenic artery (SPA) and dorsal pancreatic artery (DPA) were detected in addition to the common

hepatic artery. b) Angiogram of the LIPA: Many branches of the LIPA were distributed circumferentially to the

proximal area of the remnant stomach, and supplied arterial blood to more than half of the remnant stomach

(arrowheads). c) Angiogram of the SPA: Branches of the SPA supplied blood to the greater curvature of the

distal area of the remnant stomach (arrowheads). d) Angiogram of the DPA: A few of the terminal branches of

the DPA supplied blood to the greater curvature; most of the terminal branches of the DPA were localized at the

distal area of the remnant stomach (arrowheads).

*, anastomosis of the remnant stomach to the duodenum

Figure 3

Intraoperative indocyanine green (ICG) fluorography was performed using a near-infrared imaging camera to

confirm the vessel flows to the remnant stomach while the splenic artery was clamped, immediately before

separating the pancreatic parenchyma. ICG was intravenously administered. a) Control image obtained

immediately before ICG administration: the remnant stomach and adjacent organs were observed in the surgical

field. b) Angiogram obtained 20 seconds (sec) after ICG administration: After the liver and duodenum initially

appeared, the lesser curvature of the remnant stomach became fluoresced. c) Angiogram obtained 25 sec after

ICG administration: The proximal portion of the remnant stomach was totally intensified. d) Angiogram

obtained 30 sec after ICG administration: The remnant stomach was entirely intensified to the same brightness

as that of the liver and the duodenum. e) The vessel flows on the serosa of the remnant stomach appeared to be

normal immediately before abdominal closure.

Abbreviations: DI, diaphragm, DU, duodenum; L, liver; PA, pancreas; PV, portal vein; S, stomach

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Figure 4

Digital subtraction angiography (DSA) was performed to detect whether or not a visceral artery

pseudoaneurysm developed 12 days after DP. a) Angiogram of the celiac artery: The LIPA (arrow) was the only

artery identified to the remnant stomach. b) Angiogram of the LIPA (arrow): Arterial flows were detected

focusing around the proximal area of the remnant stomach (arrowheads).

Figure 5

Esophagogastroduodenoscopy (EGD) was performed before (a, b) and after (c, d) distal pancreatectomy (DP).

EGD images of a) the body and b) fornix of the remnant stomach demonstrated atrophic changes before DP.

The EGD images of c) the body and d) fornix of the remnant stomach showed atrophic changes with sufficient

mucosal blood flow after DP.

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Figure 1

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Figure 5

Supplementary Material

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