PMC3514816_01
Gastrointestinal endoscopy revealed a depressed-type tumor in the greater curvature of the middle third of the stomach. Biopsy specimens showed a moderately to poorly differentiated adenocarcinoma of the stomach.
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Endoscopically, the tumor invasion was evaluated as not reaching the submucosa, but the tumor had a concomitant peptic ulcer scar (Figure 1).
Intraabdominal findings from the laparoscopy-assisted distal gastrectomy with lymphadenectomy. (a) Dissection of the infrapyloric lymph nodes (station 6) from the pancreatic head: the right gastroepiploic vessels were exposed and divided. (b) Dissection of lymph node stations 7, 8a, 9, and 11p: suprapancreatic lymph nodes and lymph nodes around the celiac axis were dissected along the common hepatic artery and the splenic artery. (c) Transection of the duodenum: the duodenum was cut 1 cm distal to the pylorus using an endoscopic stapling device (Endo GIA, Duet TRS, Covidien, Tokyo, Japan). (d) Anastomosis: a Roux-en Y gastrojejunostomy was made. The jejunal limb was pulled up through the retrocolic route.
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Intraoperative findings are shown in Figure 2.
(a) A postoperative chest radiograph taken in the operating room showed bilateral diffuse ground glass attenuation. The central shadow was not widened: the cardiopulmonary rate was 48%. The tip of the intratracheal tube was located near the tracheal bifurcation (black arrow). (b) A chest radiograph demonstrated progression of the diffuse ground glass attenuation and appearance of alveolar consolidation. The photograph was taken in the intensive care unit 2 hours after surgery. (c) A chest radiograph revealed significant resolution of pulmonary abnormalities 3 days after the operation.
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Blood pressure and heart rate remained stable throughout the surgery.  Figure 3(a) shows the chest radiograph that was taken in the operating room just after surgery was completed.  A chest radiograph demonstrated progression of diffuse ground glass attenuation and the appearance of alveolar consolidation (Figure 3(b)). The patient's respiratory condition improved gradually, and she was extubated on the third postoperative day (POD) (Figure 3(c)).