Remnant gastric ischemia is the most significant complication in distal pancreatectomy (DP) after distal gastrectomy (DG). Some studies have reported the safety of asynchronous DP in patients who underwent DG. We report a case of simultaneous robotic DG and DP. A 78‐year‐old man was diagnosed with gastric and pancreatic cancer. We preoperatively confirmed the absence of anomalies in the left inferior phrenic artery. Robotic simultaneous DG and DP was performed; subtotal resection of the stomach was carried out, enabling the left inferior phrenic artery to maintain perfusion of the remnant stomach, even after ligation of the splenic artery. The remnant stomach was preserved as scheduled, and indocyanine green fluorescence imaging confirmed sufficient remnant stomach tissue perfusion. Robotic surgery using the da Vinci surgical system (with a fluorescence imaging system and technology enabling surgical precision) is suitable for this surgical procedure because it considers tumor radicality and allows for function preservation.

Background The frequency of metastasis to the pancreas is very low, and the frequency of metastasis from squamous cell carcinoma of the esophagus is even lower. Although curative resection of these metastatic lesions has been reported for some patients, the survival benefit of these procedures has not yet been clearly determined. Case presentation The patient was a 54-year-old man who was found to have lower thoracic esophageal cancer. Computed tomography showed a 2-cm tumor in the tail of his pancreas. Since no other obvious distal metastases were observed, the patient underwent simultaneous surgical procedures that excised both the esophageal squamous cell carcinoma and the pancreatic metastasis. Histopathologic examination confirmed squamous cell carcinoma in both specimens. The patient has been free of disease for 9 months since the resection. A literature review of all relevant cases to date found that the site of the primaries of all cases of esophageal cancers with metastasis to the pancreas was the lower thoracic esophagus. Conclusion Complete simultaneous resections of esophageal squamous cell carcinoma and a solitary metastasis to the pancreas is beneficial and may produce good outcomes. However, because of the low number of such reports, further studies are needed to confirm the benefits of surgery.

Background Neuroendocrine tumors of the minor papilla are very rare, and only 20 cases have been reported in the literature. Neuroendocrine carcinoma of the minor papilla with pancreas divisum has not been reported previously, making this the first reported case. Neuroendocrine tumors of the minor papilla have been reported in association with pancreas divisum in about 50% of cases reported in the literature. We herein present our case of neuroendocrine carcinoma of the minor papilla with pancreas divisum in a 75-year-old male with a systematic literature review of the previous 20 reports of neuroendocrine tumors of the minor papilla. Case presentation A 75-year-old Asian man was referred to our hospital for evaluation of dilation of the main pancreatic duct noted on abdominal ultrasonography. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed a dilated dorsal pancreatic duct, which was not connected to the ventral pancreatic duct; however, it opened to the minor papilla, indicating pancreas divisum. The common bile duct had no communication with the pancreatic main duct and opened to the ampulla of Vater. A contrast-enhanced computed tomography scan showed a 12-mm hypervascular mass near the ampulla of Vater. Endoscopic ultrasonography showed a defined hypoechoic mass in the minor papilla with no invasion. The biopsies performed at the previous hospital found adenocarcinoma. The patient underwent a subtotal stomach-preserving pancreaticoduodenectomy. The pathological diagnosis was neuroendocrine carcinoma. At the 15-year follow-up visit, the patient was doing well with no evidence of tumor recurrence. Conclusion In our case, because the tumor was discovered during a medical check-up relatively early in the course of disease, the patient was doing well at the 15-year follow-up visit, with no evidence of tumor recurrence. Diagnosing a tumor of the minor papilla is very difficult because of the relatively small size and submucosal location. Carcinoids and endocrine cell micronests in the minor papilla occur more frequently than generally thought. It is very important to include neuroendocrine tumors of the minor papilla in the differential diagnosis of patients with recurrent pancreatitis or pancreatitis of unknown cause, especially for patients with pancreas divisum.

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Background: Ischemic gastropathy is one of the unique postoperative complications associated with distal pancreatectomy with celiac axis resection for locally advanced pancreatic cancer. Therefore, it is essential to evaluate blood flow to the stomach following a resection; however, no intraoperative procedures have been established to assess this issue. Herein we describe two cases in which intraoperative evaluation of real-time blood flow in the residual stomach was performed using indocyanine green fluorescence and da Vinci Firefly technology during a robot-assisted distal pancreatectomy with celiac axis resection. Methods: Robot-assisted distal pancreatectomy with celiac axis resection was performed using a da Vinci Xi surgical system on two patients with locally advanced pancreatic cancer and suspected invasion of the celiac artery. ICG (0.5 mg/kg) was injected intravenously after resection to evaluate real-time blood flow of the stomach using a da Vinci Firefly system. Blood flow of the stomach was evaluated 60 seconds after the intravenous injection of ICG. Results: Case 1 was confirmed that there was sufficient blood flow in the residual stomach. Therefore, reconstruction of the left gastric artery was not performed, and the surgery was completed with preservation of the entire stomach. Case 2 was performed a proximal gastrectomy at first because the tumor directly involved the gastric lesser curvature and the left gastric artery. Next, ICG was injected intravenously, and after confirming good blood flow in the residual stomach and stomach stump, an esophageal residual gastric anastomosis was performed. Good postoperative outcomes were achieved and there was no evidence of ischemic gastropathy and delayed gastric emptying in both two cases. Conclusions: This method is very useful in determining whether or not to perform reconstruction of the left gastric artery and/or additional resection of the remnant stomach during a robot-assisted distal pancreatectomy with celiac axis resection.