Patients with unresectable gastric cancer initially exhibiting one noncurative factor may obtain a survival benefit from chemotherapy and subsequent curative surgery.

By examining the reconstructed gastric tube during esophagectomy using indocyanine green fluorescence (ICG) angiography, we have established a '90-second rule' to confirm good blood perfusion at the anastomosis site. We examined the surgical outcome (rate of anastomotic leakage) of 70 consecutive patients who underwent esophagectomy with gastric tube reconstruction using ICG fluorescence angiography. All of the anastomoses were made in the area where less than 90 seconds was needed for enhancement using ICG fluorescence angiography (i.e. within the 90-second rule). In 18 cases for which the time until enhancement of the gastric tube tip exceeded 60 seconds, the anastomosis site was decided by reference to the ICG fluorescence angiogram, and the hypoperfused area was excised, and this significantly shortened the median time until enhancement of the gastric tube tip from 95.5 (60.0-204.0) seconds to 41.0 (9.0-77.0) seconds (P < 0.001). In three cases, the anastomosis was made at the site where more than 60 seconds was needed for ICG enhancement. In one case where ICG enhancement had taken 77 seconds, minor anastomotic leakage occurred. The overall rate of anastomotic leakage in this series was 1.4%. Blood flow in the reconstructed gastric tube is sufficient if the anastomosis is made in the area where ICG fluorescence angiography demonstrates enhancement within 60 seconds. Gastric tube necrosis can be avoided if the area showing an enhancement time exceeding 90 seconds is excised. The 90-second rule is a safe and effective method for deciding the site of anastomosis.

The gastric tube was divisible into three zones according to the dominant arteries present in the greater curvature under ICG fluorescence. The left gastroepiploic artery was enhanced in a direction opposite that of physiological blood flow in all cases. The median period from initial enhancement of the root of the right gastroepiploic artery to the most cranial branch of the left gastroepiploic artery until perfusion up to the tip of the gastric tube did not differ significantly between the "good" and the "sparse or absent" groups (P = 0.24, 0.68) CONCLUSIONS: It is essential to preserve the whole vessel arcade of the greater curvature to achieve good blood perfusion in the gastric tube. The ICG fluorescence method has potential usefulness for evaluation of blood flow in the gastric tube.