A Case of Laparoscopic Distal Gastrectomy after Failure of Laparoscopic Gastric Antral Devascularization for Gastric Antral Vascular Ectasia.

INTRODUCTION

Gastric antral vascular ectasia (GAVE) is a condition characterized by clusters of dilated capillaries in the gastric antrum, leading to gastrointestinal bleeding. Although massive hemorrhage is rare, some cases present with recurrent minor bleeding, which can make endoscopic hemostasis challenging. Here, we report a case of GAVE that was refractory to argon plasma coagulation (APC) and required surgical intervention.

CASE PRESENTATION: A 74-year-old man with end-stage renal disease who was on hemodialysis was referred to our hospital for evaluation of refractory anemia. Upper gastrointestinal endoscopy revealed the characteristic "watermelon stomach" appearance, with radially and longitudinally distributed dilated capillaries in the gastric antrum, leading to a diagnosis of GAVE. Despite undergoing APC 4 times, his anemia persisted. Given the refractory nature of the condition, surgical intervention was considered. To preserve the stomach, we initially performed laparoscopic gastric antral devascularization to reduce the blood flow to the affected area. Intraoperatively, dilated marginal vessels were observed along the greater curvature of the gastric antrum. The marginal artery was ligated along the greater curvature from the watershed area to the pylorus and pyloric ring. Indocyanine green (ICG) fluorescence imaging revealed delayed enhancement in the marginal artery resection area, indicating reduced perfusion. However, after a 2-month postoperative observation period, no improvement in the anemia was observed, and follow-up endoscopy revealed no significant changes in the gastric antral lesions. Consequently, a laparoscopic distal gastrectomy was performed. Following the procedure, the anemia stabilized, and the postoperative course was uneventful.

CONCLUSIONS

Gastric antral devascularization was ineffective for the treatment of GAVE, even when combined with ICG blood flow assessment. For refractory GAVE unresponsive to endoscopic therapy, a distal gastrectomy appears to be the most effective treatment.