Intraoperative gastroscopy for gastric surgery

Release of liposomally formulated near-infrared fluorescent probes included in giant cluster vesicles by ultrasound irradiation

Detection of tumors and regional lymph nodes during surgery has been proposed in the diagnosis of lymphatic metastasis and the surgical treatment of malignant diseases. Giant cluster vesicles (GCVs), including liposomally formulated indocyanine green (LP-ICG) derivatives, are a possible candidate for agents to realize the two contradictory properties, i.e., retention in tissue for lesion-marking and trace for sentinel lymph nodes (SLNs) identification. We attempted to release the LP-ICG derivatives from GCVs using ultrasound contrast agents (UCAs) under ultrasound irradiation. An absorption spectrophotometer quantitatively evaluated the amounts of released LP-ICG derivatives. As a result, we demonstrated that it depended on conditions for sound pressure, burst length, and number density of UCAs, and had a sound pressure threshold independent of burst length and number density of UCAs. The results will aid to determine appropriate conditions to maximize the released amount of LP-ICG derivatives while keeping safety.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Preoperative indocyanine green fluorescence injection to accurately determine a proximal margin during robotic distal gastrectomy

INTRODUCTION

Adequate surgical margins following gastrectomy for gastric cancer are required. In addition, a method for accurately detecting tumor location without palpation is needed during robotic surgery. Although several methods have been reported, most of these either lack accuracy or require increased time and effort during intraoperative detection. Herein, we introduce a new method for detecting tumor location using preoperative indocyanine green (ICG) marking and the built-in ICG detection system of the da Vinci Xi Surgical System in robotic gastrectomy to determine appropriate surgical margins.

MATERIALS AND SURGICAL TECHNIQUE

We used this method to determine the resection line in six patients who underwent robotic distal gastrectomy for clinical T1 gastric cancer. One to three days before surgery, ICG was diluted to 1.0 mg/mL, and 0.1 mL of this diluted ICG solution was endoscopically injected at one site into the submucosal layer of the stomach, 1 cm proximal to the tumor edge. Gastrectomy was performed using the da Vinci Xi surgical platform, equipped with a near-infrared fluorescence imaging system (Firefly®). The diameter of the fluorescent signal during gastrectomy was estimated to be approximately 2 cm. The resection line was determined on the outer edge of the fluorescent signal, which ensured a tumor-free margin of ≥2 cm. Fluorescent signals were successfully observed in all cases. Moreover, the required 2-cm surgical margin was achieved in all cases.

DISCUSSION

We could successfully determine proximal margins using preoperative ICG injection marking during robotic distal gastrectomy for gastric cancer.

The First Systematic Gastroscopy Training Program for Surgeons in Korea

BACKGROUND

Endoscopic evaluation of the stomach is essential for preoperative planning and post-surgical surveillance for various diseases of the stomach, including malignancy. The gastroscopy education program for surgeons is currently in its infancy and is not systematically organized in Korea. This study aimed to introduce the first systematic gastroscopy education program for surgeons in Korea.

METHODS

The gastroscopy education program entitled "Gastroscopy School for Surgeons (GSS)" comprised of theoretical education, dry lab hands-on training, and clinical practice. All participants were beginners without any gastroscopy experience. Clinical practice started after the completion of the theoretical and dry lab training. The gastroscopy practices utilized simple luminal observation, biopsy, localization using clips or dye injection, and limited therapeutic gastroscopy. The educational performances and surveys from 33 participants were analyzed.

RESULTS

The participants consisted of surgical residents, general surgeons, gastrointestinal-specialized surgeons, and physicians. Participants performed a total of 2,272 gastroscopies, 2,008 of which were post-gastrectomy cases. Currently, of the 33 participants, 7 (21.2%) of the participants performed gastroscopy regularly, and 7 (21.2%) occasionally. According to the self-reported survey, one participant assessed their current gastroscopic technique to be at the expert level, and 25 (75.8%) at a proficient level. All participants considered gastroscopy education for surgeons to be necessary, and 28 (84.8%) stated that systematic education is not currently provided in Korea.

CONCLUSION

We introduced the first systematic gastroscopy education program for surgeons in Korea, namely the GSS, which is practical and meets clinical needs. More training centers are needed to expand gastroscopy training among Korean surgeons.

Intraoperative Tumor Identification During Laparoscopic Distal Gastrectomy: a Novel Fluorescent Clip Marking Versus Metal Clip Marking and Intraoperative Gastroscope

BACKGROUND

In complete laparoscopic distal gastrectomy, the gastric resection line is difficult to determine due to a lack of tactile sensation. The use of intraoperative gastroscopy and intraoperative radiography has been reported, but the burden on personnel and technical complexity present impediments. In our department, based on lesion extent determined with preoperative gastroscopy, a fluorescent clip is used to mark the oral side of the lesion, which is resected after confirmation with a fluorescent laparoscopic system. In this study, we investigated the efficacy of fluorescent clip marking (FCM) in achieving an accurate resection line and reducing the operative time.

METHODS

Fifty-six patients with gastric cancer who underwent complete laparoscopic distal gastrectomy from January 2018 to March 2021 were divided into two groups: the FCM group (n = 32) and the conventional metal clip marking and intraoperative gastroscopy (MCMG) group (n = 24). Short-term outcomes, including the resection margins, gastric resection time, and operative time, were compared and examined.

RESULTS

The fluorescent clips were visible in all cases, and all stumps were negative according to permanent preparations. The operative times for FCM and MCMG were 350 (216-533) vs. 373.5 (258-651) min, respectively, with no significant difference (p = 0.316), while the gastric resection times were 636.5 (321-2572) vs. 1457.5 (843-4973) s, respectively, and were significantly shorter in the FCM group (p < 0.0001).

CONCLUSIONS

FCM shortened the gastric resection time and could possibly shorten the operative time. FCM is feasible and safe and can potentially be used as a tumor-marking agent to determine accurate surgical resection lines.

CLINICAL TRIAL REGISTRATION

Examination of Gastric Cancer, Research Ethics Committee of the Kawaguchi Municipal Medical Centre (Saitama, Japan), approval number: 2019-33. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf.

Surgical management of duodenal web in an adult presenting with melaena; Case report and literature review

Introduction

Duodenal web is a rare pathology presenting infrequently in adults. Diagnosis is challenging and definitive management is commonly delayed. We present a case of a patient with a late diagnosis of duodenal web, who underwent laparotomy, intraoperative gastroscopy and surgical removal of the web performed by two general surgeons.

Case presentation

A 32-year-old woman with a previous diagnosis of irritable bowel syndrome presented with a three day history of abdominal pain, nausea and anorexia, and a one day history of melaena and haematemesis. Investigations including a magnetic resonance enterography, barium swallow study and gastroscopy revealed the diagnosis. The patient underwent laparotomy and excision of duodenal web. Intraoperative gastroscopy assisted with identification of the web's anatomical location. A longitudinal duodenotomy was performed and this was closed in a transverse fashion using the Heineke-Mikulicz technique.

Discussion

This case reports successful application of intraoperative gastroscopy during laparotomy and duodenotomy. Longitudinal duodenotomy with excision of the web and transverse closure of the duodenum appears to be the best approach. There are no previous publications detailing gastroscopy at the time of laparotomy with duodenal web. This technique may be utilised in appropriate situations to improve operative accuracy.

Conclusion

Duodenal web is a rare entity in adults, and delayed diagnosis may lead to significant patient morbidity. Incorporating intraoperative endoscopy ensures accurate anatomical visualisation. This technique avoids duodenectomy, organ damage, bypass, or an unnecessarily large incision.

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Duodenal web is a rare diagnostic dilemma found infrequently in adults.

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Duodenal web is frequently misdiagnosed and may not be visible on gastroscopy.

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Investigations such as magnetic resonance enterography and barium swallow studies may be useful adjuncts for diagnosis.

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Surgical management via laparotomy and duodenotomy are the best agreed cure for duodenal web.

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Intraoperative gastroscopy is a novel technique that may improve patient outcomes by enhancing anatomical accuracy.

Short- and long-term oncological outcomes of totally laparoscopic gastrectomy versus laparoscopy-assisted gastrectomy for clinical stage I gastric cancer

BACKGROUND

Totally laparoscopic gastrectomy (TLG), which involves a complete intracorporeal gastric transection and the creation of an anastomosis, has been gradually adopted. However, a potential limitation of intracorporeal transection is the lack of tactile feedback, and whether this limitation influences oncological outcomes is unclear. The aim of this study is to evaluate the short- and long-term oncological safety of TLG using endoscopy-guided intracorporeal gastric transection for clinical stage (cStage) I gastric cancer.

METHODS

A total of 1875 consecutive patients who underwent laparoscopic gastrectomy for cStage I gastric cancer between January 2007 and March 2015 were enrolled in this study. Marking clips were preoperatively placed and a transection line was determined by perceiving it tactually in laparoscopy-assisted gastrectomy (LAG) or endoscopically in TLG. After propensity score matching, 1366 patients (683 each for LAG and TLG groups) were selected to primarily test the non-inferiority of TLG to that of LAG for relapse-free survival (RFS).

RESULTS

In the propensity-matched population, the 5-year RFS rates of the LAG and TLG groups were 94.3% (95% confidence interval (CI) 92.2-95.8%), and 95.6% (95% CI 93.8-96.9%), respectively. The hazard ratio (TLG/LAG) was 0.77 (95% CI 0.48-1.24, P for non-inferiority < 0.01). There were no significant differences in the recurrence profiles. The incidence of the remnant of marking clips or tumor tissue did not differ (LAG: 1.0% vs. TLG: 1.9%, P = 0.177).

CONCLUSIONS

TLG using preoperative markings and intraoperative endoscopic guidance provides cStage I gastric cancer patients with comparable oncological outcomes to the conventional method.

Clinical Significance of Intra-operative Gastroscopy for Tumor Localization in Totally Laparoscopic Partial Gastrectomy

BACKGROUND

Tumor localization during totally laparoscopic gastrectomy is challenging owing to the invisibility of tumors on the serosal surface. We aimed to evaluate the clinical significance of intra-operative gastroscopy in totally laparoscopic partial gastrectomy.

METHODS

We reviewed 1084 gastric cancer patients who underwent either intra- or extracorporeal partial gastrectomy between 2014 and 2018. The intracorporeal group with intra-operative gastroscopy (intra-operative gastroscopy group, n = 187), the intracorporeal group without intra-operative gastroscopy (non-intra-operative gastroscopy group, n = 267), and the extracorporeal group (n = 630) were evaluated for the adequacy of surgical resection margins. We assessed whether total gastrectomy could be avoided according to the performance of intra-operative gastroscopy if the tumor was located within 3-5 cm away from the gastroesophageal junction.

RESULTS

The proximal margin positivity was lesser in the intra-operative gastroscopy group than in the non-intra-operative gastroscopy group (0% versus 2.2%; P = 0.045) but similar to that in the extracorporeal group (0% versus 0.6%; P = 0.579). The number of cases with proximal resection margins < 1 cm was lower in the intra-operative gastroscopy group than in the non-intra-operative gastroscopy group (3.7% versus 9.4%; P = 0.025) but comparable with that in the extracorporeal group (3.7% versus 4.1%; P = 0.815). Among 94 patients with lesions located within 3-5 cm apart from the gastroesophageal junction, the intra-operative gastroscopy group (n = 47) had fewer patients who underwent total gastrectomy than the non-intra-operative gastroscopy group (n = 47) (12.8% versus 44.7%; P = 0.001). Intra-operative gastroscopy was the only independent factor that prevented total gastrectomy (P = 0.001).

CONCLUSION

Intra-operative gastroscopy can provide margin safety during intracorporeal partial gastrectomy, avoiding unnecessary total gastrectomy.

Intraoperative Tumor Localization of Early Gastric Cancers

Recently, endoscopic screening systems have enabled the diagnosis of gastric cancer in the early stages. Early gastric cancer (EGC) is typically characterized by a shallow invasion depth and small size, which can hinder localization of EGC tumors during laparoscopic surgery. Here, we review nine recently reported tumor localization methods for the laparoscopic resection of EGCs. Preoperative dye or blood tattooing has the disadvantage of spreading. Preoperative 3-dimensional computed tomography reconstruction is not performed in real time during laparoscopic gastrectomy. Thus, they are considered to have a low accuracy. Intraoperative portable abdominal radiography and intraoperative laparoscopic ultrasonography methods can provide real-time feedback, but these methods require expertise, and it can be difficult to define the clips in some gastric regions. Despite a few limitations, intraoperative gastrofibroscopy provides real-time feedback with high accuracy. The detection system using an endoscopic magnetic marking clip, fluorescent clip, and radio-frequency identification detection system clip is considered highly accurate and provides real-time feedback; we expect a commercial version of this setup to be available in the near future. However, there is not yet an easy method for accurate real-time detection. We hope that improved devices will soon be developed and used in clinical settings.

Wireless Light-emitting Marker Using Magnetic Field Resonance for Laparoscopic Gastrointestinal Surgery

BACKGROUND

In laparoscopic gastrointestinal surgery, the location of the tumor is identified mainly with marking methods, such as ink tattooing and intraoperative gastrointestinal endoscopy and marking with a metal clip followed by confirmation with intraoperative x-ray fluoroscopy. Each method has disadvantages, such as complexity, instability of ink sticks, and radiation exposure. Thus, a simple and less-invasive marking method is needed.

METHODS

We developed a wireless light-emitting marker with a miniature light-emitting diode that uses a magnetic field resonance mechanism. It emits 4 individual colors-red, blue, green, and white. We confirmed the usefulness of this marker system in ex vivo and in vivo animal experiments.

RESULTS

In the ex vivo experiment in porcine intestines, use of the wireless marker was successful, as each color of emitted light was recognized from outside the intestine. In the live animal experiment, it was confirmed that the light emitted by the marker system was visible in the porcine intestinal tract during laparoscopic surgery. The light emitted by the wireless marker in the intestinal tract was confirmed with a laparoscope in a simulated animal surgery.

CONCLUSION

We have developed an innovative, radiation-free and reliable light-emitting marker system that uses a magnetic field resonance mechanism that emits four colors of light during laparoscopic surgery.

Laparoscopic Local Resection through Subserosal Dissection with Endoscopic Air-Insufflation for Submucosal Tumors Located Near the Esophagogastric Junction

Purpose

A novel resection method, namely, laparoscopic local resection through subserosal dissection with endoscopic air-insuff lation (LRSDEA) was used for submucosal tumors located near the esophagogastric junction (SMT-EGJ) to avoid major gastric resection.

Methods

A total of 9 cases underwent LRSDEA. We sequentially performed: laparoscopic dissections around EGJ, subserosal dissections around SMTs using laparoscopic electrocautery and ultrasonic shears, and finally, enucleation of SMTs. During these procedures, intraoperative endoscopic tumor localization, as well as endoscopic air-insufflation allowed for safe resection. These procedures are shown in the supplementary video clip. The clinicopathological characteristics and surgical results were analyzed.

Results

All laparoscopic procedures were successfully performed without requiring a major gastrectomy. The mean operation time was 126.1 minutes, and estimated blood loss was 12.0 ml. There were no postoperative complications. Pathological diagnoses were 6 leiomyomas, 2 gastrointestinal stromal tumors, and 1 gastric duplication.

Conclusion

LRSDEA is an effective and safe treatment option for SMT-EGJ, as major resection of the stomach is avoided.

Application of Near-Infrared Fluorescence Imaging with Indocyanine Green in Totally Laparoscopic Distal Gastrectomy

Purpose

Recently, totally laparoscopic gastrectomy has been gradually accepted by surgeons worldwide for gastric cancer treatment. Complete dissection of the lymph nodes and the establishment of the surgical margin are the most important considerations for curative gastric cancer surgery. Previous studies have demonstrated that indocyanine green (ICG)-traced laparoscopic gastrectomy significantly improves the completeness of lymph node dissection. However, it remains difficult to identify the tumor location intraoperatively for gastric cancers that are staged ≤T3. Here, we investigated the feasibility of ICG fluorescence for lymph node mapping and tumor localization during totally laparoscopic distal gastrectomy.

Materials and Methods

Preoperative and perioperative data from consecutive patients with gastric cancer who underwent a totally laparoscopic distal gastrectomy were collected and analyzed. The patients were categorized into the ICG (n=61) or the non-ICG (n=75) group based on whether preoperative endoscopic mucosal ICG injection was performed.

Results

The ICG group had a shorter operation time and less intraoperative blood loss. Moreover, significantly more lymph nodes were harvested in the ICG group than the non-ICG group. No pathologically positive margin was found and there was no significant difference in either the proximal or distal surgical margins between the 2 groups.

Conclusions

Near-infrared fluorescence imaging with ICG can be successfully used in totally laparoscopic distal gastrectomy, and it contributes to both the completeness of D2 lymph node dissection and confirmation of the gastric transection line. Well-designed prospective randomized studies are needed in the future to fully validate our findings.

Detection of indocyanine green fluorescence to determine tumor location during laparoscopic gastrectomy for gastric cancer: Results of a prospective study

INTRODUCTION

In laparoscopic gastrectomy, a method to locate the margin of an early-stage cancerous lesion that is invisible from the serosal surface and impalpable during laparoscopic procedures is needed to determine an appropriate transection line. We conducted a prospective study to develop a new marking method using preoperative submucosal injection of indocyanine green (ICG).

METHODS

Patients undergoing laparoscopic gastrectomy for T1 gastric cancer were recruited. The first 11 patients comprised the learning set and the subsequent 18 patients the validation set. ICG was endoscopically injected in the submucosal layer of the stomach approximately 1 cm away from the tumor edge 1 or 3 days before surgery. The diameters of the visualized ICG were compared with those of a conventional marking method using India ink in 10 historical controls.

RESULTS

In the learning set, the optimal amount of ICG was determined to be 0.1 mL at a concentration of 0.5 mg/mL. In the validation set, the same procedure was repeated. No technical problems or adverse reactions related to ICG injection were observed. In all cases, ICG was successfully detected, and negative surgical margins were pathologically confirmed. The mean long diameter of the visualized ICG fluorescence measured at the mucosal surface of the stomach was significantly smaller in the current study than in the historical controls in whom India ink was used (21 vs 52 mm, P < 0.0001).

CONCLUSIONS

The preoperative submucosal ICG marking was safely performed and successfully detected without excessive blurring during laparoscopic gastrectomy.

Comparison of the short-term outcomes between totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy for gastric cancer: a meta-analysis

BACKGROUND

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two common surgical approaches for upper and middle gastric cancer. Which surgical approach offers more advantages is still controversial due to a lack of evidence from randomized controlled trials (RCTs). This meta-analysis was conducted to compare the short-term outcomes between the two surgical approaches.

METHODS

A systematic literature search was performed to evaluate short-term outcomes between TLTG and LATG, including overall postoperative complications, anastomosis-related complications, time for anastomosis, operation time, intraoperative blood loss, harvested lymph nodes, proximal margin, distal margin, time to first flatus, time to first diet, and postoperative hospital stay. Short-term outcomes were pooled and compared by meta-analysis using RevMan 5.3. Mean differences (MDs) or risk ratios (RRs) were calculated with 95% confidence intervals (CIs). P < .05 was considered statistically significant.

RESULTS

A total of 9 cohort studies fulfilled the selection criteria. The total sample included 1671 cases. The meta-analysis showed no significant difference between the two surgical approaches in overall postoperative complications (RR = 1.02, 95% CI = 0.82 to 1.26, P = .87),anastomosis-related complications (RR = 0.64, 95%CI = 0.39 to 1.03, P = .06),time for anastomosis (MD = -5.13, 95% CI = -10.54 to 0.27, P = .06),operation time (MD = -10.68, 95% CI = -23.62 to 2.26, P = .11), intraoperative blood loss (MD = -25.58, 95% CI = -61.71 to 10.54, P = .17), harvested lymph nodes (MD = 1.61, 95% CI = -2.09 to 5.31, P = .39), proximal margin (MD = -0.37, 95% CI = -0.78 to 0.05, P = .09), distal margin (MD = 0.79, 95% CI = -0.57 to 2.14, P = .25), time to first flatus (MD = 0.01, 95% CI = -0.13 to 0.15, P = .87), time to first diet (MD = -0.22, 95% CI = -0.45 to 0.02, P = .07), and postoperative hospital stay (MD = -0.51, 95% CI = -1.10 to 0.07, P = .09).

CONCLUSIONS

TLTG is a safe and feasible surgical approach for upper and middle gastric cancer, with short-term outcomes that are similar to LATG. Nevertheless, high-quality, large-sample and multicenter RCTs are still required to further verify our conclusions.

An advanced RFID-based system to localize gastric and colon cancers during laparoscopic surgery

BACKGROUND

We aimed to improve the tumor localization system using radiofrequency identification (RFID) technology used during laparoscopic surgery for gastric and colorectal cancer. To this end, we developed a detection algorithm and designed improvement for the RFID clip.

METHODS

To evaluate the proposed system, a swine-based animal study was conducted, followed by experiments on porcine stomachs and colons using the EASIE-R simulator. The success rates of endoscopic clipping, detection time, and detection accuracy, which is the distance between the detection point and RFID tag, were measured.

RESULTS

Results of the in vivo swine animal study showed success in all three clippings and detections of the RFID clips. Results of the 60 RFID endoclip attempts using the EASIE-R simulator showed a total clipping success rate of 85.0% (n = 51/60; stomach, 83.3%, n = 25/30; colon, 86.7%, n = 26/30). The median detection times were 29.2 s for the stomach and 25.5 s for the colon. The median detection accuracy was 4.0 mm for the stomach and 4.5 mm for the colon.

CONCLUSIONS

We confirmed that the proposed RFID-based system showed improvements over the system of a previous study. This RFID-based system is effective at localizing gastric and colorectal tumors.

Safety and efficacy of post-anastomotic intraoperative endoscopy to avoid early anastomotic complications during gastrectomy for gastric cancer

BACKGROUND

Anastomotic complications such as leaks, bleeding, and stricture remain the most serious complications of surgery for gastric cancer. No perfect method exists for an accurate and reliable prevention of these complications. This study investigated the safety and efficacy of post-anastomotic intraoperative endoscopy (PAIOE) for avoidance of early anastomotic complications during gastrectomy in gastric cancer.

METHODS

This retrospective case-control study enrolled patients from a tertiary care, academic medical center. Routine PAIOE was performed on 319 patients undergoing gastrectomy for gastric cancer between 2015 and 2016. As controls, without PAIOE 270 patients from 2013 to 2014 were used for comparison. Early anastomotic complications and outcomes after PAIOE were determined.

RESULTS

Although there were no differences between the PAIOE and non-PAIOE group in terms of overall complication rates (20.1% vs 26.7%; P > 0.05), there were fewer complications related to anastomosis (3.4% vs 8.9%; P < 0.01) in the PAIOE group. The PAIOE group had rates of 2.5% for anastomotic leakage, 0.9% for intra-luminal bleeding, and 0% for anastomotic stenosis, while the non-PAIOE group exhibited rates of 5.6%, 2.6%, and 0.7%, respectively. Thirty-one abnormalities were detected in 26 PAIOE patients (9.71%) (20 venous bleeding, 7 mucosal tearing, 2 air leaks, 1 arterial bleeding, and 1 anastomotic stricture). All abnormalities were corrected by proper interventions (13 reinforced additional suture, 13 endoscopic hemostasis, and 2 re-anastomosis). There were no morbidities associated with PAIOE.

CONCLUSIONS

PAIOE appears to be a safe and reliable procedure to evaluate the stability of gastrointestinal anastomosis for gastric cancer patients. Further data collection and a well-designed prospective study are needed to confirm the validity of PAIOE.

New marking method involving a light-emitting diode and power source device to localize gastrointestinal cancer in laparoscopic surgery

Although the preoperative endoscopic marking method using dye is widely used, the dye can spread into the tissue or abdominal cavity, inducing the inflammation and leading to the wrong dissection. We developed a novel marking method using an endoscopic clip with a light emitting diode (LED) and a power source device to detect the accurate location of the site of interest. We performed this new marking method in three patients with gastrointestinal cancers. We placed an endoscopic clip with an LED on the gastrointestinal mucosa and used a power source device outside of the human body to detect the LED. We detected the clip with the LED using the power source device. We also confirmed the usefulness of this clip in three of three (100%) patients with colorectal and gastric cancer. We developed a novel marking device using an LED to identify an objective location successfully.

Role of preoperative endoscopic clipping in laparoscopic distal gastrectomy for early gastric cancer

In this study, we evaluate the usefulness of preoperative endoscopic clipping for early gastric cancer (EGC) localization in laparoscopic distal gastrectomy.We retrospectively screened all consecutive patients who underwent laparoscopic distal gastrectomy for EGC by 1 surgeon at Chungnam National University Hospital between January 2014 and December 2016. Patients who underwent combined surgery and patients who had tumors at the lower third of the stomach were excluded. Endoscopic clipping was performed prior to surgery by specialized endoscopists. During the operation, endoscopic metal clips were found using surgical devices, and laparoscopic vessel clips were attached on the presumed site; thereafter, intraoperative radiographs were obtained for confirmation.We analyzed a total of 196 patients; of them, 101 were classified into the clipping group (CG) and 95 into the non clipping group (NCG). The 2 groups were comparable regarding their demographic characteristics. The CG showed less additional resection (2 of 101 patients [2.0%] vs 9 of 95 patients [9.4%], P = .021) and better outcomes in terms of the operation time (P = .000), duration of hospital stay (P = .036), and postoperative atelectasis (P = .001) than the NCG.Preoperative endoscopic clipping was helpful in determining the exact resection margin in laparoscopic distal gastrectomy for EGC.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Risk Factors of Microscopic Invasion in Early Gastric Cancer

PURPOSE

This study aimed to evaluate the clinical significance of microscopic invasion to determine the adequate resection margin in early gastric cancer (EGC).

MATERIALS AND METHODS

A retrospective review was performed that included patients who underwent gastrectomy for clinical early gastric cancer (cEGC) at Seoul National University Hospital between January 2007 and December 2010. After subtracting the microscopic resection margin from the gross resection margin for each proximal or distal resection margin, microscopic invasion was represented by the larger value. Microscopic invasion and its risk factors were analyzed according to the clinicopathologic characteristics.

RESULTS

In total, 861 patients were enrolled in the study. Microscopic invasion of cEGC was 6.0±12.8 mm, and the proportion of patients with microscopic invasion ≥0 mm was 78.4%. In the risk group, tumor location, pT stage, and differentiation did not significantly discriminate the presence of microscopic invasion. The microscopic invasion of EGC-IIb was 13.9±16.8 mm, which was significantly greater than that of EGC-I. No linear correlation was observed between the overall tumor size and microscopic invasion (R=0.030). The independent risk factors for microscopic invasion ≥20 mm were EGC-IIb vs. EGC-I/IIa/IIc/III (odds ratio [OR], 3.103; 95% confidence interval [CI], 1.533-6.282; P=0.002) and male vs. female sex (OR, 1.655; 95% CI, 1.012-2.705; P=0.045).

CONCLUSIONS

Male sex and EGC-IIb were independent risk factors for microscopic invasion ≥20 mm. Examination of intraoperative frozen sections is highly recommended to avoid resection margin involvement, especially in cases of EGC-IIb.

Real-time detection system for tumor localization during minimally invasive surgery for gastric and colon cancer removal: In vivo feasibility study in a swine model

BACKGROUND AND OBJECTIVES

During minimally invasive surgery (MIS), it is impossible to directly detect marked clips around tumors via palpation. Therefore, we developed a novel method and device using Radio Frequency IDentification (RFID) technology to detect the position of clips during minimally invasive gastrectomy or colectomy.

METHODS

The feasibility of the RFID-based detection system was evaluated in an animal experiment consisting of seven swine. The primary outcome was to successfully detect the location of RFID clips in the stomach and colon. The secondary outcome measures were to detect time (time during the intracorporeal detection of the RFID clip), and accuracy (distance between the RFID clip and the detected site).

RESULTS

A total of 25 detection attempts (14 in the stomach and 11 in the colon) using the RFID antenna had a 100% success rate. The median detection time was 32.5 s (range, 15-119 s) for the stomach and 28.0 s (range, 8-87 s) for the colon. The median detection distance was 6.5 mm (range, 4-18 mm) for the stomach and 6.0 mm (range, 3-13 mm) for the colon.

CONCLUSIONS

We demonstrated favorable results for a RFID system that detects the position of gastric and colon tumors in real-time during MIS.

Use of endoscopy to determine the resection margin during laparoscopic gastrectomy for cancer

Background

It can be difficult to determine the transection line during totally laparoscopic surgery for early gastric cancer owing to lack of tactile feedback. This retrospective cohort study aimed to assess the role of intraoperative endoscopy in determining the resection margin in totally laparoscopic gastrectomy.

Methods

Consecutive patients with histologically confirmed gastric cancer who underwent laparoscopic gastrectomy between March 2012 and July 2015 were eligible. Preoperative placement of marking clips and intraoperative endoscopy were performed to determine the resection margin. Frozen-section analyses were also performed to confirm the absence of cancer cells at the surgical margin. Success was defined as the proportion of specimens with all clips present and by the proportion of resections with a negative surgical margin following initial transection.

Results

Total laparoscopic gastrectomy with intraoperative endoscopy was performed in 522 patients; a total of 662 surgical margins were analysed. The overall success rate was 99·8 per cent (661 of 662 margins). The success rate of achieving a negative surgical margin during the initial transection was 98·9 per cent (550 of 556 margins).

Conclusion

Preoperative placement of marking clips and intraoperative endoscopy is helpful in the determination of a safe surgical margin in patients with gastric cancer who undergo laparoscopic gastrectomy.

Simple and reliable method for tumor localization during totally laparoscopic gastrectomy: intraoperative laparoscopic ultrasonography combined with tattooing

We have developed a new method to localize a tumor during totally laparoscopic gastrectomy that uses intraoperative laparoscopic ultrasonography combined with preoperative clipping and tattooing. One or 2 days before the surgery, endoscopic clipping was performed just proximal to the tumor, followed by tattooing with India ink at the clipping site. Examination by intraoperative laparoscopic ultrasonography was performed at the tattooed site to detect the clips. The resection line of the stomach was determined with use of the detected clips as a marker of the proximal margin of the tumor. This method was attempted in 14 patients who underwent totally laparoscopic gastrectomy, and the clips were successfully identified in all patients. The clips were visualized as several layers of a hyperechoic bar, which was termed a "ladder sign." The mean time from insertion of the laparoscopic probe to identification of the clips was 2 min. The ladder sign is an important finding in this method.

Endoscopic marking clip with an IC tag and receiving antenna to detect localization during laparoscopic surgery

BACKGROUND

Conventional tattooing using India ink for preoperative marking during colonoscopy has been widely used. However, the ink used in this method can spread into the abdominal cavity and induce peritonitis. Therefore, we developed a new marking method using an endoscopic clip with an integrated circuit (IC) tag to accurately identify an objective location. We applied the novel method in laparoscopic surgery using a porcine model and also evaluated it with resected human gastrointestinal tissue.

METHODS

We placed an endoscopic clip with an IC tag through a forceps aperture in the gastrointestinal tract, by using a porcine surgery model. After the endoscopic procedure, we performed laparoscopic surgery and approached the receiving antenna in the abdominal cavity to detect the IC tag through the porcine intestine. In an ex vivo examination with human colon tissues, the clip with the IC tag was placed on the mucosal surface to determine its ability to be detected. The receiving antenna near the serosal side of the human colon segment accurately detected the clip with the IC tag.

RESULTS

We detected the clip with an IC tag with a detection device, by using a laparoscopic surgery model in vivo. We also confirmed its usefulness in five of five (100 %) human colon tissue samples tested ex vivo.

CONCLUSION

We developed a novel marking device using an IC tag to identify an objective location. We successfully demonstrated the usefulness of the clip with the IC tag and the antenna device used for its detection in a porcin laparoscopic surgery model and in resected human colon tissue.

A novel endoscopic fluorescent band ligation method for tumor localization

BACKGROUND

Accurate tumor localization is essential for minimally invasive surgery. This study describes the development of a novel endoscopic fluorescent band ligation method for the rapid and accurate identification of tumor sites during surgery.

METHODS AND MATERIALS

The method utilized a fluorescent rubber band, made of indocyanine green (ICG) and a liquid rubber solution mixture, as well as a near-infrared fluorescence laparoscopic system with a dual light source using a high-powered light-emitting diode (LED) and a 785-nm laser diode. The fluorescent rubber bands were endoscopically placed on the mucosae of porcine stomachs and colons. During subsequent conventional laparoscopic stomach and colon surgery, the fluorescent bands were assayed using the near-infrared fluorescence laparoscopy system.

RESULTS

The locations of the fluorescent clips were clearly identified on the fluorescence images in real time. The system was able to distinguish the two or three bands marked on the mucosal surfaces of the stomach and colon. Resection margins around the fluorescent bands were sufficient in the resected specimens obtained during stomach and colon surgery.

CONCLUSION

These novel endoscopic fluorescent bands could be rapidly and accurately localized during stomach and colon surgery. Use of these bands may make possible the excision of exact target sites during minimally invasive gastrointestinal surgery.

A Simplified Technique for Tumor Localization Using Preoperative Endoscopic Clipping and Radio-opaque Markers during Totally Laparoscopic Gastrectomy

Tumor localization during intracorporeal anastomosis after totally laparoscopic distal gastrectomy (TLDG) is challenging. The aim of this study was to assess the simplicity and feasibility of locating tumors in the stomach using radio-opaque markers and preoperative endoscopic clipping. The intra- and postoperative findings of 29 patients who underwent TLDG with intracorporeal anastomosis between January 2012 and March 2013 were reviewed. Preoperative endoscopic clips were applied just proximal to the tumor by specialized endoscopists, and surgical gauze with an attached radio-opaque marker (3 mm x 60 mm) was prepared. The marker was fixed to either the anterior or posterior of the stomach, above the predicted site of the tumor, using suture ties. Portable abdominal radiography was used during the laparoscopic surgery, and the stomach was resected using guidance by the radiomarker. The radio-opaque marker and the endoscopic clips were clearly visible by intraoperative abdominal radiography. All patients received curative resection. No complications or deaths were encountered. The mean distance between the endoscopic clips and the radiomarker by portable intraoperative radiography was 21.3 ± 18.3 mm, whereas the actual in situ mean distance was 20.7 ± 17.6 mm. This difference was not statistically significant ( P > 0.05). It is imperative that preoperative endoscopic clips are applied just proximal to the tumor by specialized endoscopists. The use of a radio-opaque marker is a simple and feasible way to locate tumors during totally laparoscopic gastrectomy.

A noble method for intraoperative fine localization during laparoscopic gastric local resection: endoscopic submucosal cutting and light transmission

BACKGROUND

The main requirements when performing laparoscopic local resection for early mucosal tumors of the stomach are a clearly defined cancer-free margin and precise tumor localization. In this study, a novel method for precise intraoperative tumor localization and appropriate resection in a porcine model is introduced: endoscopic submucosal cutting and light transmission (ESCLT).

METHODS

A total of 15 cases of laparoscopic local resection were performed in 6 pigs. The size of the target lesions was approximately 20 mm. The imaginary lesions were located in the high body anterior wall, posterior wall, lower body posterior wall, angle, and antrum anterior wall of the stomach. Mucosal marking around the lesions, mucosal precutting surrounding the marking, and submucosal cutting along the precutting line using white light endoscopy were sequentially performed. Next, an endoscopic light source was placed directly in front of the lesion. Exact oval-shaped submucosal cutting margins were identified via laparoscopy. Laparoscopic local resection was performed after the minimal distance from the stapler line to the submucosal cutting line was confirmed. The sizes of the mucosal marking, submucosal cutting line, and the entire resected mucosa and serosa were measured.

RESULTS

The procedure was completed successfully in all pigs. Local resection was completed on all of the lesions. The mean endoscopic and laparoscopic procedure times were 26.1 and 12.7 min, respectively. The mean size of the resected specimens was: (i) marking lesion, 22 × 19.5 mm; (ii) submucosal cutting line, 26.7 × 23.2 mm; (iii) entire resected mucosa, 37 × 31 mm; and (iv) entire resected serosa, 41.7 × 33.1 mm. There was no intraoperative morbidity.

CONCLUSION

ESCLT provides a precise and useful method of intraoperative tumor localization during laparoscopic local resection of the stomach in terms of minimizing the resection of normal stomach tissue and guaranteeing adequate mucosal safety margins.

[Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]

Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.

Development of a non-blurring, dual-imaging tissue marker for gastrointestinal tumor localization

BACKGROUND

Knowing the exact location of gastrointestinal tumors both preoperatively and intraoperatively is essential for planning and performing laparoscopic surgery. Different techniques have been introduced to ascertain tumor locations during surgery, but none of these are fully satisfactory at establishing the minimum margins for organ resection while retaining curability. A new, non-blurring tissue marker, detectable by both X-ray computed tomography (CT) and near-infrared (NIR) fluorescence laparoscopy, has been developed, and we here examine its utility using an animal model.

METHODS

Liposomes, comprised phospholipids and an NIR fluorescent dye (an indocyanine green derivative), and emulsions, consisting of phospholipids and oily radiographic contrast medium, were combined with polyglycerol-polyricinoleate to form giant cluster-like vesicles. This vesicular dispersion (300 μl) was administered into the porcine gastric submucosa using a gastroendoscope, and the detectability of the marker was examined using X-ray CT and NIR fluorescence laparoscopy.

RESULTS

One hour after the administration of the vesicular dispersion, X-ray CT identified four individual injection sites, each at a 1-cm radius of a metal hemostasis clip. NIR fluorescence laparoscopy detected individual fluorescent spots 18 hours after the administration of the vesicular dispersion.

CONCLUSION

We anticipate that this newly developed tissue marker will contribute to the preoperative simulation of laparoscopic gastrointestinal cancer surgery and its intraoperative navigation.

Gastroscopic image graph: application to noninvasive multitarget tracking under gastroscopy

Gastroscopic examination is one of the most common methods for gastric disease diagnosis. In this paper, a multitarget tracking approach is proposed to assist endoscopists in identifying lesions under gastroscopy. This approach analyzes numerous preobserved gastroscopic images and constructs a gastroscopic image graph. In this way, the deformation registration between gastroscopic images is regarded as a graph search problem. During the procedure, the endoscopist marks suspicious lesions on the screen and the graph is utilized to locate and display the lesions in the appropriate frames based on the calculated registration model. Compared to traditional gastroscopic lesion surveillance methods (e.g., tattooing or probe-based optical biopsy), this approach is noninvasive and does not require additional instruments. In order to assess and quantify the performance, this approach was applied to stomach phantom data and in vivo data. The clinical experimental results demonstrated that the accuracy at angularis, antral, and stomach body was 6.3 ± 2.4 mm, 7.6 ± 3.1 mm, and 7.9 ± 1.6 mm, respectively. The mean accuracy was 7.31 mm, average targeting time was 56 ms, and the P value was 0.032, which makes it an attractive candidate for clinical practice. Furthermore, this approach provides a significant reference for endoscopic target tracking of other soft tissue organs.

Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach

Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.

Development of a novel marking system for laparoscopic gastrectomy using endoclips with radio frequency identification tags: feasibility study in a canine model

BACKGROUND

Intraoperative identification of early gastric cancer is difficult to conduct during laparoscopic procedures. In this study, we investigated the feasibility and accuracy of a newly developed marking system using endoclips with radio frequency identification (RFID) tags in a canine model.

METHODS

RFID is a wireless near field communication technology. Among the open frequency bands available for medical use, 13.56 MHz is suitable for a surgical marking system because of the similar and linear signal decay both in air and in biological tissues. The proposed system consists of four parts: (a) endoclips with RFID tags, (b) endo-clip applier equipment, (c) laparoscopic locating probe, and (d) signal processing units with audio interface. In the experimental setting using canine models, RFID-tagged endoclips were applied to the mucosa of each dog's stomach. During the subsequent operation, the clips with RFID tags placed in five dogs were located by the detection of the RFID signal from the tag (RFID group), and the conventional clips in the other six dogs were located by finger palpation (FP group). The detected sites were marked by ablation on the serosal surface. Distance between the clips and the metal pin needles indicating ablated sites were measured with X-ray radiographs of the resected specimen.

RESULTS

All clips were successfully detected by the marking system in the RFID group (10/10) and by finger palpation in the FP group (17/17). The medians of detection times were 31.5 and 25.0 s, respectively; the distances were 5.63 and 7.62 mm, respectively. The differences were not statistically significant. No adverse event related to the procedures was observed.

CONCLUSIONS

Endoclips with RFID tags were located by our novel marking system in an experimental laparoscopic setting using canine stomachs with substantial accuracy comparable to conventional endoclips located by finger palpation through an open approach.

A novel endoscopic fluorescent clip visible with near-infrared imaging during laparoscopic surgery in a porcine model

BACKGROUND

In gastrointestinal cancer surgery, particularly in early cancer, accurate tumor localization is important in order to determine the extent of resection. In laparoscopic surgery, because of the inability to palpate the lesion, the most prevalent method of localization is endoscopic tattooing. However, complicated maneuvering makes it difficult to control local dye spreading and dye leakage into the intraperitoneal cavity. A simpler, safe method is needed. In this study, we developed a novel method for applying fluorescence-coated endoscopic clips to visualize locations inside the colon during laparoscopic surgery. We tested the procedure in an in vivo porcine model and with ex vivo human colon tissues.

METHODS

Bovine serum albumin was conjugated to indocyanine green or the succinimidyl ester CF™ 790 to form a pasty mixture, which was used to coat the front ends of endoscopic clips. The fluorescence-coated clips were endoscopically placed on the mucosal surface of a porcine colon. Using an Olympus near-infrared laparoscopy system, we attempted to identify the fluorescent clips from the outer, serosal side of the porcine colon during laparoscopic surgery in vivo. The clips were also evaluated using ex vivo human colon tissues.

RESULTS

After placing two clips on the inner, mucosal surface of the porcine colon, we used near-infrared laparoscopy to view them from the outer, serosal surface of the colon in real time during in vivo laparoscopic surgery. We also identified the fluorescence-coated clips through human colon tissues in an ex vivo study.

CONCLUSIONS

We developed a novel, fluorescence-coated clip that can be placed endoscopically for rapid, exact localization of colonic lesions. The clips were successfully visualized with near-infrared fluorescence imaging during laparoscopic surgery in an in vivo porcine model and in ex vivo human colon tissues.

Efficacy of intraoperative gastroscopy for tumor localization in totally laparoscopic distal gastrectomy for cancer in the middle third of the stomach

BACKGROUND

Determining resection margins for gastric cancer, which generally is not exposed to the serosal surface of the stomach, is the most important priority during totally laparoscopic gastrectomy (TLG). This study aimed to evaluate the usefulness of intraoperative gastroscopy for direct marking of tumors during TLG for gastric cancer in the middle third of the stomach.

METHODS

From May 2011 through July 2012, 20 patients with a diagnosis of adenocarcinoma in the middle third of the stomach were enrolled in this case series. Preoperative gastroscopy for tumor localization was not performed for these patients. After the first portion of the duodenum was mobilized from the pancreas and clamped with a laparoscopic intestinal clamp, 2-3 ml of indigo carmine was administered through an endoscopic injector into the gastric muscle layer at the proximal margin of the tumor.

RESULTS

Based on intraoperative gastroscopic findings, distal subtotal gastrectomy was performed for 18 patients, with the authors deciding to perform total gastrectomy for two patients. A specimen was extracted after distal gastrectomy to confirm sufficient distance from the resection margin to the tumor before reconstruction. All the patients had tumor-free margins and required no additional resection. No morbidity related to gastroscopic procedure occurred, and the time required has been gradually decreased to about 5 min.

CONCLUSIONS

Intraoperative gastroscopy for tumor localization is an accurate and comfortable method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

Clinical impact of tumor infiltration at the transected surgical margin during gastric cancer surgery

BACKGROUND

When transected surgical margins are involved by tumor cells during gastrectomy for gastric cancer, dissemination of tumor cells to the peritoneal cavity may be a concern.

OBJECTIVES

The aim of this study is to evaluate the prognostic value of tumor infiltration at the transected surgical margin during gastrectomy.

METHODS

A total of 1,717 patients with gastric cancer who underwent R0 gastrectomy were included. The relationship between positive margins on frozen biopsy during gastrectomy and clinicopathologic data was examined. The prognostic impact of this intraoperative event was evaluated by univariate and multivariate analysis.

RESULTS

The intraoperative positive resection margin occurred in 69 patients (4.01%). Tumor size >5 cm, tumor located in the upper third or whole stomach, Bormann type IV gastric cancer, and signet ring cell histology were independent factors associated with that intraoperative event. pT and pN stages were significant prognostic factors associated with locoregional and/or peritoneal recurrence and overall recurrence. Tumor infiltration at the transected margin was not an independent prognostic factor associated with any recurrence.

CONCLUSIONS

Microscopic tumor involvement at the margin during gastric cancer surgery does not increase locoregional and/or peritoneal recurrence or overall recurrence independently if R0 resection is achieved by re-resection of the margin.

Comparison of laparoscopy-assisted and totally laparoscopic Billroth-II distal gastrectomy for gastric cancer

Purpose

In laparoscopic distal gastrectomy for gastric cancer, most surgeons prefer extra-corporeal anastomosis because of technical challenges and unfamiliarity with intra-corporeal anastomosis. Herein, we report the feasibility and safety of intra-corporeal Billroth-II anastomosis in gastric cancer.

Methods

From April 2004 to March 2011, 130 underwent totally laparoscopic distal gastrectomy with intra-corporeal Billroth-II reconstruction, and 269 patients underwent laparoscopy-assisted distal gastrectomy with extra-corporeal Billroth-II reconstruction. Surgical efficacies and outcomes between two groups were compared.

Results

There were no differences in demographics and clinicopathological characteristics. The mean operation and reconstruction times of totally laparoscopic distal gastrectomy were statistically shorter than laparoscopy-assisted distal gastrectomy (P = 0.019; P < 0.001). Anastomosis-related complications were observed in 11 (8.5%) totally laparoscopic distal gastrectomy and 21 (7.8%) laparoscopy-assisted distal gastrectomy patients, and the incidence of these events was not significantly different. Post-operative hospital stays for totally laparoscopic distal gastrectomy were shorter than laparoscopy-assisted distal gastrectomy patients (8.3 ± 3.2 days vs. 9.9 ± 5.3 days, respectively; P = 0.016), and the number of times parenteral analgesic administration was required in laparoscopy-assisted distal gastrectomy patients was more frequent after surgery.

Conclusion

Intra-corporeal Billroth-II anastomosis is a feasible procedure and can be safely performed with the proper experience for laparoscopic distal gastrectomy. This method may be less time consuming and may produce a more cosmetic result.

Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing

BACKGROUND

Knowledge of the intraoperative location of lesions is a prerequisite for deciding the proper extent of gastric resection or the choice of anastomosis technique during totally laparoscopic distal gastrectomy (TLDG) for early gastric cancer (EGC). In this study we introduce a novel tumor localization method for TLDG: endoscopic blood tattooing.

METHODS

Twenty-three consecutive patients scheduled for TLDG for EGC were enrolled in this prospective study. The day before surgery, 2-3 ml of autologous blood was injected into the gastric muscle layer at 3-4 cm proximal to the lesion during endoscopy.

RESULTS

The study subjects consisted of 15 males and 8 females with a mean age of 61 ± 10.4 years. During surgery, the endoscopic blood tattooed sites were successfully identified in all 23 patients. No complications associated with the procedure occurred, and no patient had microscopic residual tumor cells at the proximal resection margin, with a mean proximal margin length of 3.3 ± 2.7 cm. Eighteen patients underwent TLDG with Billroth II anastomosis, four patients with Roux-en-Y gastrojejunostomy, and one patient with laparoscopic total gastrectomy. At final pathologic examinations, 20 patients were of stage IA and 3 were of stage IB according to the UICC TNM classification (6th ed.).

CONCLUSIONS

Endoscopic blood tattooing provides a simple and useful means of localizing lesions during TLDG for EGC. Although the superiority of this technique over other localization methods needs to be evaluated further, the authors recommend endoscopic blood tattooing as an alternative to other intraoperative localization methods for laparoscopic surgery for EGC.

A novel endoscopic fluorescent clip for the localization of gastrointestinal tumors

BACKGROUND

Accurate tumor localization is essential for gastrointestinal surgery, especially in cases of early cancer. This study was designed to develop a novel fluorescent clip for rapid and exact visualization of tumor sites.

METHODS

A transparent polymer matrix containing highly bright fluorochromes was coated on the front end of endoscopic clips. The fluorescent clips were placed on the mucosal surface of a porcine colon and stomach, and the operator then attempted to identify the fluorescent clips from the outer serosal side of the colon and stomach. A 532-nm diode laser and filter glass were used for visualizing the fluorescence signals through the colonic tissue. A 650-nm diode laser and a digital charge-coupled device (CCD) camera equipped with a bandpass emission filter were used for the imaging of the fluorescent clips through the thick stomach tissue.

RESULTS

When a green light from a 532-nm diode laser (power density=0.35 mW/cm2) was applied on the serosal surface of the porcine colon, we could identify all clips that had been placed endoscopically on the mucosal surface of the inner colonic wall. By using the light from a 650-nm diode laser (power density=0.7 mW/cm2), we identified all fluorescent clips through the stomach wall in real time. Similar results were also obtained with the filtered xenon lamp.

CONCLUSION

An endoscopic fluorescent clip can be useful for the rapid and exact localization of tumors, and this technique can also be useful during laparoscopic surgery.

Image-based Approach for Surgical Resection of Gastric Submucosal Tumors

Purpose

This study was done to evaluate the usefulness of preoperative computed tomography (CT) and intraoperative laparoscopic ultrasound to facilitate treatment of gastric submucosal tumors.

Materials and Methods

The feasibility of laparoscopic wedge resection as determined by CT findings of tumor size, location, and growth pattern was correlated with surgical findings in 89 consecutive operations. The role of laparoscopic ultrasound for tumor localization was analyzed.

Results

Twenty-three patients were considered unsuitable for laparoscopic wedge resection because of large tumor size (N=13) or involvement of the gastroesophageal junction (N=9) or pyloric channel (N=1). Laparoscopic wedge resection was not attempted in 11 of these patients because of large tumor size. Laparoscopic wedge resection was successfully performed in 65 of 66 (98.5%) patients considered suitable for this procedure. Incorrect interpretation of preoperative CT resulted in a change of surgery type in seven patients (7.9%): incorrect CT diagnosis on gastroesophageal junction involvement (N=6) and on growth pattern (N=1). In 18 patients without an exophytic growth pattern, laparoscopic ultrasound was necessary and successfully localized all lesions.

Conclusions

Preoperative CT and laparoscopic ultrasound are useful for surgical planning and tumor localization in laparoscopic wedge resection.

Intraoperative portable abdominal radiograph for tumor localization: a simple and accurate method for laparoscopic gastrectomy

BACKGROUND

During laparoscopic gastrectomy, it is impossible to identify early gastric cancer (EGC) lesions; therefore, a precise localization technique is required. In this study, we evaluated a novel method of intraoperative portable abdominal radiograph for localization of EGC lesions after preoperative endoscopic clipping.

METHODS

A retrospective study of 80 patients who had undergone laparoscopic gastrectomies with our intraoperative abdominal radiographic method of tumor localization was performed. During preoperative endoscopy, endoscopic metal clips were applied just proximal to the tumor. A plain abdominal radiograph taken immediately after oral administration of effervescent agents was employed to select candidates for intraoperative localization. Intraoperative vessel clips were laparoscopically applied along the greater and lesser curvatures, and a portable abdominal radiograph was taken to identify the location of endoscopic clips relative to laparoscopic vessel clips.

RESULTS

In all patients, endoscopic clips were applied proximal to the lesion without complications. Both intraluminally and extraluminally placed clips were successfully detected by intraoperative portable abdominal radiograph in all patients. Mean ± standard deviation (SD) proximal margin length was 34.2 ± 20.2 mm. All patients had tumor-free resection margin.

CONCLUSIONS

Preoperative endoscopic clipping and intraoperative portable abdominal radiograph is an accurate and simple tumor localization method in laparoscopic gastrectomy.

Safety of modified double-stapling end-to-end gastroduodenostomy in distal subtotal gastrectomy

BACKGROUND AND OBJECTIVES

Double-stapling end-to-end gastroduodenostomy (DS-BI) has several potential advantages over other anastomotic techniques in that it is a simple procedure, with no additional gastrotomy on the remnant stomach, and less tension on the anastomosis site. We evaluated the safety of DS-BI by comparing it with the hand-sewn Billroth II gastrojejunostomy (B-II).

METHODS

Medical records of 933 consecutive patients (DS-BI 428, B-II 505) who underwent distal subtotal gastrectomy were retrospectively reviewed. Several clinicopathological features and treatment results were compared between the two groups.

RESULTS

The overall complication rates were 9.3% in the DS-BI group and 15.2% in the B-II group (P = 0.007). Anastomosis-related complications, such as anastomosis-site leakage, stenosis, and intraluminal bleeding, did not differ between the two groups (1.2% in the DS-BI group and 1.8% in the B-II group, P = 0.59). All the anastomosis-related complications were managed conservatively. Postoperative mortality rates were 0% in the DS-BI group and 0.4% (2/505) in the B-II group.

CONCLUSIONS

Modified DS-BI is a safe procedure, with short-term results similar to those of hand-sewn Billroth II anastomosis.

Combined endoscopic and laparoscopic approach for palliative resection of metastatic melanoma of the stomach

Background

Metastatic tumours of the stomach present a clinical dilemma for the surgeon. Palliative surgical resection can alleviate symptoms and prolong survival in selected patients. However, previous studies have used open methods of surgical resection with potentially high morbidity and mortality. We describe the use of laparoscopic wedge resection of the stomach for palliative resection of metastatic melanoma to highlight the benefits of this technique.

Case presentation

A 58 year old male was investigated for iron deficiency anaemia while under treatment for pulmonary metastatic malignant melanoma. An upper gastrointestinal endoscopy revealed a 5 cm diameter ulcer on the anterior wall of the stomach, biopsies from the ulcer confirmed metastatic melanoma. Laparoscopic wedge resection of the stomach lesion was performed without complication.

Conclusion

Laparoscopic approach has many benefits and is useful for the palliative resection of rare tumours of the stomach in order to preserve the quality of life. Its use should be considered in selected patients.