Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Summary

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Abstract

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

Introduction

Laparoscopic surgery has been become the treatment of choice for early gastric cancer in East Asian countries, including Korea and Japan.¹ The advantage of this surgery has been well demonstrated in several clinical trials for early gastric cancer (EGC).^2-4 Most of the procedures in these trials were accomplished by laparoscopy, but identification of the tumor location, resection of the stomach, including the primary tumor, and reconstruction were performed via minilaparotomy. Therefore, surgery requiring minilaparotomy has been labeled "laparoscopy-assisted gastrectomy."

Recently, however, surgical procedures ....

Protocol

Ethics Statement: This procedure involving human subjects has been approved by the Institutional Review Board (IRB) at Ajou University Hospital.

1. Preparation for Surgery

1. Allow a soft diet one day before surgery, with nothing by mouth after midnight before the surgery.
   Note: Do not insert a nasogastric tube before and during the surgery. This protocol does not use any tube to deflate the stomach. Instead of that, the intra-gastric gas can be aspirated by laparoscopic puncture needle if the stomach is distended causing limited view for laparoscopic surgery.
2. After placing the patient on the operating table, admin....

Results

Of 20 patients who underwent intraoperative gastroscopy, 18 underwent distal subtotal gastrectomy, guided by findings at gastroscopy. However, we performed total gastrectomy on two patients, because the proximal tumor margin was too close to the esophagogastric junction, as determined on intraoperative gastroscopy. The distance from the tumor to the proximal resection margin was 3.5 cm and 2.5 cm in these two patients, respectively (Table 1).

Discussion

In this protocol, we introduced a procedure for intraoperative gastroscopy to accurately and reliably identify tumor location in the middle third of the stomach. We were able to successfully perform distal subtotal gastrectomy based on the findings of intraoperative gastroscopy.

To date, various methods have been applied to identify the location of early gastric cancer in the laparoscopic view. Most common methods used preoperative gastroscopic clipping, and surgeons could detect the location .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Pentothal Sodium	JW pharmatheutical Co.	644912100	It was used as induction asgent
Rocumeron	Ilsung pharmatheutical Co.	655402960	It was used for general anesthestia as muscle relaxant.
SevoFRAN	Hana pharmatheutical Co.	657801060	It was used as general anesthetics
Endoscopy system	Olympus Corp.	CLV-260	It was used for intraoperative GFS
Laparoscopic surgery system	Striker Endoscopy	1488 HD 3-CHIP	It was a system for laparoscopic surgery
Ultrasonic scissor	Johnson and Johnson Medical Corp.	HAR23	It was used during tissue dissection
Laparoscopic clip	Johnson and Johnson Medical Corp.	ER420	It was used for ligation of the vessels.
Indigo carmine	Korea United Pharma	Carmine	It was injected into the gastric wall
Linear stapler	Johnson and Johnson Medical Corp.	ECHELON FLEX Powered Endopath Stapler	It was used for resection the stomach
Gastroscopic injector	TaeWoong Medical	Cobra injector	I was used for gastroscopic injection of blue dye