A Promising Method for Tumor Localization during Total Laparoscopic Distal Gastrectomy: Preoperative Endoscopic Clipping based on Negative Biopsy and Selective Intraoperative Radiography Findings

Abstract

PurposePrecise localization of tumors and creation of sufficient proximal resection margins are complicated processes during total laparoscopic distal gastrectomy (TLDG) for clinical T1/T2 gastric cancers. Various solutions to this problem have also yielded many disadvantages. In this study, we reviewed a preoperative endoscopic clipping method based on the results of negative biopsy and selective intraoperative radiography.Materials and MethodsA retrospective review of 345 consecutive patients who underwent TLDG and preoperative endoscopic clipping for tumor localization was conducted. During preoperative endoscopy, the endoscopists performed negative biopsies just 1–2 cm selectively above the tumor's upper limit. After confirming the biopsy results, endoscopic metal clips were applied just proximal to the negative biopsy site the day before surgery. Selective intraoperative tumor localization using portable abdominal radiography was performed only when we could not ensure a precise resection line.ResultsNegative biopsy was performed in 244 patients. Larger tumor size (P=0.008) and more distally located tumors (P=0.052) were observed more frequently in the negative biopsy group than in the non-negative biopsy group. The non-negative biopsy group had significantly higher frequencies of differentiated tumor types than the negative biopsy group (P=0.003). Of the 244 patients who underwent negative biopsies, 6 had cancer cells in their biopsy specimens. We performed intraoperative radiography in 12 patients whose tumors had difficult-to-determine proximal margins. No tumors were found in the proximal resection margins of any patients.ConclusionsOur tumor localization method is a promising and accurate method for securing a sufficient resection margin during TLDG.

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

“…However, one of the major disadvantages of this method is that it may cause intraperitoneal spraying and make locating the tumor, as well as dissecting the lymph nodes, more difficult [ 10 ]. Real time intraoperative endoscopic location of the tumor is another frequently used method; however, this approach increases the workload of endoscopists and leads to a prolonged operation time [ 11 ]. In addition, performing the surgery may become more difficult as a result of the limited space caused by gastrointestinal tract distention.…”

Simple and Reliable Method for Gastric Subepithelial Tumor Localization Using Endoscopic Tattooing before Totally Laparoscopic Resection

“…Pre-operative three-dimensional computed tomography (3D-CT) reconstruction has the disadvantages of requiring endoscopic clipping before CT scan and cooperation with a radiologist for 3D reconstruction [ 11 , 26 ]. Endoscopic clipping needs intraoperative X-ray or laparoscopic ultrasonography for localization due to the lack of tactile sensation inherited from total laparoscopic surgery [ 27 ]. Three recently developed methods, the magnetic clip, fluorescent clip, and radio-frequency identification clip, need expensive detection systems in the operative room [ 14 , 28 , 29 ].…”

Development of a New Laparoscopic Detection System for Gastric Cancer Using Near-Infrared Light-Emitting Clips with Glass Phosphor

“…To overcome this problem, two combination methods have recently been reported to precisely determine the resection margin. One method is intraoperative endoscopy in combination with laparoscopic surgery [ 10 ], and the other is preoperative endoscopic clipping in combination with intraoperative radiography [ 11 ]. However, these two methods require an additional diagnostic apparatus and manpower.…”