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Fluorescence lymphangiography-guided full-thickness oncologic gastric resection

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Abstract

Background

We aimed to assess the feasibility of a novel hybrid endoscopic/laparoscopic non-exposed, full-thickness, single-wall gastric resection technique guided by a fluorescence lymphangiography to identify the lymphatic pathway and the sentinel node basin.

Methods

Eight large white pigs (4 acute and 4 survival models) were included. Indocyanine green was injected submucosally around a pseudo-tumor at four points (1 ml, 0.1 mg/ml). The lymphatic spreading pathway was identified by the means of near-infrared (NIR) laparoscopic camera, and the resection line was planned outside of the fluorescent signals, to include all the potential lymphatic channels. Lymph node (LN) dissection was performed at greater curvature side and the infrapyloric area preserving the infragastric artery for all pigs. At the lesser curvature, 3–4 branches of the gastric artery were preserved in all acute and in two survival (group A), while in the remaining animals, 1–2 branches were preserved (group B). Perfusion of the remaining stomach was examined by NIR angiography. The gastric motility and function were evaluated by the means of a dynamic MRI immediately after the procedure and repeated after 1 week in surviving animals.

Results

The hybrid full-thickness resection with bilateral sentinel LN basin dissection were successfully performed with no intra-operative or post-operative complications. The removed specimen was including all the area with florescent signal. The remaining stomach demonstrated a good perfusion at the NIR angiography. The dynamic MRI revealed a preserved emptying function in the acute animals and in the group A, and a loss of function in the group B.

Conclusions

Fluorescence-lymphangiography guided hybrid resection was feasible to remove a relatively large part of the stomach including the lymphatic spreading pathway and sentinel basin. The extent of dissection in the lesser curvature side can affect the post-operative function and further researches are warranted to optimize the concept.

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Acknowledgements

This study was supported by an IHU-Strasbourg feasibility Grant (PI: Pr. Seong-Ho Kong) and by the ELIOS (Endoscopic Luminescent Imaging for precision Oncologic Surgery) project grant. Michele Diana is the recipient of the ELIOS project grant from the ARC foundation for Cancer Research, aiming at the development of fluorescence-guided surgery.

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Authors and Affiliations

  1. IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France

    Seong-Ho Kong, Francesco Marchegiani, Renato Soares, Jacques Marescaux & Michele Diana

  2. Department of Surgery, Seoul National University Hospital, Seoul, South Korea

    Seong-Ho Kong, Yun-Suhk Suh, Hyuk-Joon Lee & Han-Kwang Yang

  3. IRCAD, Research Institute against Cancer of the Digestive System, 1, Place de l’Hôpital, 67091, Strasbourg, France

    Yu-yin Liu, Bernard Dallemagne, Jacques Marescaux & Michele Diana

  4. Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan

    Yu-yin Liu

  5. Cancer Research Institute, Seoul National University Hospital, Seoul, South Korea

    Hyuk-Joon Lee & Han-Kwang Yang

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  1. Seong-Ho Kong
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  2. Francesco Marchegiani
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Correspondence to Michele Diana.

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Disclosures

Jacques Marescaux is the President of both IRCAD and IHU-Strasbourg Institutes, which are partly funded by Karl Storz, Medtronic and Siemens. Authors Seong-Ho Kong, Francesco Marchegiani, Renato Soares, Yu-Yin Liu, Yun-Suhk Suh, Hyuk-Joon Lee, Dallemagne B, Han-Kwang Yang and Michele Diana have no conflicts of interest or financial ties to disclose.

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Kong, SH., Marchegiani, F., Soares, R. et al. Fluorescence lymphangiography-guided full-thickness oncologic gastric resection. Surg Endosc 33, 620–632 (2019). https://doi.org/10.1007/s00464-018-6402-y

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