Laparoscopic subtotal gastrectomy with a new marking technique, endoscopic cautery marking: preservation of the stomach in patients with upper early gastric cancer
- 383 Downloads
Laparoscopic subtotal gastrectomy (LsTG) has several advantages, including technical safety and preservation of postoperative function, compared with total or proximal gastrectomy for early gastric cancer. However, LsTG has some technical issues with respect to achieving a safe resection margin and patency in patients with lesions close to the cardia or fornix. When LsTG is performed for lesions located rather close to the cardia or fornix, conventional marking clips can physically hinder transection by an endoscopic linear stapler. Additionally, tracing the tumor boundary to create a precise resection line is difficult. To resolve these issues, we introduced a new marking technique called endoscopic cautery marking (ECM) involving the creation of small cauterized spots.
Of 791 patients who underwent laparoscopic gastrectomy from 2015 to 2017, 16 underwent LsTG with ECM. Before surgery, ECM was performed and the pathological tumor boundary was traced according to preoperative biopsies. Under intraoperative endoscopic guidance, we divided the stomach with an endoscopic linear stapler on the proximal side of the ECM site and examined the stump by pathological frozen section analysis to confirm the absence of cancer.
The median length of the endoscopically measured distance from the esophagogastric junction to the tumor was 30.0 mm (range 15–40 mm), and the median pathological proximal margin was 11.5 mm (range 0–26 mm). Although the ECM site was completely resected in all patients, frozen section analysis showed a positive margin in one lesion, which had an unclear tumor boundary due to gastritis. For this patient, we converted the procedure to laparoscopic completion gastrectomy. No severe complications or recurrences occurred.
LsTG with ECM was technically feasible, and short-term outcomes were acceptable in this preliminary study. Further experience and investigations are imperative to verify the oncological and functional implications of LsTG with ECM.
KeywordsGastric cancer Minimally invasive surgery Preservation Surgical diagnostic technique Gastrectomy Surgical margin
Compliance with ethical standards
Drs. Satoshi Kamiya, Manabu Ohashi, Naoki Hiki, Satoshi Ida, Koshi Kumagai, Souya Nunobe, and Takeshi Sano have no conflict of interest or financial ties to disclose.
Supplementary Video 1 (MP4 252243 KB)
- 1.Hiki N, Katai H, Mizusawa J, Nakamura K, Nakamori M, Yoshikawa T, Kojima K, Imamoto H, Ninomiya M, Kitano S, Terashima M, Stomach Cancer Study Group of Japan Clinical Oncology Group (2017) Long-term outcomes of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG0703). Gastric Cancer 21(1):155–161CrossRefGoogle Scholar
- 2.Katai H, Mizusawa J, Katayama H, Takagi M, Yoshikawa T, Fukagawa T, Terashima M, Misawa K, Teshima S, Koeda K, Nunobe S, Fukushima N, Yasuda T, Asao Y, Fujiwara Y, Sasako M (2017) Short-term surgical outcomes from a phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer: Japan Clinical Oncology Group Study JCOG0912. Gastric Cancer 20(4):699–708CrossRefGoogle Scholar
- 13.Okada K, Fujisaki J, Kasuga A, Omae M, Hirasawa T, Ishiyama A, Inamori M, Chino A, Yamamoto Y, Tsuchida T, Nakajima A, Hoshino E, Igarashi M (2011) Diagnosis of undifferentiated type early gastric cancers by magnification endoscopy with narrow-band imaging. J Gastroenterol Hepatol 26(8):1262–1269CrossRefGoogle Scholar
- 14.Horiuchi Y, Fujisaki J, Yamamoto N, Shimizu T, Miyamoto Y, Tomida H, Omae M, Ishiyama A, Yoshio T, Hirasawa T, Yamamoto Y, Tsuchida T, Igarashi M, Takahashi H (2016) Accuracy of diagnostic demarcation of undifferentiated-type early gastric cancers for magnifying endoscopy with narrow-band imaging: endoscopic submucosal dissection cases. Gastric Cancer 19(2):515–523CrossRefGoogle Scholar
- 15.Horiuchi Y, Fujisaki J, Yamamoto N, Shimizu T, Omae M, Ishiyama A, Yoshio T, Hirasawa T, Yamamoto Y, Tsuchida T, Igarashi M, Takahashi H (2017) Accuracy of diagnostic demarcation of undifferentiated-type early gastric cancer for magnifying endoscopy with narrow-band imaging: surgical cases. Surg Endosc 31(4):1906–1913CrossRefGoogle Scholar
- 16.Asada-Hirayama I, Kodashima S, Sakaguchi Y, Ono S, Niimi K, Mochizuki S, Tsuji Y, Minatsuki C, Shichijo S, Matsuzaka K, Ushiku T, Fukayama M, Yamamichi N, Fujishiro M, Koike K (2016) Magnifying endoscopy with narrow-band imaging is more accurate for determination of horizontal extent of early gastric cancers than chromoendoscopy. Endosc Int Open 4(6):E690–E698Google Scholar
- 17.Numata N, Oka S, Tanaka S, Yoshifuku Y, Miwata T, Sanomura Y, Arihiro K, Shimamoto F, Chayama K (2016) Useful condition of chromoendoscopy with indigo carmine and acetic acid for identifying a demarcation line prior to endoscopic submucosal dissection for early gastric cancer. BMC Gastroenterol 16(1):72CrossRefGoogle Scholar
- 20.Squires MH 3rd, Kooby DA, Pawlik TM, Weber SM, Poultsides G, Schmidt C, Votanopoulos K, Fields RC, Ejaz A, Acher AW, Worhunsky DJ, Saunders N, Jin LX, Levine E, Cho CS, Bloomston M, Winslow E, Cardona K, Staley CA 3rd, Maithel SK (2014) Utility of the proximal margin frozen section for resection of gastric adenocarcinoma: a 7-Institution Study of the US Gastric Cancer Collaborative. Ann Surg Oncol 21(13):4202–4210CrossRefGoogle Scholar
- 22.Raziee HR, Cardoso R, Seevaratnam R, Mahar A, Helyer L, Law C, Coburn N (2012) Systematic review of the predictors of positive margins in gastric cancer surgery and the effect on survival. Gastric Cancer 15(Suppl 1):S116–S124Google Scholar
- 27.Postlewait LM, Squires MH 3rd, Kooby DA, Poultsides GA, Weber SM, Bloomston M, Fields RC, Pawlik TM, Votanopoulos KI, Schmidt CR, Ejaz A, Acher AW, Worhunsky DJ, Saunders N, Swords D, Jin LX, Cho CS, Winslow ER, Cardona K, Staley CA, Maithel SK (2015) The importance of the proximal resection margin distance for proximal gastric adenocarcinoma: a multi-institutional study of the US Gastric Cancer Collaborative. J Surg Oncol 112(2):203–207CrossRefGoogle Scholar
- 30.Tokuhara T, Nakata E, Tenjo T, Kawai I, Satoi S, Inoue K, Araki M, Ueda H, Higashi C (2017) A novel option for preoperative endoscopic marking with India ink in totally laparoscopic distal gastrectomy for gastric cancer: a useful technique considering the morphological characteristics of the stomach. Mol Clin Oncol 6(4):483–486CrossRefGoogle Scholar