Fluorescence lymphangiography-guided full-thickness oncologic gastric resection
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.
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.
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.
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.
KeywordsNear-infrared fluorescence guided surgery Full-thickness resection Sentinel node navigation surgery Image guided surgery Dynamic MRI Capillary lactate test
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.
Compliance with ethical standards
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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- 2.Ahn HS, Lee HJ, Hahn S, Kim WH, Lee KU, Sano T, Edge SB, Yang HK (2010) Evaluation of the seventh American Joint Committee on Cancer/International Union Against Cancer Classification of gastric adenocarcinoma in comparison with the sixth classification. Cancer 116:5592–5598CrossRefPubMedGoogle Scholar
- 3.Kitagawa Y, Takeuchi H, Takagi Y, Natsugoe S, Terashima M, Murakami N, Fujimura T, Tsujimoto H, Hayashi H, Yoshimizu N, Takagane A, Mohri Y, Nabeshima K, Uenosono Y, Kinami S, Sakamoto J, Morita S, Aikou T, Miwa K, Kitajima M (2013) Sentinel node mapping for gastric cancer: a prospective multicenter trial in Japan. J Clin Oncol 31:3704–3710CrossRefPubMedGoogle Scholar
- 9.Kong SH, Noh YW, Suh YS, Park HS, Lee HJ, Kang KW, Kim HC, Lim YT, Yang HK (2015) Evaluation of the novel near-infrared fluorescence tracers pullulan polymer nanogel and indocyanine green/gamma-glutamic acid complex for sentinel lymph node navigation surgery in large animal models. Gastric Cancer 18:55–64CrossRefPubMedGoogle Scholar
- 15.Diana M, Halvax P, Pop R, Schlagowski I, Bour G, Liu YY, Legner A, Diemunsch P, Geny B, Dallemagne B, Beaujeux R, Demartines N, Marescaux J (2015) Gastric supply manipulation to modulate ghrelin production and enhance vascularization to the cardia: proof of the concept in a porcine model. Surg Innov 22:5–14CrossRefPubMedGoogle Scholar
- 16.Diana M, Dallemagne B, Chung H, Nagao Y, Halvax P, Agnus V, Soler L, Lindner V, Demartines N, Diemunsch P, Geny B, Swanstrom L, Marescaux J (2014) Probe-based confocal laser endomicroscopy and fluorescence-based enhanced reality for real-time assessment of intestinal microcirculation in a porcine model of sigmoid ischemia. Surg Endosc 28:3224–3233CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Diana M, Halvax P, Dallemagne B, Nagao Y, Diemunsch P, Charles AL, Agnus V, Soler L, Demartines N, Lindner V, Geny B, Marescaux J (2014) Real-time navigation by fluorescence-based enhanced reality for precise estimation of future anastomotic site in digestive surgery. Surg Endosc 28:3108–3118CrossRefGoogle Scholar
- 18.Diana M, Pop R, Beaujeux R, Dallemagne B, Halvax P, Schlagowski I, Liu YY, Diemunsch P, Geny B, Lindner V, Marescaux J (2015) Embolization of arterial gastric supply in obesity (EMBARGO): an endovascular approach in the management of morbid obesity. Proof of the concept in the porcine model. Obes Surg 25:550–558CrossRefGoogle Scholar
- 23.Yoshida M, Kubota K, Kuroda J, Ohta K, Nakamura T, Saito J, Kobayashi M, Sato T, Beck Y, Kitagawa Y, Kitajima M (2012) Indocyanine green injection for detecting sentinel nodes using color fluorescence camera in the laparoscopy-assisted gastrectomy. J Gastroenterol Hepatol 27(Suppl 3):29–33CrossRefPubMedGoogle Scholar
- 24.Park JW, Sohn DK, Hong CW, Han KS, Choi DH, Chang HJ, Lim SB, Choi HS, Jeong SY (2008) The usefulness of preoperative colonoscopic tattooing using a saline test injection method with prepackaged sterile India ink for localization in laparoscopic colorectal surgery. Surg Endosc 22:501–505CrossRefGoogle Scholar
- 27.Goto O, Takeuchi H, Kawakubo H, Matsuda S, Kato F, Sasaki M, Fujimoto A, Ochiai Y, Horii J, Uraoka T, Kitagawa Y, Yahagi N (2015) Feasibility of non-exposed endoscopic wall-inversion surgery with sentinel node basin dissection as a new surgical method for early gastric cancer: a porcine survival study. Gastric Cancer 18:440–445CrossRefPubMedGoogle Scholar
- 33.Diana M, Agnus V, Halvax P, Liu YY, Dallemagne B, Schlagowski AI, Geny B, Diemunsch P, Lindner V, Marescaux J (2015) Intraoperative fluorescence-based enhanced reality laparoscopic real-time imaging to assess bowel perfusion at the anastomotic site in an experimental model. Br J Surg 102:e169–e176CrossRefPubMedGoogle Scholar
- 36.Curcic J, Sauter M, Schwizer W, Fried M, Boesiger P, Steingoetter A (2015) Validation of a golden angle radial sequence (GOLD) for abdominal T1 mapping during free breathing: demonstrating clinical feasibility for quantifying gastric secretion and emptying. J Magn Reson Imaging 41:157–164CrossRefPubMedGoogle Scholar
- 39.Kwiatek MA, Fox MR, Steingoetter A, Menne D, Pal A, Fruehauf H, Kaufman E, Forras-Kaufman Z, Brasseur JG, Goetze O, Hebbard GS, Boesiger P, Thumshirn M, Fried M, Schwizer W (2009) Effects of clonidine and sumatriptan on postprandial gastric volume response, antral contraction waves and emptying: an MRI study. Neurogastroenterol Motil 21:928–971CrossRefPubMedGoogle Scholar