Name: intraoperative gastroscopy for tumor localization in laparoscopic surgery for gastric adenocarcinoma
Uploaded: 2016-08-09T13:00:00
Description: Watch this Scientific Journal Video about Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma at JoVE.com

This study was supported by a grant from the National R&amp;D Program for Cancer Control, Ministry of Health &amp; Welfare, Republic of Korea (1320270).

Ethics Statement: This procedure involving human subjects has been approved by the Institutional Review Board (IRB) at Ajou University Hospital.
1. Preparation for Surgery
<ol>
	<li>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 punctu...

<ol>
	<li>Kim, Y. W., Yoon, H. M., Eom, B. W., Park, J. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=History+of+minimally+invasive+surgery+for+gastric+cancer+in+Korea.">History of minimally invasive surgery for gastric cancer in Korea.</a> J Gastric Cancer. 12, 13-17 (2012).</li><li>Kim, H. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+and+mortality+of+laparoscopic+gastrectomy+versus+open+gastrectomy+for+gastric+cancer:+an+interim+report--a+phase+III+multicenter,+prospective,+randomized+Trial+(KLASS+Trial).">Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report--a phase III multicenter, prospective, randomized Trial (KLASS Trial).</a> Ann Surg. 251, 417-420 (2010).</li><li>Kim, M. C., Kim, K. H., Kim, H. H., Jung, G. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopy-assisted+by+conventional+open+distal+gastrectomy+and+extraperigastric+lymph+node+dissection+in+early+gastric+cancer.">Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer.</a> J Surg Oncol. 91, 90-94 (2005).</li><li>Kim, Y. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improved+quality+of+life+outcomes+after+laparoscopy-assisted+distal+gastrectomy+for+early+gastric+cancer:+results+of+a+prospective+randomized+clinical+trial.">Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial.</a> Ann Surg. 248, 721-727 (2008).</li><li>Kinoshita, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopy-assisted+and+total+laparoscopic+Billroth-I+gastrectomy+for+gastric+cancer:+a+report+of+short-term+outcomes.">Comparison of laparoscopy-assisted and total laparoscopic Billroth-I gastrectomy for gastric cancer: a report of short-term outcomes.</a> Surg Endosc. 25, 1395-1401 (2011).</li><li>Song, K. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+totally+laparoscopic+gastrectomy+less+invasive+than+laparoscopy-assisted+gastrectomy?:+prospective,+multicenter+study.">Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?: prospective, multicenter study.</a> J Gastrointest Surg. 12, 1015-1021 (2008).</li><li>Hyung, W. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+tumor+localization+using+laparoscopic+ultrasonography+in+laparoscopic-assisted+gastrectomy.">Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy.</a> Surg Endosc. 19, 1353-1357 (2005).</li><li>Jeong, O., Cho, S. B., Joo, Y. E., Ryu, S. Y., Park, Y. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+technique+for+intraoperative+tumor+localization+during+totally+laparoscopic+distal+gastrectomy:+endoscopic+autologous+blood+tattooing.">Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing.</a> Surg Endosc. 26, 1778-1783 (2012).</li><li>Kim, H. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+portable+abdominal+radiograph+for+tumor+localization:+a+simple+and+accurate+method+for+laparoscopic+gastrectomy.">Intraoperative portable abdominal radiograph for tumor localization: a simple and accurate method for laparoscopic gastrectomy.</a> Surg Endosc. 25, 958-963 (2011).</li><li>Kim, H. I., Cho, I., Jang, D. S., Hyung, W. 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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 ...

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 &#34;laparoscopy-assisted gastrectomy.&#34;
Recently, however, surgical procedures have evolved to minimize trauma, improving the postoperative quality of life for patients. Since this concept has also been applied in laparoscopic surgery for gastric cancer, some experienced laparoscopic surgeons have tried to avoid minilaparotomy. Totally laparoscopic gastrectomy (TLG) for gastric cancer requires that all procedures are completed using only laparoscopic devices, without requiring an additional minilaparotomy for specimen resection and anastomosis. Since this type of surgery results in less pain and faster recovery relative to open or laparoscopy-assisted surgery, which require laparotomy, more surgeons prefer it.5,6 However, an obstacle to TLG for gastric cancer is tumor localization without direct visualization or palpation to determine the area of stomach resection.
Tumor absence at the resection margin is very important to achieve success in gastric cancer surgery. If there is tumor involvement at the resection margin during distal gastrectomy for gastric cancer, additional resection is needed to avoid leaving tumor in the remaining stomach. In open and laparoscopy-assisted surgery, the primary tumor can be easily localized by palpation or direct visualization through a temporary gastrostomy. However, because the primary tumor is not easily detected in the laparoscopic view, determining resection margins for EGC in TLG may be difficult.
Several other methods requiring additional preoperative gastroscopy to determine resection margins have been proposed.7-9 However, additional preoperative gastroscopy can be inconvenient for patients. We introduced a procedure for intraoperative gastroscopy to directly mark tumors during TLG for gastric cancer in the middle third of the stomach.
In this protocol, we applied the laparoscopic surgery for patients with early gastric cancers at the preoperative studies, which are not included in absolute indication for endoscopic submucosal dissection.

<table border="0" cellpadding="0" cellspacing="0" width="717">
	<tbody>
		<tr height="20">
			<td height="20" style="height:20px;width:216px;">Pentothal Sodium</td>
			<td style="width:157px;">JW pharmatheutical Co.</td>
			<td style="width:119px;">644912100</td>
			<td style="width:225px;">It was used as induction asgent</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">Rocumeron</td>
			<td style="width:157px;">&#160;Ilsung pharmatheutical Co.</td>
			<td style="width:119px;">655402960</td>
			<td style="width:225px;">It was used for general anesthestia as muscle relaxant.</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">SevoFRAN</td>
			<td style="width:157px;">Hana pharmatheutical Co.</td>
			<td style="width:119px;">657801060</td>
			<td style="width:225px;">It was used as general anesthetics</td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;width:216px;">Endoscopy system</td>
			<td style="width:157px;">Olympus Corp.</td>
			<td style="width:119px;">CLV-260</td>
			<td style="width:225px;">It was used for intraoperative GFS</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">Laparoscopic surgery system</td>
			<td style="width:157px;">Striker Endoscopy</td>
			<td style="width:119px;">1488 HD 3-CHIP</td>
			<td style="width:225px;">It was a system for laparoscopic surgery</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">Ultrasonic scissor</td>
			<td style="width:157px;">Johnson and Johnson Medical Corp.</td>
			<td style="width:119px;">HAR23</td>
			<td style="width:225px;">It was used during tissue dissection</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">Laparoscopic clip</td>
			<td style="width:157px;">Johnson and Johnson Medical Corp.</td>
			<td style="width:119px;">ER420</td>
			<td style="width:225px;">It was used for ligation of the vessels.</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">Indigo carmine</td>
			<td style="width:157px;">Korea United Pharma</td>
			<td style="width:119px;">Carmine</td>
			<td style="width:225px;">It was injected into the gastric wall</td>
		</tr>
		<tr height="60">
			<td height="60" style="height:60px;width:216px;">Linear stapler</td>
			<td style="width:157px;">Johnson and Johnson Medical Corp.</td>
			<td style="width:119px;">ECHELON FLEX Powered Endopath Stapler</td>
			<td style="width:225px;">It was used for resection the stomach</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;width:216px;">Gastroscopic injector</td>
			<td style="width:157px;">TaeWoong Medical</td>
			<td style="width:119px;">Cobra injector</td>
			<td style="width:225px;">I was used for gastroscopic injection of blue dye</td>
		</tr>
	</tbody>
</table>

intraoperative gastroscopy for tumor localization in laparoscopic surgery for gastric adenocarcinoma

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.

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).
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Watch this Scientific Journal Video about Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma at JoVE.com

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

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.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

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