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. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracorporeal+esophagojejunostomy+using+a+circular+stapler+with+a+new+purse-string+suture+technique+during+laparoscopic+total+gastrectomy.">Intracorporeal esophagojejunostomy using a circular stapler with a new purse-string suture technique during laparoscopic total gastrectomy.</a> J Am Coll Surg. 216, e11-e16 (2013).</li><li>Japanese Gastric Cancer Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Japanese+gastric+cancer+treatment+guidelines+2010+(ver.+3).">Japanese gastric cancer treatment guidelines 2010 (ver. 3).</a> Gast Can. 14, 113-123 (2011).</li><li>Lee, H. H., Song, K. Y., Park, C. H., Jeon, H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+of+surgical+endoscopists+in+Korea:+assessment+of+the+learning+curve+using+a+cumulative+sum+model.">Training of surgical endoscopists in Korea: assessment of the learning curve using a cumulative sum model.</a> J Surg Educ. 69, 559-563 (2012).</li><li>Cho, W. 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=Hybrid+natural+orifice+transluminal+endoscopic+surgery:+endoscopic+full-thickness+resection+of+early+gastric+cancer+and+laparoscopic+regional+lymph+node+dissection--14+human+cases.">Hybrid natural orifice transluminal endoscopic surgery: endoscopic full-thickness resection of early gastric cancer and laparoscopic regional lymph node dissection--14 human cases.</a> Endoscopy. 43, 134-139 (2011).</li><li>Abe, N., 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=Endoscopic+full-thickness+resection+with+laparoscopic+assistance+as+hybrid+NOTES+for+gastric+submucosal+tumor.">Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor.</a> Surg Endosc. 23, 1908-1913 (2009).</li><li>Hoetker, M. S., 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=Molecular+in+vivo+imaging+of+gastric+cancer+in+a+human-murine+xenograft+model:+targeting+epidermal+growth+factor+receptor.">Molecular in vivo imaging of gastric cancer in a human-murine xenograft model: targeting epidermal growth factor receptor.</a> Gastrointest Endosc. 76, 612-620 (2012).</li><li>Ishihara, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Infrared+endoscopy+in+the+diagnosis+and+treatment+of+early+gastric+cancer.">Infrared endoscopy in the diagnosis and treatment of early gastric cancer.</a> Endoscopy. 42, 672-676 (2010).</li></ol>

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 ...

The overall goal of this procedure is to directly mark tumors with intraoperative gastroscopy during a total laparoscopic gastrectomy for early gastric cancer in the middle third of the stomach. This method can help answer key questions in the laparoscopy surgery field for early gastric cancer. The main advantage of this technique is that the exact location of early gastric cancer is identified during laparoscopy gastrectomy to preserve the proximal part of the stomach.To being, place the patient on the operating table. And administer 100 milligrams of thiopental sodium. After intravenous injection of a muscle relaxant, insert the endotracheal tube through the oral cavity and start the anesthetic gas according to the text protocol.Place the patient in a reverse trendelenburg position and stand at their right side. Make a 10 millimeter infraumbilical incision. And insert the first trocar into the abdominal cavity.Immediately connect the carbon dioxide gas tube to the trocar and with a pressure of 15 to 18 millimeters of mercury, create a pneumoperitoneum. Next, insert a rigid 30 degree laparoscope through the trocar, and use a monitor to explore the abdominal cavity connected to a laparoscopic system. Insert a 12 millimeter trocar on the right upper side of the umbilicus in a working port.Then insert three 5 millimeter trocars at working ports on the left upper side of the umbilicus and both upper outer quadrants of the abdomen. Using ultrasonic endoscopic scissors, dissect the gastrocolic ligament along the transverse colon, toward the inferior pole of the spleen. Then, using a laparoscopic clip, ligate the left gastroepiploic artery and vein originating from the splenic vessels at the root.And use the scissor to resect them. With the scissors, dissect the peripyloric lymph nodes around the pylorus and the head of the pancreas. And resect the right gastroepiploic vessels at their origin.Before resection of the first part of the duodenum, use a laparoscopic clamp to clamp the duodenum to prevent migration of gas into the small bowel during the gastroscopic procedure. To perform intraoperative gastroscopy, begin by moving to the left side of the patient's head. Then insert a gum shield into the patient's mouth.A gum shield is inserted into the patient's mouth to avoid injury to the teeth, and to allow the gastroscope to be inserted smoothly. Turn the patient's head to the left side and through the mouth and esophagus, carefully insert the gastroscope into the stomach avoiding injury to the mucosa of the oral cavity, esophagus and stomach. Insufflate the stomach by injecting gas through the gastroscope to locate the primary lesion.After approximating the distance between the proximal margin of the tumor and the esophagogastric junction according to the text protocol. And if total gastrectomy is not necessary, insert an endoscopic injector through a small hole in the gastroscope. Next, with the injector needle inserted obliquely two to three centimeters proximal from the tumor margin, slowly inject two to three milliliters of indigo carmine, avoiding intra or extraluminal leakage.It is important to insert a needle of the injector into the gastric wall obliquely to avoid a perforation of the gastric wall by the needle. In addition, indigo carmine should injected very slowly to identify intraluminal leakage during the procedure. After the injection is complete, aspirate the inflation gas through the gastroscope to make the laparoscopic procedure easier.After the gastroscopic procedure, return to the right side of the patient and in laparoscopic view, confirm the proximal portion of the tumor by identifying serosal staining by blue dye. While the dye is still present, using an endoscopic clip, mark the stained portion to be resected, avoiding involvement of the tumor at the resection margin. After resecting the duodenum, and dissecting the lymph node according to the text protocol, use two endoscopic staplers to resect the stomach at the proper location guided by the marking clip at least three centimeters proximal from the tumor margin.As soon as the distal stomach is resected, insert the specimen into an endoscopic bag and withdraw it from the abdominal cavity through a two to three centimeter extension of the infraumbilical trocar site. Send the tissue from the proximal margin to pathology for intraoperative histological evaluation. Finally, after confirmation of tumor-free tissue in the proximal portion of the resected stomach, use intracorporeal linear staples to perform and anastomosis between the remaining stomach and the proximal duodenum.Of the 20 patients who underwent intraoperative gastroscopy, 18 underwent distal subtotal gastrectomy guided by the findings during the gastroscopy. Total gastrectomy was performed on two patients because the proximal tumors were too close to the esophagogastric junction. At 3.5 centimeters and 2.5 centimeters respectively, as determined during intraoperative gastroscopy.The total mean operative time for distal gastrectomy was 188 minutes. The mean time for tumor localization with intraoperative gastroscopy was 8.4 minutes. And it gradually decreased from 11.8 minutes to 4.6 minutes.The mean tumor size in patients who underwent distal gastrectomy was 2.89 centimeters. Early gastric cancer was the final diagnosis in 16 patients, but one exhibited muscle invasion and another exhibited serosal invasion. The mean distance from the tumor to resection margin was 3.3 centimeters.The most common histologic cancer identified type was signet ring cell carcinoma. There was no morbidity, except for gastric stasis and adhesive illius in two patients. Finally, there were no complications related to intraoperative gastroscopy.Once mastered, this technique can be done in five minutes from insert of gastroscopy to injection of the blue dye into gastric wall, if it is performed properly. While attempting this procedure, it's important to remember to avoid the intra and extraluminal leakage during injection of the dye. After its development, this technique paved the way for researchers in the field of gastric cancer surgery to explore intraoperatively the exact location of early gastric cancers in a total laparoscopic gastrectomy without any laparotomy.After watching this video, you should have a good understanding of how to use intraoperative gastroscopy to localize early gastric cancer in the middle third of the stomach during a total laparoscopy gastrectomy. Don't forget that working with the intraoperative gastroscopy can be extremely hazardous and the precautions such as preventing injury to the oral cavity or the throat should always be taken while performing this procedure.

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