J Gastric Cancer.  2017 Sep;17(3):220-227. 10.5230/jgc.2017.17.e25.

A Promising Method for Tumor Localization during Total Laparoscopic Distal Gastrectomy: Preoperative Endoscopic Clipping based on Negative Biopsy and Selective Intraoperative Radiography Findings

• Chung JW
• Seo KW
• Jung K
• Park MI
• Kim SE
• Park SJ
• Lee SH
• Shin YM

• KMID: 2389826
• DOI: http://doi.org/10.5230/jgc.2017.17.e25

Abstract

PURPOSE
Precise localization of tumors and creation of sufficient proximal resection margins are complicated processes during total laparoscopic distal gastrectomy (TLDG) for clinical T1/T2 gastric cancers. Various solutions to this problem have also yielded many disadvantages. In this study, we reviewed a preoperative endoscopic clipping method based on the results of negative biopsy and selective intraoperative radiography.
MATERIALS AND METHODS
A retrospective review of 345 consecutive patients who underwent TLDG and preoperative endoscopic clipping for tumor localization was conducted. During preoperative endoscopy, the endoscopists performed negative biopsies just 1-2 cm selectively above the tumor's upper limit. After confirming the biopsy results, endoscopic metal clips were applied just proximal to the negative biopsy site the day before surgery. Selective intraoperative tumor localization using portable abdominal radiography was performed only when we could not ensure a precise resection line.
RESULTS
Negative biopsy was performed in 244 patients. Larger tumor size (P=0.008) and more distally located tumors (P=0.052) were observed more frequently in the negative biopsy group than in the non-negative biopsy group. The non-negative biopsy group had significantly higher frequencies of differentiated tumor types than the negative biopsy group (P=0.003). Of the 244 patients who underwent negative biopsies, 6 had cancer cells in their biopsy specimens. We performed intraoperative radiography in 12 patients whose tumors had difficult-to-determine proximal margins. No tumors were found in the proximal resection margins of any patients.
CONCLUSIONS
Our tumor localization method is a promising and accurate method for securing a sufficient resection margin during TLDG.

Keyword

Stomach neoplasms; Laparoscopy; Gastrectomy; Tumor localization; Negative biopsy

MeSH Terms

Biopsy*
Endoscopy
Gastrectomy*
Humans
Laparoscopy
Methods*
Radiography*
Radiography, Abdominal
Retrospective Studies
Stomach Neoplasms

Figure

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  Fig. 1 Preoperative localization procedures. (A) Negative biopsy was performed 1–2 cm above the main lesion to aid in defining the proximal resection line. (B) Several metal clips were applied just proximal to the site of negative biopsy based on negative biopsy results. (C) ICG was injected to help precisely identify the lesion during surgery. ICG = indocyanine green.

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  Fig. 2 Intraoperative localization procedures. (A) The proximal resection line according to the information acquired from preoperative endoscopic clipping and ICG tattooing. (B) Metallic laparoscopic vessel clips along the greater and lesser curvatures of the external surface of the stomach followed by drawing an artificial line. ICG = indocyanine green.

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  Fig. 3 Radiograph show the location of metallic clips and endoscopic clips.

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  Fig. 4 Study profile with result. EGC = early gastric cancer; cT1 = clinical T1.

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