Local resection of the stomach for gastric cancer

Abstract

The local resection of the stomach is an ideal method for preventing postoperative symptoms. There are various procedures for performing local resection, such as the laparoscopic lesion lifting method, non-touch lesion lifting method, endoscopic full-thickness resection, and laparoscopic endoscopic cooperative surgery. After the invention and widespread use of endoscopic submucosal dissection, local resection has become outdated as a curative surgical technique for gastric cancer. Nevertheless, local resection of the stomach in the treatment of gastric cancer in now expected to make a comeback with the clinical use of sentinel node navigation surgery. However, there are many issues associated with local resection for gastric cancer, other than the normal indications. These include gastric deformation, functional impairment, ensuring a safe surgical margin, the possibility of inducing peritoneal dissemination, and the associated increase in the risk of metachronous gastric cancer. In view of these issues, there is a tendency to regard local resection as an investigative treatment, to be applied only in carefully selected cases. The ideal model for local resection of the stomach for gastric cancer would be a combination of endoscopic full-thickness resection of the stomach using an ESD device and hand sutured closure using a laparoscope or a surgical robot, for achieving both oncological safety and preserved functions.

Keywords: Gastric cancer; Laparoscopic endoscopic cooperative surgery; Local resection; Sentinel node.

Fig. 1

The lesion lifting method for laparoscopic local resection. a With the patient in the supine position, under gastroscopic guidance, a gastric puncture is made on the T-bars of a stomach wall lifting device, transabdominally. b The lesion is then lifted with the two T-bars, and multiple firings of the linear stapler aid in en bloc resection of the lesion. The entire procedure is performed under gastroscopic vision to ensure that the lesion is not included in the stapled suture line. c After performing resection and suturing simultaneously using a linear stapler, the specimen is collected and removed in a specimen collection bag

Fig. 2

The non-touch lesion lifting method for laparoscopic local resection. a The traction sutures placed laparoscopically in the healthy serosa on the periphery of the tumor replace the role played by T-bars. b The lesion is lifted using these sutures and en bloc resection is achieved by the multiple firings of a linear stapler

Fig. 3

Laparoscopic endoscopic cooperative surgery for local resection. This figure shows the crown method for small cancer. The traction sutures placed laparoscopically in the healthy serosa on the periphery of the tumor. Under the traction of the lesion by these sutures, a full-thickness resection is performed by the endoscopist using the ESD devices. After the lesion is removed intraluminally using the gastroscope, the defect of the stomach wall is closed by hand suturing using a laparoscope

Fig. 4

The old technique of local resection for early gastric cancer reported by Dr. Takagi. a Before the surgery, tattooing and targeted biopsies are performed at four points around the tumor to ensure a safe margin is achieved, and the center of the main lesion is then resected by EMR to determine the depth of invasion. If the biopsy findings suggest mucosal cancer, then a laparotomy is performed. b Local resection of the stomach is performed with the dissection line set beyond the tattooed sites. The sampling dissection of the perigastric nodes dyed by India ink is also performed to assess the lymph node status and staging

Fig. 5

The ideal model for local resection of the stomach for gastric cancer. a A laparoscopic fluorescence-guided sentinel node biopsy is performed during surgery to verify a negative lymph node status. The en bloc dissection of the lymphatic basin is performed laparoscopically, and the bright nodes are sent to the pathological section to carry out an intraoperative molecular diagnosis of micrometastasis. b The combination of endoscopic full-thickness resection of the stomach using an ESD device and hand suturing closure using a laparoscope or a surgical robot is performed to achieve oncological safety and well preserved functions