Gastric Resection Under Retroflexed Endoscopic Guidance: A Reliable Procedure for Totally Laparoscopic Subtotal Gastrectomy

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Background/Aims: Totally laparoscopic distal gastrectomy (TLDG) has become a feasible and safe surgical option for early gastric cancer. However, determining the transection line of the stomach without palpation is still difficult. This study aimed to assess the efficacy of TLDG for gastric resection under retroflexed endoscopic guidance (GRREG) in patients with gastric cancer in the middle third of the stomach. Methods: Fifteen patients with gastric cancer underwent TLDG using GRREG. Preoperative tumor localization using endoscopic metal clips was performed in all cases. After lymphadenectomy, two-thirds of the estimated transection line was occluded by an endoscopic stapler, beginning at the lesser curvature. Under gastric occlusion, the gastroscope was passed via the narrow lumen along the greater curvature followed by retroflexion to reveal the occlusion line, marking clips, and tumor in the same field of view. This view verified the safe oncological transection line. Results: All patients had cancer-free margins and did not require additional surgery. The mean (±SD) proximal margin was 23.5 ± 10.4 mm. There were no procedure-related complications. Conclusions: GRREG was a safe and effective technique for TLDG. Ideal transection of the stomach was achieved using a combination of an endoscopic stapler and gastroscope retroflexion.

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