Are intraoperative abdominal radiographs necessary for identification of clips during totally laparoscopic or robotic gastrectomy?

Abstract

Purpose: Preoperative endoscopic clipping is a popular method in identifying the location of tumors during total laparoscopic or robotic gastrectomy. We investigated the usefulness of additional intraoperative abdominal radiographs to identify the location of clips. Methods: We retrospectively analyzed 331 patients with early gastric cancer who underwent endoscopic clipping before total laparoscopic or robotic gastrectomy between September 2012 and September 2018. Endoscopists applied two clips 1 cm from the proximal aspect of the upper margin of the tumor which was located above the angle of the stomach. We compared outcomes of patients who underwent preoperative abdominal radiographs only (group A) and those who underwent additional abdominal radiographs (group B). Results: Of the total patients, 80 (24.2%) underwent additional intraoperative abdominal radiographs. The rates of positive frozen biopsy in the two groups were not significantly different (group A vs. group B: 2.8% vs. 3.8%, P=0.456). The additional resection rate was significantly higher in group B compared to group A (8.8% vs. 2.8%, P=0.048). The mean distance from the tumor was 3.3 cm (2.4) in group A and 2.4 cm (1.3) in group B (P<0.001). Large tumor size (2.4 cm) was significantly associated with additional resection (odds ratio, 5.53; 95% confidence interval, 1.17-26.30; P=0.031). Conclusion: Additional intraoperative abdominal radiographs may be unnecessary for confirmation of proximal resection margin, if the resection line can be predetermined with preoperative abdominal radiographs. For large tumors, to avoid additional resection, the resection line should be placed 1 cm or more proximally from the preoperatively applied clips.