title: Gastric Resection Under Retroflexed Endoscopic Guidance: A Reliable Procedure for Totally Laparoscopic Subtotal Gastrectomy.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
authors.forename: Hisashi
authors.initials: H
authors.lastname: Gunji
authors.forename: Daisuke
authors.initials: D
authors.lastname: Horibe
authors.forename: Masaya
authors.initials: M
authors.lastname: Uesato
authors.forename: Masayuki
authors.initials: M
authors.lastname: Kano
authors.forename: Kouichi
authors.initials: K
authors.lastname: Hayano
authors.forename: Naoyuki
authors.initials: N
authors.lastname: Hanari
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Kawahira
authors.forename: Hideki
authors.initials: H
authors.lastname: Hayashi
authors.forename: Hisashiro
authors.initials: H
authors.lastname: Matsubara
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000379:methods*; D005773:Gastroscopy; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D061646:Operative Time; D013274:Stomach Neoplasms / Q000601:surgery*